Rotator Cuff Repair With Bone Marrow Stimulation Versus Rotator Cuff Repair With Patch Augmentation: A Systematic Review

Abstract

Background:

Bone marrow stimulation (BMS) and patch augmentation (PA) are 2 adjuncts used during rotator cuff repair (RCR) to support the repair construct and promote healing.

Purpose:

To systematically review the literature to compare the clinical efficacy and retear rate outcomes of RCR with PA versus RCR with BMS.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

A systematic review was conducted by searching the PubMed, the Cochrane Library, and Embase databases to identify Level 1 and 2 studies that compared the clinical efficacy of RCR alone with RCR plus BMS or RCR plus PA. The search phrase used was rotator cuff repair AND (patch OR augmentation OR bioinductive OR implant OR bone marrow stimulation OR microfracture OR crimson duvet OR BMS). Patients were assessed based on the visual analog scale for pain, the Constant-Murley score, the American Shoulder and Elbow score, and retear rates.

Results:

Twenty studies (Level 1 or 2) met the inclusion and exclusion criteria, including 351 patients undergoing RCR with PA (mean age, 60 years) and 475 patients undergoing RCR with BMS (mean age, 59.9 years). The mean follow-up time was 20.6 months in the PA group and 21.1 months in the BMS group. None of the included studies directly compared PA and BMS, and there were no significant differences in weighted improvements among patient-reported outcomes from pre- to postoperative values between augmentation groups. Patients undergoing RCR with PA demonstrated no significant difference in retear rates at the latest follow-up compared with patients undergoing RCR with BMS. High heterogeneity among the included studies in the augmentation technique and tear grade was noted.

Conclusion:

Patients undergoing RCR with PA or BMS have demonstrated similar improvements in both patient-reported and functional outcomes. Further randomized controlled studies are needed to directly compare these 2 RCR augmentation groups, as well as compare different patch types and different BMS techniques.

Keywords

bone marrow stimulation patch shoulder rotator cuff repair

Rotator cuff tears are a common shoulder injury that can cause pain, weakness, and shoulder dysfunction, with a prevalence of around 20% in the population.^26,37,52 In the United States, rotator cuff repair (RCR) is one of the most common orthopaedic surgeries, with approximately 200,000 to 250,000 RCRs performed annually, and the procedure is increasingly performed among patients aged 50 to 64 years.^13,35,54 RCR has been shown to improve functional outcomes and patient satisfaction significantly and is the standard of care for surgical repair of the rotator cuff.^25,35,51 However, retear rates have varied widely, ranging from 9% to 41%.^‡ In recent years, multiple adjuncts to RCR have been used to improve outcomes and reduce retear rates. Among these interventions are patch augmentation (PA) and bone marrow stimulation (BMS).

PA during RCR has been increasing in popularity, particularly for large and massive tears.³ A patch can be made of various biological degradable and nondegradable materials and is placed over the repaired rotator cuff tendon as a mechanical support to enhance the repair construct.³⁴ Depending on the materials utilized, PA can promote vascularization and cellular growth, encouraging tendon-to-bone healing as it infiltrates tissue cells at the repair site.^1,9,10,17 The increasing popularity of PA during RCR is supported by multiple studies demonstrating lower retear rates and improved clinical outcomes in patients undergoing RCR with PA versus RCR alone.^6,16,38 Similarly, BMS is another biological option used to enhance tendon healing in RCR, as it stimulates the body's natural healing processes.^30,31,49 BMS is performed by inserting multiple small holes or channels, commonly within the greater tuberosity footprint, to expose mesenchymal stem cells and growth factors from the bone marrow to the RCR site. Some previous studies have found that RCR with BMS demonstrates improved long-term healing rates compared with RCR alone.^36,44 Another study analyzed the effect of using both methods versus an RCR-only control group.⁵⁶ However, to our knowledge, the superiority of PA versus BMS in the setting of RCR has not been studied. Therefore, this study aimed to systematically review the literature to compare the efficacy and safety of RCR with PA and RCR with biological augmentation of BMS. The authors hypothesized that there would be no significant difference in outcomes and retear rates between the 2 groups.

