When to Consider Augmentation in Rotator Cuff Repair

Pictured above: Arthroscopic visualization of a completed rotator cuff repair augmented with a bovine collagen implant.

In rotator cuff repair, the challenge is not only achieving fixation but maintaining biologic tendon healing over time.

Repair failure remains a concern particularly for patients with large or chronic tears and poor-quality tendon tissue. As a result, augmentation has emerged as a strategy to enhance tendon healing.

“Early efforts to reduce retear rates focused on structurally stronger repairs via innovations in implant choice and repair technique,” says Cleveland Clinic orthopaedic surgeon Joseph Tramer, MD. “More recently, the focus has shifted to improving the biologic environment that helps tendons heal.”

When standard repair may not be enough

Dr. Tramer considers applying a graft or bioinductive implant when factors identified before or during surgery suggest the tendon is less likely to heal successfully after standard repair alone.

Factors that prompt him to consider augmentation include:

• Large or retracted tears. Larger tears and tears that require substantial tension to restore the tendon to the footprint are at higher risk for failure. These tears also are more likely to be associated with muscle atrophy and poor tendon quality.
• Chronic tears. Longer-standing tears are more likely to show muscle atrophy and fatty infiltration, both of which reduce the likelihood of durable healing.
• Poor healing biology. Older age, diabetes and smoking are among the factors associated with decreased blood flow and reduced healing capacity.
• High-demand patients. Patients whose work or activities place substantial stress on the shoulder may benefit from added reinforcement.

Many of these variables are incorporated into the Rotator Cuff Healing Index (RoHI), which can help quantify the risk of healing failure. Dr. Tramer uses the score during preoperative counseling, but the final decision to use augmentation is often made during surgery after assessing tendon quality, thickness, mobility and repair tension.

A range of biologic and structural options

There are various types of grafts available for rotator cuff augmentation. Dr. Tramer most often uses two categories:

• Bovine collagen implant. These implants are intended primarily to enhance biology by introducing collagen to the area. Early research suggests they may help lower retear rates following rotator cuff repair. These implants are relatively straightforward to apply but provide less structural reinforcement than other grafts.
• Human dermal allograft. This option is used when additional structural support is needed, particularly in larger or more retracted tears or when tissue quality is poor. Dermal allografts are mechanically more robust but generally more technically demanding to apply.

“We have access to a range of augmentation options and can tailor graft choice to tear pattern, tissue quality and patient-specific healing risk,” Dr. Tramer says.

Augmentation in practice

At Cleveland Clinic, augmentation is used selectively rather than routinely.

Dr. Tramer first performs a standard arthroscopic repair with anchors and sutures. He then determines whether the repair would benefit from additional support based on the appearance and behavior of the tendon at the time of surgery.

“If I’m concerned that the tendon will need more support to heal back to bone, I utilize augmentation over the repaired tendon and secure it arthroscopically,” he says.

He emphasizes that augmentation is an adjunct to a repairable cuff tear, not a substitute for sound repair technique or a solution for every irreparable tear. However, having multiple graft options has expanded the range of patients who may be candidates for repair.

“Augmentation has increased my confidence in repairing some tears for which I previously may have recommended arthroplasty or other salvage options,” Dr. Tramer says. “It gives us another tool for patients with higher-risk tears or less favorable biology.”

Use in partial-thickness tears

Augmentation also may have a role in selected partial-thickness tears.

Historically, treatment options for symptomatic partial tears that failed conservative management were often limited to debridement or conversion to full-thickness takedown and repair. Bioinductive implants may offer an intermediate option by being placed over the diseased tendon to support healing without completing the tear.

“For selected symptomatic partial-thickness tears, this can provide a useful middle ground and may allow a faster recovery than takedown and repair,” Dr. Tramer says.

The unanswered question: Will improved healing justify the cost?

While augmentation is not necessary for every patient, having access to the full treatment spectrum — including standard repair, augmented repair, bioinductive treatment for partial tears and arthroplasty — can help surgeons better match treatment to pathology and healing risk.

Although augmentation adds cost, its use is increasing as evidence of improved healing grows. Whether that leads to better long-term outcomes, fewer revisions or greater value is uncertain.

“Some studies show lower retear rates with augmentation, but improved healing doesn’t always translate into better patient-reported outcomes in the short term,” Dr. Tramer says. “The key question is whether better healing leads to better long-term function, durability and value. Those answers will require longer follow-up.”