How to Manage Failed Rotator Cuff Repair: Biologic Augmentation

  • Paolo Avanzi
  • Luca Dei Giudici
  • Antonio Gigante
  • Claudio Zorzi


Failure of a rotator cuff repair complicates up to 94% of the cases, and revision surgery is often required. Initial good results seem to decrease after 2 years from surgeries; therefore new techniques that could enhance the repair are being developed in order to decrease the retear rate. The procedures that add a biological enhancement, directly or indirectly, fall under the term of biological augmentation. Several types of grafts are currently available, including autografts, xenografts, allografts, and synthetic grafts, each with different advantages and disadvantages, obtaining various degrees of improvement compared to standard repairs. Bioengineering allowed the addition of special molecules and cells to those scaffolds, enhancing the intrinsic biological potentiality and modulating the healing response of the host, with interesting findings. Clinical, functional, imaging, and laboratory data suggest that patch augmentation for rotator cuff repair is a safe procedure that constantly enhances the mechanical strength, resulting in a repair tissue that is healthier and stronger. Application of growth factors and mesenchymal stem cells from different origins, instead, has yet to be applied in human studies, but in vitro and animal experimentations suggest that it will be soon possible to obtain a repaired tendon that is completely similar to the native tissue.


Biologic augmentation Revision Repair Scaffold Shoulder Graft 


  1. 1.
    Weeks KD, Dines JS, Rodeo SA, Bedi A. The basic science behind biologic augmentation of tendon-bone healing: a scientific review. Instr Course Lect. 2014;63:443–50.PubMedGoogle Scholar
  2. 2.
    Baleani M, Schrader S, Veronesi CA, Rotini R, Giardino R, Toni A. Surgical repair of the rotator cuff: a biomechanical evaluation of different tendon grasping and bone suture fixation techniques. Clin Biomech (Bristol, Avon). 2003;18:721–9.CrossRefGoogle Scholar
  3. 3.
    Strauss EJ, McCormack RA, Onyekwelu I, Rokito AS. Management of failed arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2012;20:301–9. Scholar
  4. 4.
    Valencia Mora M, Morcillo Barrenechea D, Martín Ríos MD, Foruria AM, Calvo E. Clinical outcome and prognostic factors of revision arthroscopic rotator cuff tear repair. Knee Surg Sport Traumatol Arthrosc. 2016;25(7):2157–63. Scholar
  5. 5.
    Shamsudin A, Lam PH, Peters K, Rubenis I, Hackett L, Murrell GAC. Revision versus primary arthroscopic rotator cuff repair. Am J Sports Med. 2015;43:557–64. Scholar
  6. 6.
    Lädermann A, Denard PJ, Burkhart SS. Revision arthroscopic rotator cuff repair: systematic review and authors’ preferred surgical technique. Arthrosc J Arthrosc Relat Surg. 2012;28:1160–9. Scholar
  7. 7.
    Yoo JC, Ahn JH, Koh KH, Lim KS. Rotator cuff integrity after arthroscopic repair for large tears with less-than-optimal footprint coverage. Arthroscopy. 2009;25:1093–100. Scholar
  8. 8.
    Tuoheti Y, Itoi E, Yamamoto N, Seki N, Abe H, Minagawa H, et al. Contact area, contact pressure, and pressure patterns of the tendon-bone interface after rotator cuff repair. Am J Sports Med. 2005;33:1869–74. Scholar
  9. 9.
    Burkhart SS, Diaz Pagàn JL, Wirth MA, Athanasiou KA. Cyclic loading of anchor-based rotator cuff repairs: confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation. Arthroscopy. 1997;13:720–4.CrossRefGoogle Scholar
  10. 10.
    McCormack RA, Shreve M, Strauss EJ. Biologic augmentation in rotator cuff repair--should we do it, who should get it, and has it worked? Bull Hosp Jt Dis. 2014;72:89–96.Google Scholar
  11. 11.