Methods

This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a PRISMA checklist. Two independent reviewers (J.J.L. and E.C.M.) searched the PubMed, Embase, and the Cochrane Library database up to December 10, 2025. The electronic search strategy used was as follows: rotator cuff repair AND (“patc”; OR“augmentatio”; OR “bioinductiv”; OR “implan”; OR “bone marrow stimulation”; OR “microfractur”; OR “crimson duve”; OR “bm”). A total of 650 studies were reviewed by title and/or abstract to determine study eligibility based on inclusion criteria. In cases of disagreement, a third reviewer (J.W.B.) made the final decision. The inclusion and exclusion criteria followed the PICOS (participants, interventions, comparators, outcomes, and study design) framework. Studies selected for inclusion met the following criteria: (1) participants: patients undergoing arthroscopic RCR; (2) intervention: PA or BMS; (3) comparator: no augmentation; (4) outcomes: clinical efficacy and adverse events; (5) study design: Level 1 and 2 randomized controlled trials (RCTs) that were published in English. The exclusion criteria included Level 3 to 5 studies that did not meet the inclusion criteria and studies that did not have a minimum of 1-year follow-up. Data extraction from each study was performed independently and then reviewed by a second author (J.W.B.). There was no need for funding or a third party to obtain any of the data collected. Risk of bias was assessed using the Cochrane Collaboration's risk of bias tool,²⁰ which incorporates assessments of randomization, blinding, completeness of outcome data, selection of reported outcomes, and other sources of bias.

Reporting Outcomes

Outcomes assessed included patient-reported outcomes (PROs). PROs included the visual analog scale (VAS) for pain, the Constant-Murley (CM) score,¹⁴ and the American Shoulder and Elbow Surgeons (ASES) score.⁴² The primary complication assessed was RCR rates.

Study Methodology Assessment

The Modified Coleman Methodology Score (MCMS)¹² was used to evaluate the quality of the study methodology. The MCMS has a potential score ranging from 0 to 100. Scores ranging from 85 to 100 are excellent, 70 to 84 are good, 55 to 69 are fair, and <55 are poor. The primary outcomes assessed by the MCMS include study size and type, follow-up time, attrition rates, the number of interventions per group, and a proper description of the study methodology.

Statistical Analysis

Descriptive statistics for numerical demographic characteristics (age and follow-up) and PROs were calculated as weighted means to account for differences in sample sizes across included studies. Weighted means were calculated using the formula: $w . a . = \frac{\sum (n_{i} * x_{i})}{\sum (n_{i})}$ . Where n_i is the sample size of the i^th study, and x_i is the mean value of the variable in the i^th study. Percent improvement for each outcome was calculated using the formula: $p . i . = (\frac{Post - op w . a .}{Pre - op w . a .} - 1) * 100$ , where “post-op w.a.” and “pre-op w.a.” refer to the weighted mean of an augmentation group for a given outcome. In the cases where standard deviations were not provided, a quarter of the mean was used as the standard deviation.^21,23,24 A chi-square test was used to assess the statistical significance of RCR rates between the 2 groups. To compare the postoperative percent improvement between groups for PROs, a 2-sample weighted t test was performed using the {weights} package in R⁴⁰ (R Foundation for Statistical Computing), with weights proportional to each contributing study's sample size. Statistical significance was set as $a < . 05 .$

Results

Twenty studies met the inclusion and exclusion criteria (Figure 1), including 826 patients (PA: n = 351; BMS: n = 475). The mean patient age at the time of repair was 60 and 59.9 years in the PA and BMS groups, respectively, and the mean follow-up time was 20.6 months in the PA group and 21.1 months in the BMS group (Table 1). The percentages of men were 53.8% and 53.7% in the PA and BMS groups, respectively.

