Rotator cuff repair augmentation: a review of current techniques

Introduction

Rotator cuff tears are among the most prevalent orthopedic injuries, affecting approximately 40% of people over 60 years old (1). The gold standard for treatment after failed conservative management is surgical repair. While previous studies have demonstrated that successful rotator cuff repairs (RCRs) can lead to favorable long-term outcomes, retear rates remain high, with some studies reporting recurrence in 40% to 94% of patients (2-5). These retears can occur either at the suture-tendon or tendon-bone junction and may be due to tension at the repair site, poor quality of the tendon being repaired, or other patient-specific factors (6). A meta-analysis by McElvany et al., which evaluated outcomes in over 8,000 patients, found that nearly 26% of RCRs failed to heal, and more than a quarter of cases failed to restore full tendon integrity (7). Several factors contribute to an increased risk of retear, including patient age, smoking, tear size, fatty infiltration, tissue quality, and other comorbidities (8). Additionally, an intact supraspinatus tendon is associated with a reduced risk of osteoarthritis, making failed RCRs a significant concern for long-term joint deterioration, including articular degeneration, superior humeral translation, and rotator cuff arthropathy (9,10). For patients at high risk for failure, augmentation may offer a promising option to enhance healing and improve outcomes. The purpose of this review is to assess the current methods of augmentation for RCR and to provide an updated analysis of augmentation techniques for RCRs from 2010 to 2025. The review includes detailed descriptions of each augmentation technique, along with associated outcomes and available evidence supporting their use in clinical practice.

Methods

This review included studies from 2010–2025 that investigated augmentation techniques for RCR and provided quantitative outcomes, such as functional scores, retear rates, and tendon healing. Only peer-reviewed studies reporting on full-thickness rotator cuff tears with postoperative follow-up were considered. Studies were excluded if they lacked quantitative outcome data or had insufficient follow-up. The augmentation methods reviewed included bioinductive collagen implants, platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC). Surgical procedures primarily involved arthroscopic RCR. In most studies, the augmentation material was applied directly to the tear site or used as a scaffold between the tendon and bone, though there were variations in surgical methods and the timing of augmentation. For example, some studies administered PRP during the repair, while others applied it postoperatively. Patient demographics varied, but most studies involved adult patients with a mean age ranging from 40 to 70 years. The follow-up periods in the studies ranged from 6 months to 5 years, with functional scores typically assessed through tools like the Constant-Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, and Visual Analog Scale (VAS) for pain. Table 1 outlines a summary of the outcomes from augmentation techniques.

RCR augmentation

Augmentation represents a recent advancement in RCR surgery, emerging as a valuable adjunct to improve outcomes in surgical management. By enhancing mechanical stability and promoting better biological healing, augmentation techniques can increase the likelihood of a successful repair and patient outcome (8,20). Augmentation is particularly indicated for patients with large to massive rotator cuff tears, chronic tears characterized by poor tissue quality, or revision repairs (2,21,22). A large tear is typically defined as one involving greater than 3 cm of the tendon, while a massive tear generally exceeds 5 cm or involves two or more tendons (23). Fatty infiltration, often assessed using the Goutallier classification, is considered significant at stages 2 or higher, with severe infiltration (stage 4) generally indicating poor reparability. Additionally, the reparability of the tear, evaluated based on tendon quality and retraction, plays a critical role in determining whether augmentation is appropriate. The decision to incorporate augmentation often depends on several factors, including the Rotator Cuff Healing Index (RoHI) score, which evaluates the likelihood of successful healing based on preoperative factors. Patients with high-risk features such as advanced age, significant retraction, fatty infiltration, or poor bone density are more likely to benefit from augmentation (8,24). Additionally, patients with previous retear, especially those with recurrent tears at the tendon-bone interface, are often considered for augmentation during revision repair procedures (8). It is also essential to consider other comorbidities, such as diabetes or smoking, which may negatively affect healing and increase the risk of failure. Augmentation approaches include structural options (dermal allografts), bioinductive treatments (collagen implants), and hematological interventions (PRP, BMAC, and fibrin clots) (24-26). While the literature remains varied, and the use of these techniques is still a topic of ongoing debate, existing studies have shown promising results, suggesting their potential to improve surgical success in challenging cases, particularly when the risk of failure is higher in both primary and revision repairs.

