Surgical management of rotator cuff tears is controversial and complex, ranging from nonoperative management to reverse shoulder arthroplasty.
Purpose:
To systematically review and evaluate the outcomes of graft augmentation or interposition versus rotator cuff repair (RCR) alone and evaluate via meta-analysis whether the use of a graft leads to superior outcomes versus RCR alone.
Study Design:
Systematic review and meta-analysis.
Methods:
An electronic literature search (Medline, Embase, CINAHL) was conducted. Studies with a minimum follow-up of 1 year and minimum sample size of 10 that provided clinical results of RCR or rotator cuff reconstruction using any type of augmentation tissue or matrix were included. Methodological quality was evaluated by assessment of the risk of bias in the included studies. Studies comparing outcomes of RCR with graft augmentation or interposition versus repair alone (control group) were subjected to meta-analysis.
Results:
The authors identified 774 articles and included 36 in the systematic review; 5 of the 36 studies underwent meta-analysis. Except for one outcome measure in a single study, all surgical interventions (RCR alone, RCR with augmentation, and RCR with interposition) improved clinical scores and outcome measures. Because of variability in study outcomes, no graft option was found to be superior. Compared with RCR alone, graft augmentation or interposition provided significantly lower retear rates (P = .05) and higher American Shoulder and Elbow Surgeons (ASES) scores (P = .005), but improvements in UCLA (University of California, Los Angeles) scores (P = .29) and pain scores (P = .1) did not reach statistical significance.
Conclusion:
In the meta-analysis, graft augmentation or interposition appeared to provide a lower retear rate and improved ASES scores when compared with RCR alone. Future prospective, randomized, controlled, and appropriately powered trials are needed for more definitive recommendations.
AgrawalV. Healing rates for challenging rotator cuff tears utilizing an acellular human dermal reinforcement graft. Int J Shoulder Surg. 2012;6(2):36-44.
2.
AudenaertEVan NuffelJSchepensAVerhelstMVerdonkR. Reconstruction of massive rotator cuff lesions with a synthetic interposition graft: a prospective study of 41 patients. Knee Surg Sports Traumatol Arthrosc. 2006;14(4):360-364.
3.
BadheSPLawrenceTMSmithFDLunnPG. An assessment of porcine dermal xenograft as an augmentation graft in the treatment of extensive rotator cuff tears. J Shoulder Elbow Surg. 2008;17(suppl 1):35S-39S.
4.
BarberFABurnsJPDeutschALabbeMRLitchfieldRB. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012;28(1):8-15.
5.
BektaserBOcguderASolakSGonenEYalcinNKilicarslanK. Free coracoacromial ligament graft for augmentation of massive rotator cuff tears treated with mini-open repair. Acta Orthop Traumatol Turc. 2010;44(6):426-430.
6.
BishopJKleppsSLoIKBirdJGladstoneJNFlatowEL. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg. 2006;15(3):290-299.
7.
BoileauPBrassartNWatkinsonDJCarlesMHatzidakisAMKrishnanSG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?J Bone Joint Surg Am. 2005;87(6):1229-1240.
8.
BondJLDopirakRMHigginsJBurnsJSnyderSJ. Arthroscopic replacement of massive, irreparable rotator cuff tears using a GraftJacket allograft: technique and preliminary results. Arthroscopy. 2008;24(4):403-409.
9.
BurkhartSS. Arthroscopic debridement and decompression for selected rotator cuff tears: clinical results, pathomechanics, and patient selection based on biomechanical parameters. Orthop Clin North Am. 1993;24(1):111-123.
10.
BurkheadWZJrSchiffernSCKrishnanSG. Use of graft jacket as an augmentation for massive rotator cuff tears. Semin Arthroplasty. 2007;18(1):11-18.
11.
CelliLRovestaCMarongiuMCManzieriS. Transplantation of teres major muscle for infraspinatus muscle in irreparable rotator cuff tears. J Shoulder Elbow Surg. 1998;7(5):485-490.
12.
ChoNSYiJWRheeYG. Arthroscopic biceps augmentation for avoiding undue tension in repair of massive rotator cuff tears. Arthroscopy. 2009;25(2):183-191.
13.
ChungSWKimJYKimMHKimSHOhJH. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med. 2013;41(7):1674-1683.
14.
CiampiPScottiCNonisAet 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(5):1169-1175.
15.