Figure 1.

PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1

Studies Included ^a

Study (Year)	Augmentation Method	N	Patient Age, Years	Follow-up, Months	Sex Distribution, % Male
Patch
Avanzi et al² (2019)	Porcine dermal patch	46	68 (58-78)	24	30.4
Barber et al⁴ (2012)	Acellular human dermal matrix	22	56 (43-69)	12	81.8
Bryant et al⁵ (2016)	Porcine small intestine submucosa	34	55.3 ± 11.3	24	85.3
Cai et al⁶ (2018)	3D biological collagen	54	62.9 ± 9.7	24	47.1
Camacho Chacon et al⁷ (2024)	Regeneten bioinductive implant	30	54.2 ± 2.4	24	46.7
Iannotti et al²³ (2006)	Porcine small intestine submucosa	15	58	12	73.3
Ide et al²⁴ (2017)	Recombinant human bone morphogenetic protein-12/absorbable collagen sponge	16	61 (48-71)	12	60
Kim et al²⁷ (2024)	Porcine-derived absorbable patch-type atelocollagen	31	62.5 ± 7	12	58.6
Lee et al³² (2022)	Human dermal matrix	22	60.2 ± 8.4	60	31.8
Ruiz et al⁴³ (2024)	Regeneten bioinductive implant	61	56.6 ± 6.9	12	51.7
Snow et al⁴⁸ (2023)	Human dermal allograft patch	20	62.4 (47-73)	12	60
Total	-	351	60	20.6	54.1
BMS
Hong et al²¹ (2024)	Bone channelling	103	60.1 (30-75)	24	47.6
Lapner et al³¹ (2021)	Bone channelling	41	58.8 ± 8.8	24	31.7
Lapner et al³⁰ (2023)	Bone channelling	84	60 ± 8.1	24	69.1
Milano et al³⁶ (2013)	Microfractures	35	60.6 ± 10.1	28	62.9
Osti et al³⁹ (2013)	Microfractures	28	61.2 (38-73)	12	57.1
Ruiz et al⁴⁴ (2021)	Nanofractures	36	60.1 ± 7.9	12	38.9
Shibata et al⁴⁶ (2023)	Bone channelling	30	63.9 ± 9.5	24	86.7
Toro et al⁵⁰ (2022)	Microfractures	62	58.9 ± 7.7	12	56.6
Yang et al⁵³ (2025)	Microfractures	56	57.6 ± 6.6	24	39.2
Total	-	475	59.9	21.1	53.7

Patient age is reported as a mean ± SD (if available) or (range). Follow-up duration is reported as a minimum follow-up, and the “total” row is reported as a weighted mean. BMS, bone marrow stimulation; 3D, 3-dimensional.

BMS Preparation and Administration Method

All 9 studies^§ described details of BMS administration. Various awls were used to stimulate bone marrow. In 8 studies^{21,30,36,39,44,46,50,53} (88.9%), the distance between holes ranged from 3 to 5 mm; only Lapner et al³¹ used a smaller distance of 1 mm. Eight studies featured a hole diameter of 1 to 2 mm.^{21,30,31,36,39,44,46,50} One study reported a hole diameter of 5 mm.⁵³ Six studies^{21,30,31,36,46,50} (66.7%) reported a hole depth of 3 to 5 mm; 2 studies^39,53 reported a shallower depth of 1-4 mm, while the other⁴⁴ reported a greater depth of 9 mm. The studies varied slightly in the description of the location of drilling, either placing the BMS holes at the greater tuberosity,^21,36,39,53 at the metaphyseal bone region of the humerus,^30,31 or simply defined as at the location of the anchor/footprint region.^44,46

Tear Type

Four studies^2,7,21,43 included patients with small and medium rotator cuff tears. Two studies^21,53 included patients with small, medium, and large tears. Eight studies^{5,6,24,27,39,43,46,48} included patients with medium or large tears. Two studies^4,32 included only patients with large tears. One study²³ included patients with large or massive tears. Four studies^30,31,36,50 did not report the tear size inclusion criteria; 2 of these studies^30,31 reported the mean coronal and sagittal tear sizes for their BMS group. One study³¹ reported the tear size mean to be 1.9 cm sagittal and 2.3 cm coronal, and the other study³⁰ reported the tear size mean to be 2.1 cm sagittal and 2 cm coronal, thereby characterizing them as a medium tear⁵⁵ (Table 2).