Structural augmentation

Structural augmentation in RCR is a technique designed to reinforce the repaired tendon using a patch or graft. This augmentation provides structural support, enhancing the strength of the repair and seeking to reduce the risk of failure. It is particularly beneficial in cases involving large or massive tears, typically defined as those measuring ≥5 cm in diameter or involving multiple tendons, where tendon retraction and muscle atrophy may compromise repair integrity (23). Additionally, it is useful when tissue quality is suboptimal, characterized by poor tendon integrity, thinning, or significant fatty infiltration (e.g., Goutallier grade ≥2) (24,27-29). While synthetic grafts and xenografts were previously used, studies demonstrated an association with inflammatory responses that often led to suboptimal outcomes (22). More advanced approaches, utilizing extracellular matrices and dermal allografts, have since been developed to address these challenges (2,30). Today, several commercially available techniques are available for use with improved ease of graft deliverability.

Arthrex ArthroFLEX decellularized dermal allograft

The Arthrex ArthroFLEX dermal allograft (Arthrex, Naples, FL, USA) is an acellular extracellular matrix (ECM) derived from human dermis and designed to provide structural support for soft tissue repairs. The ArthroFLEX undergoes a decellularization process using a non-denaturing anionic detergent and an endonuclease to remove immunogenic material (31). This process preserves the ECM’s structural integrity while promoting host cellular and vascular ingrowth, allowing the graft to function as a collagen scaffold for tissue regeneration. In RCR, the ArthroFLEX allograft is typically placed over the tendon repair or used as a bridge between the tendon and adjacent tissue. Its effectiveness as a RCR augmentation has been well-documented in clinical studies, showing improvements in biomechanical strength and tendon healing. For instance, a study by Ely et al. using a cadaver RCR model demonstrated that ArthroFLEX reduced gap formation and increased load-to-failure resistance (32). Similarly, a prospective comparative study by Gilot et al. found that patients receiving the ArthroFLEX graft with RCR had significantly lower retear rates (10%) compared to the control group, which did not receive augmentation (26%) (P=0.024) (11). Moreover, patients who received ArthroFLEX showed greater improvements in functional outcomes. The ASES scores increased significantly more in the treatment group (63.8 to 88.9 points) compared to the control group (62.1 to 72.6 points) (P=0.021). At 24 months after surgery, patients with the ArthroFLEX graft also showed better results on the 12-item Short Form Health Survey (SF-12) and Western Ontario Rotator Cuff (WORC) index. Additionally, these patients experienced superior pain control, increased range of motion, and improved subjective outcomes at the final follow-up. Overall, the Arthrex ArthroFLEX dermal allograft offers a promising solution for enhancing the success of RCR, improving both structural integrity and long-term patient outcomes.

Wright GraftJacket

The GraftJacket (Wright Medical Technology, Arlington, TN, USA) is a processed human dermal allograft widely used in RCR augmentation. This acellularized allograft is designed to minimize the immunogenic response, providing an ideal scaffold for host tissue regeneration and facilitating the incorporation of the matrix into the healing tissue (33,34). The GraftJacket’s native collagen structure and vascular channels promote cellular regeneration and revascularization, enhancing the repair’s healing potential. Compared to xenograft and synthetic alternatives, the GraftJacket has been shown to provide superior biomechanical strength (35). In a randomized controlled trial by Barber et al., patients who received GraftJacket augmentation for large, two-tendon rotator cuff tears demonstrated significantly better outcomes than those who did not receive augmentation. The GraftJacket group had an intact rotator cuff rate of 85% compared to just 40% of the control group (P<0.01) (12). Furthermore, the GraftJacket group showed greater improvement in functional outcomes, with significant increases in ASES and Constant scores (P=0.035 and P=0.008, respectively). While the procedure added 30 to 60 minutes to operative time, no adverse events related to GraftJacket augmentation were reported (12). In another study, Bond et al. reported that among the 16 patients treated for massive rotator cuff tears with GraftJacket augmentation, 15 patients (93.8%) reported high patient satisfaction, 13 patients (81.3%) achieved full incorporation of the graft into native tissue on magnetic resonance imaging (MRI), and no complications were reported (36). In addition, a study by Burkhead et al. found that GraftJacket augmentation led to significant improvements in pain and functional status (37). Specifically, 64% of patients reported reduced pain, and 70% experienced improved functional outcomes following surgery. There were three recurrent tears found on MRI that were smaller than preoperative MRI scans; however, two of the three patients reported high satisfaction. No other complications were observed, including no infections or inflammatory reactions (37). In contrast, Gouk et al. reported that when used for interposition grafting, only 14% of the grafts were completely intact at 6 months (38). Overall, the GraftJacket allograft offers a highly effective option for augmenting RCR, enhancing tendon healing, improving biomechanical strength, and achieving better patient outcomes. However, given the variability in reported outcomes, particularly in cases such as those described by Gouk et al., further research is necessary to optimize patient selection, refine surgical techniques, and better understand long-term efficacy.