    Labbé MR. Arthroscopic technique for patch augmentation of rotator cuff repairs. Arthrosc J Arthrosc Relat Surg. 2006;22:1136.e1–6. Scholar
  12. 12.
    Petri M, Greenspoon JA, Moulton SG, Millett PJ. Patch-augmented rotator cuff repair and superior capsule reconstruction. Open Orthop J. 2016;10:315–23. Scholar
  13. 13.
    Barber FA, Burns JP, Deutsch A, Labbé MR, Litchfield RB. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012;28:8–15. Scholar
  14. 14.
    Ricchetti ET, Aurora A, Iannotti JP, Derwin KA. Scaffold devices for rotator cuff repair. J Shoulder Elb Surg. 2012;21:251–65. Scholar
  15. 15.
    DeFranco MJ, Derwin K, Iannotti JP. New therapies in tendon reconstruction. J Am Acad Orthop Surg. 2004;12:298–304.CrossRefGoogle Scholar
  16. 16.
    Aurora A, McCarron JA, van den Bogert AJ, Gatica JE, Iannotti JP, Derwin KA. The biomechanical role of scaffolds in augmented rotator cuff tendon repairs. J Shoulder Elb Surg. 2012;21:1064–71. Scholar
  17. 17.
    Shea KP, Obopilwe E, Sperling JW, Iannotti JP. A biomechanical analysis of gap formation and failure mechanics of a xenograft-reinforced rotator cuff repair in a cadaveric model. J Shoulder Elb Surg. 2012;21:1072–9. Scholar
  18. 18.
    Mikos AG, McIntire LV, Anderson JM, Babensee JE. Host response to tissue engineered devices. Adv Drug Deliv Rev. 1998;33:111–39.CrossRefGoogle Scholar
  19. 19.
    Ferguson DP, Lewington MR, Smith TD, Wong IH. Graft utilization in the augmentation of large-to-massive rotator cuff repairs: a systematic review. Am J Sports Med. 2016;44:2984–92. Scholar
  20. 20.
    Le BTN, Wu XL, Lam PH, Murrell GAC. Factors predicting rotator cuff retears. Am J Sports Med. 2014;42:1134–42. Scholar
  21. 21.
    Wu XL, Briggs L, Murrell GAC. Intraoperative determinants of rotator cuff repair integrity. Am J Sports Med. 2012;40:2771–6. Scholar
  22. 22.
    Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elb Surg. 1999;8:599–605.CrossRefGoogle Scholar
  23. 23.
    Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83.Google Scholar
  24. 24.
    Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res. 1990;254:81–6.Google Scholar
  25. 25.
    Denard PJ, Koo SS, Murena L, Burkhart SS. Pseudoparalysis: the importance of rotator cable integrity. Orthopedics. 2012;35:e1353–7. Scholar
  26. 26.
    Hamada K, Fukuda H, Mikasa M, Kobayashi Y. Roentgenographic findings in massive rotator cuff tears. A long-term observation. Clin Orthop Relat Res. 1990;254:92–6.Google Scholar
  27. 27.
    Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med. 2010;38:664–71. Scholar
  28. 28.
    Gervasi E, Causero A, Parodi PC, Raimondo D, Tancredi G. Arthroscopic Latissimus dorsi transfer. Arthrosc J Arthrosc Relat Surg. 2007;23:1243.e1–4. Scholar
  29. 29.
    Neviaser JS. Ruptures of the rotator cuff of the shoulder. New concepts in the diagnosis and operative treatment of chronic ruptures. Arch Surg. 1971;102:483–5.CrossRefGoogle Scholar
  30. 30.
    Nassos JT, Chudik SC. Arthroscopic rotator cuff repair with biceps tendon augmentation. Am J Orthop (Belle Mead NJ). 2009;38:279–81.Google Scholar
  31. 31.
    Derwin KA, Baker AR, Spragg RK, Leigh DR, Farhat W, Iannotti JP. Regional variability, processing methods, and biophysical properties of human fascia lata extracellular matrix. J Biomed Mater Res A. 2008;84A:500–7. Scholar
  32. 32.
    Derwin KA, Baker AR, Spragg RK, Leigh DR, Iannotti JP. Commercial extracellular matrix scaffolds for rotator cuff tendon repair. Biomechanical, biochemical, and cellular properties. J Bone Joint Surg Am. 2006;88:2665–72. Scholar
  33. 33.