Table 2

Tear Size Included ^a

Study	Small	Medium	Large	Massive
Patch
Avanzi et al² (2019)	+	+	–	–
Barber et al⁴ (2012)	–	–	22	–
Bryant et al⁵ (2016)	–	+	+	–
Cai et al⁶ (2018)	–	+	+	–
Camacho Chacon et al⁷ (2024)	18	12	–	–
Iannotti et al²³ (2006)	–	–	4	11
Ide et al²⁴ (2017)	–	11	5	–
Kim et al²⁷ 2024	–	11	18	–
Lee et al³² (2022)	–	–	22	–
Ruiz et al⁴³ (2024)	–	+	+	–
Snow et al⁴⁸ (2023)	–	7	13	–
BMS
Hong et al²¹ (2024)	14	62	27	–
Lapner et al³¹ (2021)
Lapner et al³⁰ 2023
Milano et al³⁶ (2013)
Osti et al³⁹ (2013)	–	+	+	–
Ruiz et al⁴⁴ (2021)	+	+	–	–
Shibata et al⁴⁶ (2023)	–	22	8	–
Toro et al⁵⁰ (2022)
Yang et al⁵³ (2025)	23	26	7	–

+The study included patients with corresponding tear sizes, but the quantity was not reported. –The study did not include patients with corresponding tear size. BMS, bone marrow stimulation.

Modified Coleman Methodology Score

Table 3 shows the MCMS scores from the 20 included studies. 8 studies^{4-7,27,32,36,43} received excellent scores and 12 studies received good scores.^‖

Table 3

Modified Coleman Methodology Score ^a

Study (Year)	MCMS Score
Patch
Avanzi et al² (2019)	84
Barber et al⁴ (2012)	88
Bryant et al⁵ (2016)	86
Cai et al⁵ (2018)	90
Camacho Chacon et al⁷ (2024)	91
Iannotti et al²³ (2006)	82
Ide et al²⁴ (2017)	79
Kim et al²⁷ (2024)	91
Lee et al³² (2022)	92
Ruiz et al⁴³ (2024)	94
Snow et al⁴⁸ (2023)	83
Mean	87.3 ± 4.6
BMS
Hong et al²¹ (2024)	82
Lapner et al³¹ (2021)	79
Lapner et al³⁰ (2023)	79
Milano et al³⁶ (2013)	87
Osti et al³⁹ (2013)	81
Ruiz et al⁴⁴ (2021)	83
Shibata et al⁴⁶ (2023)	78
Toro et al⁵⁰ (2022)	78
Yang et al⁵³ (2025)	82
Mean	81 ± 2.7
Total mean, both	84.5 ± 5

Data are presented as mean ± SD, unless otherwise indicated. BMS, bone marrow stimulation; MCMS, Modified Coleman Methodology Score.

Methodologic Quality Assessment

The results of the methodologic quality assessment of included studies using the Cochrane Collaboration's risk of bias tool are presented in Figure 2. Sequence generation was adequately reported by all studies (low risk of bias). In all studies, concealment of allocation was appropriately reported (low risk of bias). All studies were deemed to be at low risk of detection bias because the outcome assessor was blinded, except for 3 studies,^6,27,39 in which the outcome assessor was not blinded (high risk of bias). Patients in most studies were blinded to their intervention group (low risk of bias), except in 6 studies,^{2,7,30,31,44,48} in which patients were aware of their treatment group (high risk of bias). Five studies^{4,21,43,50,53} reported minor loss of follow-up of 10% and 20% without proper explanation (unclear risk of bias), whereas no other studies reported significant loss of follow-up (low risk of bias).