Bioinductive collagen implant (non-structural)

Bioinductive collagen implants have gained popularity due to their unique ability to stimulate tissue regeneration and enhance the healing process. The bioinductive properties of resorbable bovine collagen create an optimal biological environment that promotes better cellular integration, tissue maturation, and gradual resorption of the implant (39,40). When used to augment full-thickness rotator cuff tears, these implants have been shown to increase tendon thickness, improve functional outcomes, and reduce pain, leading to better overall recovery and long-term results (13,14,39).

Regeneten

The Regenten implant (Smith & Nephew, Andover, MA, USA) is a resorbable, bovine collagen-based patch designed to stimulate new tissue growth and integration at the RCR site. Research has shown that the Regenten patch enhances the formation of tendon-like tissue and increases tendon thickness without triggering an inflammatory response (14). A recent systematic review by Warren et al. compared outcomes of RCR augmented with the Regenten patch to traditional RCR (13). The review found that the Regenten patch led to a lower retear rate of 8.3% compared to previously reported 15–21% in traditional RCR (41). They also found that all patients experienced improved tendon thickness (preoperative range 4.0–4.2 mm, postoperative range 4.5–7.3 mm) and patient satisfaction scores, specifically the ASES, CMS, the VAS for pain. However, the study indicated that complication rates were similar between the two approaches. Overall complications occurred in 15.5% of patients with full-thickness tears who underwent RCR with the Regeneten implant, compared to 15.8% in a registry of 1,661 cases of traditional RCR (13,42). Additionally, complications such as capsulitis and stiffness after RCR with the Regenten implant were reported in 1.8% of patients. In a prospective multicenter study by Bushnell et al., the one-year postoperative retear rate for RCR augmented with the Regenten implant was found to be 16.5%, which is lower than the retear rates typically reported for traditional RCR (32% for medium and 53% for large full-thickness tears) (14). The study also demonstrated significantly improved patient-reported outcomes, with 91.7% of patients meeting the minimally clinically important difference (MCID) for the ASES score and 86.4% meeting the MCID for the CMS score (14). However, as the study lacked a control group, direct comparisons to traditional RCR outcomes are limited. Further comparative studies and randomized controlled trials are necessary to better evaluate the Regeneten implant’s true impact. Despite this limitation, these findings further support the potential of the Regeneten implant to improve both clinical and functional outcomes in RCR.

Zimmer Tapestry Biointegrative Implant

The Zimmer Tapestry Biointegrative Implant (Zimmer Biomet Warsaw, Indiana) is a collagen-based implant with a highly porous microarchitecture, composed of a type 1 collagen polymer and poly(D,L-lactide). This advanced implant is designed to stimulate healing, integrate into the native tissue, and promote the formation of tendon-like tissue in place of the implant (43). It is created using a nanofiber electrospinning process, which enhances its structural properties and biological function. One study showed that the use of this implant leads to improvements in ASES scores, internal rotation strength, and range of motion (44). However, there is limited literature evaluating the outcomes of RCR augmented with Zimmer Tapestry, highlighting the need for further high-quality, randomized controlled trials to establish its efficacy and safety.

Hematological augmentation

Orthobiologics have gained interest as augmentations for RCR to stimulate tendon healing and reduce the risk of retears. They refer to biological treatments derived from blood products that are used to enhance healing, stimulate tissue regeneration, and improve outcomes after surgery. These therapies are unique in that they leverage the body’s native healing mechanisms to accelerate recovery, particularly for large and complex rotator cuff tears (26).

PRP

PRP is an autologous blood-derived product prepared through centrifugation. It contains plasma with a high concentration of growth factors, such as platelet-derived growth factor (PDGF), transforming growth factor (TGF)-beta, fibroblast growth factor (FGF), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF) (45). These growth factors play vital roles in tissue regeneration and repair. PDGF, for example, is essential for bone remodeling as it stimulates osteogenic progenitor cells and recruits fibroblasts for tendon remodeling. It also expresses VEGF, which promotes angiogenesis, enhancing blood supply to the damaged tissue. Therefore, when used as an augmentation for RCR, PRP can stimulate tissue regeneration and improve vascularization of the repaired tendon.