ColeBJMcCartyLPIIIKangRWAlfordWLewisPBHaydenJK. Arthroscopic rotator cuff repair: prospective functional outcome and repair integrity at minimum 2-year follow-up. J Shoulder Elbow Surg. 2007;16(5):579-585.
16.
ColemanSHFealySEhteshamiJRet al. Chronic rotator cuff injury and repair model in sheep. J Bone Joint Surg Am. 2003;85(12):2391-2402.
17.
ConstantCRMurleyAH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160-164.
18.
DeFrancoMJBershadskyBCicconeJYumJKIannottiJP. Functional outcome of arthroscopic rotator cuff repairs: a correlation of anatomic and clinical results. J Shoulder Elbow Surg. 2007;16(6):759-765.
19.
Encalada-DiazIColeBJMacgillivrayJDet al. Rotator cuff repair augmentation using a novel polycarbonate polyurethane patch: preliminary results at 12 months’ follow-up. J Shoulder Elbow Surg. 2011;20(5):788-794.
20.
FergusonDPLewingtonMRSmithTDWongIH. Graft utilization in the augmentation of large-to-massive rotator cuff repairs: a systematic review. Am J Sports Med. 2016;44(11):2984-2992.
21.
FlurinPHLandreauPGregoryTet al. Arthroscopic repair of full-thickness cuff tears: a multicentric retrospective study of 576 cases with anatomical assessment [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2005;91(S8):31-42.
22.
FuchsBWeishauptDZanettiMHodlerJGerberC. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8(6):599-605.
23.
GalatzLMBallCMTeefeySAMiddletonWDYamaguchiK. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219-224.
24.
GartsmanGM. Massive, irreparable tears of the rotator cuff: results of operative debridement and subacromial decompression. J Bone Joint Surg Am. 1997;79(5):715-721.
25.
GerberC. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res. 1992;275:152-160.
26.
GerberCFuchsBHodlerJ. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82(4):505-515.
27.
GilotGJAlvarez-PinzonAMBarcksdaleLWesterdahlDKrillMPeckE. Outcome of large to massive rotator cuff tears repaired with and without extracellular matrix augmentation: a prospective comparative study. Arthroscopy. 2015;31(8):1459-1465.
28.
GoutallierDPostelJMBernageauJLavauLVoisinMC. Fatty muscle degeneration in cuff ruptures: pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78-83.
29.
GuptaAKHugKBerkoffDJet al. Dermal tissue allograft for the repair of massive irreparable rotator cuff tears. Am J Sports Med. 2012;40(1):141-147.
30.
GuptaAKHugKBoggessBGaviganMTothAP. Massive or 2-tendon rotator cuff tears in active patients with minimal glenohumeral arthritis: clinical and radiographic outcomes of reconstruction using dermal tissue matrix xenograft. Am J Sports Med. 2013;41(4):872-879.
31.
HanuschBCGoodchildLFinnPRanganA. Large and massive tears of the rotator cuff: functional outcome and integrity of the repair after a mini-open procedure. J Bone Joint Surg Br. 2009;91(2):201-205.
32.
HarrymanDTIIMackLAWangKYJackinsSERichardsonMLMatsenFAIII. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73(7):982-989.
33.
HirookaAYonedaMWakaitaniSet al. Augmentation with a Gore-Tex patch for repair of large rotator cuff tears that cannot be sutured. J Orthop Sci. 2002;7(4):451-456.
34.
IannottiJPCodsiMJKwonYWDerwinKCicconeJBremsJJ. 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(6):1238-1244.
35.
JonesCKSavoieFHIII. Arthroscopic repair of large and massive rotator cuff tears. Arthroscopy. 2003;19(6):564-571.
36.
JonesCRSnyderSJ. Massive irreparable rotator cuff tears: a solution that bridges the gap. Sports Med Arthrosc. 2015;23(3):130-138.
37.
KimJRChoYSRyuKJKimJH. Clinical and radiographic outcomes after arthroscopic repair of massive rotator cuff tears using a suture bridge technique: assessment of repair integrity on magnetic resonance imaging. Am J Sports Med. 2012;40(4):786-793.
38.
KleppsSBishopJLinJet al. Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs. Am J Sports Med. 2004;32(7):1716-1722.
39.
KonakciKZBohleBBlumerRet al. Alpha-Gal on bioprostheses: xenograft immune response in cardiac surgery. Eur J Clin Invest. 2005;35(1):17-23.