Figure 2.

Risk of bias graph. Risk of bias is presented as a percentage across all included studies (green: low risk; yellow: unclear; red: high risk).

Patient-Reported Outcomes

Eight studies^{2,7,21,24,27,30,44,53} used the VAS, in which all scores were standardized to a 100-point scale (4 studies PA,^2,7,24,27 4 studies BMS^21,30,44,53) (Table 4). Of the 4 studies using RCR with PA, 1 study²⁷ (25%) reported P values for pre- to postoperative scores. This study found patients receiving RCR with PA to report significantly less pain from preoperative to the latest follow-up. One of 4 studies (25%) using RCR with BMS reported significant P values for pre- to postoperative scores.⁵³ No significant difference was observed between groups when comparing the percent weighted improvement from pre- to postoperative values (P = .45).

Table 4

VAS Scores for Pain Severity ^a

Study (Year)	Preop	Postop	Percent Improvement
Patch
Avanzi et al² (2019)	64.7 ± 21.2	4 ± 7.7	93.8
Camacho Chacon et al⁷ (2024)	68 ± 6	2 ± 5	97.1
Ide et al²⁴ (2017)	37.9 ± 30.3	13.8 ± 25.6	63.6
Kim et al²⁷ (2024)	41 ± 18	18 ± 16	56.1
Total weighted value	56.3	8.2	85.1
BMS
Hong et al²¹ (2024)	41 ± 10.3	9 ± 2.3	78
Lapner et al³⁰ (2023)	48 ± 27	9 ± 16	81.3
Ruiz et al⁴⁴ (2021)	39 ± 19	22 ± 21	43.6
Yang et al⁵³ (2025)	43 ± 20	14 ± 19	67.4
Total weighted value	43.3	11.1	74
P			.55

Scores are reported as mean ± SD at the latest follow-up, with the total weighted mean/improvement row reported as the weighted mean of pre- and postoperative scores and the weighted percent improvement from pre- to postoperative scores. The P value represents the weighted t test result between the weighted percent improvements of both groups. BMS, bone marrow stimulation; Postop, postoperative; Preop, preoperative; VAS, visual analog scale.

Sixteen studies^¶ used the CM score (7 studies PA,^{2,4-6,23,27,48} 9 studies BMS^§) (Table 5). Of the 7 studies using RCR with PA, 4 studies^2,6,27,32 (57.1%) reported P values on pre- to postoperative scores. All 4 studies found that patients receiving RCR with PA improved significantly from preoperative to the latest follow-up. Of the 9 studies utilizing RCR with BMS, 7 studies^{21,30,31,39,44,46,53} (78.8%) reported P values on pre- to postoperative scores. These 7 studies found that patients receiving RCR with BMS improved significantly from preoperative to the latest follow-up. There was no significant difference between groups when comparing the percent weighted improvement from pre- to postoperative (P = .15).