Although recent studies have shown the benefits of PRP on wound healing, there remains a lack of consensus on the overall efficacy of PRP as an augmentation for RCR (46-49). One key challenge is the lack of standardization in PRP delivery methods, resulting in variability in platelet concentrations, dosing regimens, and incomplete reporting of preparation protocols (50). For example, Jo et al. conducted a randomized clinical trial and found that the loss of supraspinatus muscle l cross-sectional area from immediately postoperative and 1-year postoperative on MRI was significantly less in the PRP group compared to the control (PRP: −15.54 mm², control: −85.62 mm², P=0.047). Additionally, the PRP group showed a significantly lower retear rate (20%) compared to the control group (55.6%) (P=0.023) (15). Similarly, a systematic review by Ahmad et al. that evaluated 13 meta-analyses found that PRP augmentation was associated with lower retear rates and improved functional outcome scores compared to those who did not receive the augmentation (51). Another systematic review by Yang et al. found that PRP led to reduced retear rates and improved outcomes, especially in the short term, compared to those who did not receive PRP with RCR (52). Furthermore, in a meta-analysis of 21 randomized controlled trials, Shen et al. concluded that PRP reduced retear rates, improved short-, medium-, and long-term constant and VAS scores, and short-term university of california-los angeles (UCLA) scores (16).

Despite these promising findings, a significant barrier to the widespread use of PRP in RCR is cost. The expenses related to venipuncture, centrifugation preparation, and additional operating room time can be substantial. For example, Vavken et al. noted that a 40% reduction in retear rates would require 14 patients to be treated with PRP to prevent one additional retear [number needed to treat (NNT)] (53). In another cost analysis, Samuelson et al. found that PRP would be cost-effective if the retear rate were reduced to below 31% and the cost of PRP was $270 per treatment (54). Given these considerations, further research is essential to fully evaluate the cost-effectiveness, outcomes, and potential complications associated with PRP augmentation in RCR.

There are several commercially available point-of-care biologic devices for PRP centrifugation with varying processing times, platelet concentration capabilities, and associated costs (55). For example, ProofPoint (ProofPoint Inc, Sunnyvale, CA, USA), is the most time-consuming system, as it requires manual transfer of blood products; however, it increases platelet count by fourfold (55). In contrast, AcCELLerated Biologics (AcCELLerated biologics, LLC, Tequesta, FL, USA), including the PurePRP^® AB60 pure and AbsolutePRP^® kits, achieves similar platelet concentrations to ProofPoint with a shorter processing time (55). The Arthrex Angel System (Arthrex, Naples, FL, USA) is an automated, one-button device that customizes PRP concentrations and, unlike other systems, eliminates the need for manual separation of PRP from whole blood. Celling Biosciences (Celling Biosciences, Austin, TX, USA) offers an autologous regenerative therapy PRP system that uses a nano-pore fiber technology to concentrate platelets and growth factors from whole blood. Lastly, the Terumo Blood and Cell Technologies (BCT) (Terumo Blood and Cell Technologies, Lakewood, Colorado) employs a dual-spin centrifugation process that not only captures CD34⁺ peripheral stem cells but also reduces the granulocyte population. However, the method of PRP preparation can vary significantly between devices, particularly with respect to single-spin versus double-spin methods. A study by Jildeh et al. examining these systems highlighted significant variability across devices and a lack of consensus on which method is superior (55). For instance, the single-spin method, typically quicker, may result in a higher concentration of white blood cells (WBCs), which could influence inflammation and healing (56). Conversely, the double-spin process, such as that used in Terumo BCT, is more time-consuming but yields a higher concentration of platelets with fewer WBCs, potentially leading to improved healing outcomes.

BMAC

BMAC is an emerging biological treatment option to augment RCR due to its ability to enhance healing by concentrating the patient’s own stem cells, which promote tendon regeneration and improve tendon-bone integration (57). BMAC involves harvesting stem cells from the patient’s own bone marrow and concentrating them before injecting them directly into the site of tendon damage, all of which can be performed intraoperatively. These stem cells can differentiate into mesenchymal tissues, including tendon tissue, thereby promoting healing and regeneration after RCR (58). It is believed that BMAC not only enhances the mechanical strength of the healing tendon but also improves the tendon-bone interface, facilitating better integration and overall repair quality (59). The autologous approach also minimizes immunogenicity and the risk of complications associated with graft rejection.