    McCarron JA, Milks RA, Mesiha M, Aurora A, Walker E, Iannotti JP, et al. Reinforced fascia patch limits cyclic gapping of rotator cuff repairs in a human cadaveric model. J Shoulder Elb Surg. 2012;21:1680–6. Scholar
  34. 34.
    Mori D, Funakoshi N, Yamashita F. Arthroscopic surgery of irreparable large or massive rotator cuff tears with low-grade fatty degeneration of the infraspinatus: patch autograft procedure versus partial repair procedure. Arthroscopy. 2013;29:1911–21. Scholar
  35. 35.
    Bektaser B. Free coracoacromial ligament graft for augmentation of massive rotator cuff tears treated with mini-open repair. Acta Orthop Traumatol Turc. 2010;44:426–30. Scholar
  36. 36.
    Mihara S, Ono T, Inoue H, Kisimoto T. A new technique for patch augmentation of rotator cuff repairs. Arthrosc Tech. 2014;3:e367–71. Scholar
  37. 37.
    Scheibel M, Brown A, Woertler K, Imhoff AB. Preliminary results after rotator cuff reconstruction augmented with an autologous periosteal flap. Knee Surg Sports Traumatol Arthrosc. 2007;15:305–14. Scholar
  38. 38.
    Thangarajah T, Pendegrass CJ, Shahbazi S, Lambert S, et al. Augmentation of rotator cuff repair with soft tissue scaffolds. Orthop J Sports Med. 2015;3(6):1–8. Scholar
  39. 39.
    Barber FA, Herbert MA, Ph D, Boothby MH. Ultimate tensile failure loads of a human dermal allograft rotator cuff augmentation. Arthroscopy. 2008;24:20–4. Scholar
  40. 40.
    Mazzocca AD, Trainer G, McCarthy MB, Obopilwe E, Arciero RA. Biologic enhancement of a common arthroscopic suture. Arthrosc J Arthrosc Relat Surg. 2012;28:390–6. Scholar
  41. 41.
    Wong I, Burns J, Snyder S. Arthroscopic GraftJacket repair of rotator cuff tears. J Shoulder Elb Surg. 2010;19:104–9. Scholar
  42. 42.
    Ozaki J, Fujimoto S, Masuhara K, Tamai S, Yoshimoto S. Reconstruction of chronic massive rotator cuff tears with synthetic materials. Clin Orthop Relat Res. 1986;202:173–83.Google Scholar
  43. 43.
    Mckeown ADJ, Beattie RF, Murrell GAC, Lam PH. Biomechanical comparison of expanded polytetrafluoroethylene (ePTFE ) and PTFE interpositional patches and direct tendon-to-bone repair for massive rotator cuff tears in an ovine model. Shoulder Elbow. 2016;8:22–31. Scholar
  44. 44.
    McCarron JA, Milks RA, Chen X, Iannotti JP, Derwin KA. Improved time-zero biomechanical properties using poly-L-lactic acid graft augmentation in a cadaveric rotator cuff repair model. J Shoulder Elb Surg. 2010;19:688–96. Scholar
  45. 45.
    Proctor CS, Orthopedics A, Barbara S. Long-term successful arthroscopic repair of large and massive rotator cuff tears with a functional and degradable reinforcement device. J Shoulder Elb Surg. 2014;23:1508–13. Scholar
  46. 46.
    Lenart BA, Martens KA, Kearns KA, Gillespie RJ, Zoga AC, Williams GR. Treatment of massive and recurrent rotator cuff tears augmented with a poly- L -lactide graft, a preliminary study. J Shoulder Elb Surg. 2015;24:915–21. Scholar
  47. 47.
    Ciampi P, Scotti C, Nonis A, Vitali M, Di Serio C, Peretti GM, et al. The benefit of synthetic versus biological patch augmentation in the repair of posterosuperior massive rotator cuff tears: a 3-year follow-up study. Am J Sports Med. 2014;42:1169–75. Scholar
  48. 48.
    Meyer F, Wardale J, Best S, Cameron R, Rushton N, Brooks R. Effects of lactic acid and glycolic acid on human osteoblasts: a way to understand PLGA involvement in PLGA/calcium phosphate composite failure. J Orthop Res. 2012;30:864–71. Scholar
  49. 49.
    Fini M, Bondioli E, Castagna A, Torricelli P, Giavaresi G, Rotini R, et al. Decellularized human dermis to treat massive rotator cuff tears: in vitro evaluations. Connect Tissue Res. 2012;53:298–306. Scholar
  50. 50.
    Montgomery SR, Petrigliano FA, Gamradt SC. Biologic augmentation of rotator cuff repair. Curr Rev Musculoskelet Med. 2011;4:221–30. Scholar