40.
LedermanESTothAPNicholsonGPet al. A prospective, multicenter study to evaluate clinical and radiographic outcomes in primary rotator cuff repair reinforced with a xenograft dermal matrix. J Shoulder Elbow Surg. 2016;25(12):1961-1970.
41.
LenartBAMartensKAKearnsKAGillespieRJZogaACWilliamsGR. Treatment of massive and recurrent rotator cuff tears augmented with a poly-L-lactide graft, a preliminary study. J Shoulder Elbow Surg. 2015;24(6):915-921.
42.
LiuSHBakerCL. Arthroscopically assisted rotator cuff repair: correlation of functional results with integrity of the cuff. Arthroscopy. 1994;10(1):54-60.
43.
MetcalfMSavoieFIIIKellumB. Surgical technique for xenograft (SIS) augmentation of rotator-cuff repairs. Oper Tech Orthop. 2002;12(3):204-208.
44.
MihataTLeeTQWatanabeCet al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013;29(3):459-470.
45.
MikasaM. Trapezius transfer for global tear of the rotator cuff. In: BatemanJ, ed. Surgery of the Shoulder. Philadelphia, PA: Decker; 1984:196-199.
46.
MiniaciAMacLeodM. Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff: a two to five-year review. J Bone Joint Surg Am. 1999;81(8):1120-1127.
47.
MoherDLiberatiATetzlaffJAltmanDG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-1012.
48.
MoriDFunakoshiNYamashitaF. 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(12):1911-1921.
49.
MoriDFunakoshiNYamashitaFWakabayashiT. Effect of fatty degeneration of the infraspinatus on the efficacy of arthroscopic patch autograft procedure for large to massive rotator cuff tears. Am J Sports Med. 2015;43(5):1108-1117.
50.
NadaANDebnathUKRobinsonDAJordanC. Treatment of massive rotator-cuff tears with a polyester ligament (Dacron) augmentation: clinical outcome. J Bone Joint Surg Br. 2010;92(10):1397-1402.
51.
NeriBRChanKWKwonYW. Management of massive and irreparable rotator cuff tears. J Shoulder Elbow Surg. 2009;18(5):808-818.
52.
NeumannJAZgonisMHRickertKDet al. Interposition dermal matrix xenografts: a successful alternative to traditional treatment of massive rotator cuff tears. Am J Sports Med. 2017;45(6):1261-1268.
53.
OnoYDavalos HerreraDAet al. Can grafts provide superior tendon healing and clinical outcomes after rotator cuff repairs? A meta-analysis. Orthop J Sports Med. 2016;4(12):2325967116674191.
54.
OzakiJFujimotoSMasuharaKTamaiSYoshimotoS. Reconstruction of chronic massive rotator cuff tears with synthetic materials. Clin Orthop Relat Res. 1986;202:173-183.
55.
PapadopoulosPKarataglisDBoutsiadisAFotiadouAChristoforidisJChristodoulouA. Functional outcome and structural integrity following mini-open repair of large and massive rotator cuff tears: a 3-5 year follow-up study. J Shoulder Elbow Surg. 2011;20(1):131-137.
56.
PapaliaRFranceschiFZampognaBD’AdamioSMaffulliNDenaroV. Augmentation techniques for rotator cuff repair. Br Med Bull. 2013;105:107-138.
57.
PetriMWarthRJHoranMPGreenspoonJAMillettPJ. Outcomes after open revision repair of massive rotator cuff tears with biologic patch augmentation. Arthroscopy. 2016;32(9):1752-1760.
58.
PetrieMJIsmaielAH. Treatment of massive rotator-cuff tears with a polyester ligament (LARS) patch. Acta Orthop Belg. 2013;79(6):620-625.
59.
PhipatanakulWPPetersenSA. Porcine small intestine submucosa xenograft augmentation in repair of massive rotator cuff tears. Am J Orthop (Belle Mead NJ). 2009;38(11):572-575.
60.
ProctorCS. Long-term successful arthroscopic repair of large and massive rotator cuff tears with a functional and degradable reinforcement device. J Shoulder Elbow Surg. 2014;23(10):1508-1513.
61.
RheeYGChoNSLimCTYiJWVishvanathanT. Bridging the gap in immobile massive rotator cuff tears: augmentation using the tenotomized biceps. Am J Sports Med. 2008;36(8):1511-1518.