Although the literature on BMAC as an augmentation for RCR remains limited, existing studies show promising results. For example, Schoch et al. found that BMAC applied at the time of surgery was associated with a nearly three-fold reduction in the risk of revision surgery (59). Similarly, in a comparative study by Hernigou et al., 100% of patients who received BMAC showed healed repairs on MRI at 6 months post-surgery, compared to just 67% in the non-BMAC group. Furthermore, at 10 years follow-up, 87% of those treated with BMAC maintained intact repairs, compared to only 44% of those who did not receive BMAC (17). In another study by Cole et al., patients who received BMAC demonstrated significantly improved Sugaya scores on MRI at one-year follow-up (3.43 vs. 2.63; P<0.001) (60). A recent systematic review by Carola et al. confirmed that BMAC is a safe and effective intervention for RCR, with many studies reporting improved healing rates, reduced pain, and enhanced functional outcomes (57). However, the current literature on BMAC is characterized by significant heterogeneity in study design, surgical techniques, and BMAC preparation methods. As a result, further research is needed to standardize the administration methodology to better understand the long-term outcomes and optimal use of BMAC as an augmentation for RCR.

Fibrin clot

RCRs can also be augmented with an endogenous fibrin clot, a reservoir for growth factors, offering sustained release to the repair site, while also providing a scaffold for cell migration and supporting optimal cell function (61). Additionally, the fibrin clot facilitates healing by binding matrix proteins, such as fibronectin and thrombospondin, which further enhance the tissue repair process and the overall healing response. There has also been recent interest in the addition of BMAC to aid in tendon healing and bone marrow can be used to create the fibrin clot. Furthermore, the fibrin clot has the structural integrity to be sutured on top of the RCR.

Although the use of fibrin clots as an augmentation in RCR shows promise, there is limited literature evaluating its overall efficacy. For example, Voss et al. reported that 60% of patients who underwent revision RCR augmented with a fibrin clot technique showed significant improvements in clinical and functional outcomes at 1-year follow-up. However, the failure rate remained relatively high at 40%, highlighting the need for further investigation (18). In a study by Otto et al., RCR augmented with fibrin clots containing growth factors and progenitor cells from autologous blood and BMAC resulted in improvements in clinical outcomes, including in 83% of patients with RCR failure, underscoring the potential benefits of biologic augmentation (19). These improvements were seen in outcome scores such as VAS, ASES, Simple Shoulder Test (SST), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (all P<0.001). Despite 46% of patients experiencing retears on postoperative MRI, most were asymptomatic, with only one patient showing no improvement in pain or function. The study included high-risk patients, both in primary and revision cases, with a minimum follow-up of 1 year (19). These studies suggest that while fibrin clot augmentation shows potential, further research is required to optimize its application and assess long-term efficacy.

Conclusions

Rotator cuff tears remain a common and significant orthopedic injury, with successful repair crucial for restoring tendon integrity and function. Surgical augmentation techniques for RCR have evolved significantly and show promise in improving outcomes. This review has examined the current literature and clinical evidence for a range of augmentation methods, including structural, bioinductive, and hematologic approaches. Among these, dermal allografts and bioinductive collagen implants have gained popularity, while PRP and BMAC are emerging as promising adjuncts. Despite these encouraging findings, further high-quality studies are needed to address the existing heterogeneity in study designs, the lack of standardized protocols, and the absence of clear indications for specific augmentation techniques. Standardized protocols for preparation, administration, and outcome measures are essential to enhance the reliability and comparability of future studies. Moreover, the impact of these treatments on long-term functional outcomes, quality of life, and cost-effectiveness should be thoroughly evaluated to determine the most optimal treatment approach for patients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Ting Cong) for the series “Current Concepts and Techniques in Soft Tissue Repair and Joint Preservation” published in Annals of Joint. The article has undergone external peer review.

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-13/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-13/coif). The series “Current Concepts and Techniques in Soft Tissue Repair and Joint Preservation” was commissioned by the editorial office without any funding or sponsorship. C.M.C. has received a grant from Arthrex and hospitality payments from Stryker Corp and Encore Medical. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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