  51. 51.
    Iannotti JP, Codsi MJ, Kwon YW, Derwin K, Ciccone J, Brems JJ. Porcine small intestine submucosa augmentation of surgical repair of chronic two-tendon rotator cuff tears. A randomized, controlled trial. J Bone Joint Surg Am. 2006;88:1238–44. Scholar
  52. 52.
    Walton JR, Bowman NK, Khatib Y, Linklater J, Murrell GAC. Restore orthobiologic implant: not recommended for augmentation of rotator cuff repairs. J Bone Joint Surg Am. 2007;89:786–91. Scholar
  53. 53.
    Phipatanakul WP, Petersen SA. Porcine small intestine submucosa xenograft augmentation in repair of massive rotator cuff tears. Am J Orthop (Belle Mead NJ). 2009;38:572–5.Google Scholar
  54. 54.
    Xu H, Wan H, Zuo W, Sun W, Owens RT, Harper JR, et al. A porcine-derived acellular dermal scaffold that supports soft tissue regeneration: removal of terminal galactose-alpha-(1,3)-galactose and retention of matrix structure. Tissue Eng Part A. 2009;15:1807–19. Scholar
  55. 55.
    Connor J, McQuillan D, Sandor M, Wan H, Lombardi J, Bachrach N, et al. Retention of structural and biochemical integrity in a biological mesh supports tissue remodeling in a primate abdominal wall model. Regen Med. 2009;4:185–95. Scholar
  56. 56.
    Nicholson GP, Breur GJ, Van Sickle D, Yao JQ, Kim J, Blanchard CR. Evaluation of a cross-linked acellular porcine dermal patch for rotator cuff repair augmentation in an ovine model. J Shoulder Elb Surg. 2007;16:S184–90. Scholar
  57. 57.
    Smith RD, Carr A, Dakin SG, Snelling SJ, Yapp C, Hakimi O. The response of tenocytes to commercial scaffolds used for rotator cuff repair. Eur Cell Mater. 2016;31:107–18.CrossRefGoogle Scholar
  58. 58.
    Petri M, Warth RJ, Horan MP, Greenspoon JA, Millett PJ. Outcomes after open revision repair of massive rotator cuff tears with biologic patch augmentation. Arthroscopy. 2016;32:1752–60. Scholar
  59. 59.
    Badhe SP, Lawrence TM, Smith FD, Lunn PG. An assessment of porcine dermal xenograft as an augmentation graft in the treatment of extensive rotator cuff tears. J Shoulder Elb Surg. 2008;17:35S–9S. Scholar
  60. 60.
    Giannotti S, Ghilardi M, Dell’osso G, Magistrelli L, Bugelli G, Di Rollo F, et al. Study of the porcine dermal collagen repair patch in morpho-functional recovery of the rotator cuff after minimum follow-up of 2.5 years. Surg Technol Int. 2014;24:348–52.PubMedGoogle Scholar
  61. 61.
    Steinhaus ME, Makhni EC, Cole BJ, Romeo AA, Verma NN. Outcomes after patch use in rotator cuff repair. Arthrosc J Arthrosc Relat Surg. 2016;32:1676–90. Scholar
  62. 62.
    Avanzi P. Goal post technique; for arthroscopic biological augmentation of rotator cuff repair; 2017. Accessed 14 Jan 2017.
  63. 63.
    Beitzel K, McCarthy MB, Cote MP, Russell RP, Apostolakos J, Ramos DM, et al. Properties of biologic scaffolds and their response to mesenchymal stem cells. Arthrosc J Arthrosc Relat Surg. 2014;30:289–98. Scholar
  64. 64.
    Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012;40:2248–55. Scholar
  65. 65.
    Burkhart SS, Adams CR, Burkhart SS, Schoolfield JD. A biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: the SwiveLock-FiberChain construct versus standard double-row repair. Arthrosc J Arthrosc Relat Surg. 2009;25:274–81. Scholar
  66. 66.
    Grambart ST. Sports medicine and platelet-rich plasma. Clin Podiatr Med Surg. 2015;32:99–107. Scholar
  67. 67.
    Jo CH, Shin JS, Lee YG, Shin WH, Kim H, Lee SY, et al. Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. Am J Sports Med. 2013;41:2240–8. Scholar
  68. 68.
    Randelli PS, Arrigoni P, Cabitza P, Volpi P, Maffulli N. Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study. Disabil Rehabil. 2008;30:1584–9. Scholar