62.
RockwoodCAJrWilliamsGRJrBurkheadWZJr. Debridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg Am. 1995;77(6):857-866.
63.
RodeoSAArnoczkySPTorzilliPAHidakaCWarrenRF. Tendon-healing in a bone tunnel: a biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993;75(12):1795-1803.
SanoHMinetaMKitaAItoiE. Tendon patch grafting using the long head of the biceps for irreparable massive rotator cuff tears. J Orthop Sci. 2010;15(3):310-316.
66.
ScheibelMBrownAWoertlerKImhoffAB. Preliminary results after rotator cuff reconstruction augmented with an autologous periosteal flap. Knee Surg Sports Traumatol Arthrosc. 2007;15(3):305-314.
67.
SearsBWChooAYuAGreisALazarusM. Clinical outcomes in patients undergoing revision rotator cuff repair with extracellular matrix augmentation. Orthopedics. 2015;38(4):e292-e296.
68.
SteinhausMEMakhniECColeBJRomeoAAVermaNN. Outcomes after patch use in rotator cuff repair. Arthroscopy. 2016;32(8):1676-1690.
69.
StoneKRAyalaGGoldsteinJHurstRWalgenbachAGaliliU. Porcine cartilage transplants in the cynomolgus monkey, III: transplantation of alpha-galactosidase-treated porcine cartilage. Transplantation. 1998;65(12):1577-1583.
70.
StoneKRWalgenbachAWTurekTJSomersDLWicombWGaliliU. Anterior cruciate ligament reconstruction with a porcine xenograft: a serologic, histologic, and biomechanical study in primates. Arthroscopy. 2007;23(4):411-419.
71.
SugayaHMaedaKMatsukiKMoriishiJ. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953-960.
72.
van TulderMFurlanABombardierCBouterL; Editorial Board of the Cochrane Collaboration Back Review Group. Updated method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group. Spine (Phila Pa 1976). 2003;28(12):1290-1299.
73.
VenouziouAIKokkalisZTSotereanosDG. Human dermal allograft interposition for the reconstruction of massive irreparable rotator cuff tears. Am J Orthop (Belle Mead NJ). 2013;42(2):63-70.
74.
VisuriTKiviluotoOEskelinM. Carbon fiber for repair of the rotator cuff: a 4-year follow-up of 14 cases. Acta Orthop Scand. 1991;62(4):356-359.
75.
VitaliMCusumanoAPedrettiANaim RodriguezNFraschiniG. Employment of synthetic patch with augmentation of the long head of the biceps tendon in irreparable lesions of the rotator cuff: our technique applied to 60 patients. Tech Hand Up Extrem Surg. 2015;19(1):32-39.
76.
WaltonJRBowmanNKKhatibYLinklaterJMurrellGA. Restore orthobiologic implant: not recommended for augmentation of rotator cuff repairs. J Bone Joint Surg Am. 2007;89(4):786-791.
77.
WiaterJMMoravekJEJrBudgeMDKoueiterDMMarcantonioDWiaterBP. Clinical and radiographic results of cementless reverse total shoulder arthroplasty: a comparative study with 2 to 5 years of follow-up. J Shoulder Elbow Surg. 2014;23(8):1208-1214.
78.
WilliamsGRJrRockwoodCAJrBiglianiLUIannottiJPStanwoodW. Rotator cuff tears: why do we repair them?J Bone Joint Surg Am. 2004;86(12):2764-2776.
79.
WilsonEB. Probable inference, the law of succession, and statistical inference. J Am Stat Assoc. 1927;22:209-212.
YamaguchiHSuenagaNOizumiNHosokawaYKanayaF. Open repair for massive rotator cuff tear with a modified transosseous-equivalent procedure: preliminary results at short-term follow-up. J Orthop Sci. 2011;16(4):398-404.
82.
YamamotoATakagishiKOsawaTet al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19(1):116-120.
83.
ZhengMHChenJKirilakYWillersCXuJWoodD. Porcine small intestine submucosa (SIS) is not an acellular collagenous matrix and contains porcine DNA: possible implications in human implantation. J Biomed Mater Res B Appl Biomater. 2005;73(1):61-67.
84.
ZumsteinMAJostBHempelJHodlerJGerberC. The clinical and structural long-term results of open repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2008;90(11):2423-2431.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