  69. 69.
    Randelli P, Arrigoni P, Ragone V, Aliprandi A, Cabitza P. Platelet rich plasma in arthroscopic rotator cuff repair: a prospective RCT study, 2-year follow-up. J Shoulder Elb Surg. 2011;20:518–28. Scholar
  70. 70.
    Castricini R, Longo UG, De Benedetto M, Panfoli N, Pirani P, Zini R, et al. Platelet-rich plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial. Am J Sports Med. 2011;39:258–65. Scholar
  71. 71.
    Barber FA, Hrnack SA, Snyder SJ, Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation. Arthrosc J Arthrosc Relat Surg. 2011;27:1029–35. Scholar
  72. 72.
    Kabuto Y, Morihara T, Sukenari T, Kida Y, Oda R, Arai Y, et al. Stimulation of rotator cuff repair by sustained release of bone morphogenetic Protein-7 using a Gelatin hydrogel sheet. Tissue Eng Part A. 2015;21:2025–33. Scholar
  73. 73.
    Lee K, Lee J, Kim Y, Shim Y, Jang J, Lee K. Effective healing of chronic rotator cuff injury using recombinant bone morphogenetic protein-2 coated dermal patch in vivo. J Biomed Mater Res B Appl Biomater. 2016;105:1–7. Scholar
  74. 74.
    Omae H, Steinmann SP, Zhao C, Zobitz ME, Wongtriratanachai P, Sperling JW, et al. Biomechanical effect of rotator cuff augmentation with an acellular dermal matrix graft: a cadaver study. Clin Biomech. 2012;27:789–92. Scholar
  75. 75.
    Press D. Biological augmentation of rotator cuff repair using bFGF-loaded electrospun poly (lactide-co-glycolide) fibrous membranes. Int J Nanomedicine. 2014;9:2373–85.Google Scholar
  76. 76.
    Gulotta LV, Kovacevic D, Ehteshami JR, Dagher E, Packer JD, Rodeo SA. Application of bone marrow-derived mesenchymal stem cells in a rotator cuff repair model. Am J Sports Med. 2009;37:2126–33. Scholar
  77. 77.
    Yoon JP, Chung SW, Kim JY, Lee BJ, Kim H-S, Kim JE, et al. Outcomes of combined bone marrow stimulation and patch augmentation for massive rotator cuff tears. Am J Sports Med. 2016;44:963–71. Scholar
  78. 78.
    Guilak F, Estes BT, Diekman BO, Moutos FT, Gimble JM. 2010 Nicolas Andry award: multipotent adult stem cells from adipose tissue for musculoskeletal tissue engineering. Clin Orthop Relat Res. 2010;468:2530–40. Scholar
  79. 79.
    Gimble JM, Guilak F. Adipose-derived adult stem cells: isolation, characterization, and differentiation potential. Cytotherapy. 2003;5:362–9. Scholar
  80. 80.
    Oh JH, Chung SW, Kim SH, Chung JY, Kim JY. 2013 Neer Award: effect of the adipose-derived stem cell for the improvement of fatty degeneration and rotator cuff healing in rabbit model. J Shoulder Elb Surg. 2014;23:445–55. Scholar
  81. 81.
    Gupta AK, Hug K, Boggess B, Gavigan M, Toth AP. Massive or 2-tendon rotator cuff tears in active patients with minimal glenohumeral arthritis. Am J Sports Med. 2013;41:872–9. Scholar
  82. 82.
    Gupta A, Liberati TA, Verhulst SJ, Main BJ, Roberts MH, Potty AGR, et al. Biocompatibility of single-walled carbon nanotube composites for bone regeneration. Bone Joint Res. 2015;4:70–7. Scholar
  83. 83.
    Mihata T, Lee TQ, Watanabe C, Fukunishi K, Ohue M, Tsujimura T, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthrosc J Arthrosc Relat Surg. 2013;29:459–70. Scholar
  84. 84.
    Savarese E, Romeo R. New solution for massive, irreparable rotator cuff tears: the subacromial “biodegradable spacer”. Arthrosc Tech. 2012;1:e69–74. Scholar

Copyright information

© ESSKA 2018

Authors and Affiliations

  • Paolo Avanzi
    • 1
  • Luca Dei Giudici
    • 2
  • Antonio Gigante
    • 2
  • Claudio Zorzi
    • 1
  1. 1.Department of OrthopaedicsSacro Cuore – Don Calabria HospitalVeronaItaly
  2. 2.Orthopaedic UnitCasa di Cura “Villa Igea” HospitalAnconaItaly

Personalised recommendations