Table 5

Constant-Murley Scores ^a

Study (Year)	Preop	Postop	Percent Improvement
Patch
Avanzi et al² (2019)	46.2 ± 14.4	95.5 ± 5.5	106.7
Barber et al⁴ (2012)	41 ± 9.2	91.9 ± 9.2	124.1
Bryant et al⁵ (2016)	58.4 ± 14.6	79.3 ± 19.8	35.8
Cai et al⁵ (2018)	37.3 ± 6.5	90.8 ± 3.5	143.4
Kim et al²⁷ (2024)	77.7 ± 9.6	89.1 ± 9.6	14.7
Lee et al³² (2022)	52.8 ± 18.4	71.1 ± 7.7	34.7
Snow et al⁴⁸ (2023)	31.6 ± 17	83.9 ± 16.6	165.5
Total weighted value	48.8	87.5	78.6
BMS
Hong et al²¹ (2024)	51.6 ± 12.9	69.9 ± 17.5	35.5
Lapner et al³¹ (2021)	52 ± 17	83 ± 12	59.6
Lapner et al³⁰ (2023)	53.8 ± 19.4	81.7 ± 9.1	51.9
Milano et al³⁶ (2013)	60.8 ± 17.4	94.5 ± 14	55.4
Osti et al³⁹ (2013)	44.6 ± 12	60.8 ± 9.3	36.3
Ruiz et al⁴⁴ (2021)	42.8 ± 14.7	74.1 ± 15	73.1
Shibata et al⁴⁶ (2023)	43 ± 12.6	83.5 ± 12.8	94.2
Toro et al⁵⁰ (2022)	53.4 ± 19.63	90.8 ± 5.9	70
Yang et al⁵³ (2025)	47 ± 19.7	89.7 ± 12.8	89.6
Total weighted value	50.7	80.1	58
P			.15

Scores are reported as mean ± SD at the latest follow-up, with the total weighted mean/improvement row reported as the weighted mean of pre- and postoperative scores and the weighted percent improvement from pre- to postoperative scores. The P value represents the weighted t test result between the weighted percent improvements of both groups. BMS, bone marrow stimulation; CM, Constant-Murley; Postop, postoperative; Preop, preoperative.

Eleven studies^# used the ASES score (6 studies, PA^{4,5,27,32,43,48}; 5 studies, BMS^{21,30,31,50,53}) (Table 6). Of the 6 studies using RCR with PA, 2 studies^27,32 (33.3%) reported P values on pre- to postoperative. Both studies found that patients receiving RCR with PA reported better ASES scores from preoperative to the latest follow-up. Of the 5 studies using RCR with BMS, 4 studies^30,31,50,53 (75%) reported P values on pre- to postoperative scores. Those 4 studies found that patients receiving RCR with BMS reported better ASES scores from preoperative to the latest follow-up. No significant difference was observed between groups when comparing the percent weighted improvement from pre- to postoperative (P = .70). Ruiz et al⁴³ study was not included in the weighted analysis because it did not report postoperative ASES scores.

Table 6

American Shoulder and Elbow Surgeons Scores ^a

Study	Preop	Postop	Percent Improvement
Patch
Barber et al⁴ (2012)	48.5 ± 4.2	98.9 ± 4.2	103.9
Bryant et al⁵ (2016)	52.2 ± 13.1	84.6 ± 21.2	62.
Kim et al²⁷ (2024)	66.1 ± 18.8	91.2 ± 13.1	38.
Lee et al³² (2022)	48.7 ± 19.7	78.9 ± 12.8	62
Ruiz et al⁴³ (2024)	44.6 ± 16.4	NR	NR
Snow et al⁴⁸ (2023)	36.6 ± 14.6	79.6 ± 17.7	117.5
Total weighted value	51.7	86.9	68.2
BMS
Hong et al²¹ (2024)	65.6 ± 16.4	92.9 ± 23.2	41.6
Lapner et al³¹ (2021)	45 ± 17	84 ± 17	86.7
Lapner et al³⁰ (2023)	47.9 ± 19.4	90.3 ± 13.1	88.5
Toro et al⁵⁰ (2022)	70.1 ± 14	96.9 ± 4.4	38.2
Yang et al⁵³ (2025)	45.3 ± 17.8	87.4 ± 15.3	92.9
Total weighted value	56.3	91	61.6
P			.70

Scores are reported as mean ± SD at the latest follow-up, with the total weighted mean/improvement row reported as the weighted mean of pre- and postoperative scores and the weighted percent improvement from pre- to postoperative scores. The P value represents the weighted t test result between the weighted percent improvements of both groups. ASES, American Shoulder and Elbow Surgeons; BMS, bone marrow stimulation; NR, not reported; PA, patch augmentation; Postop, postoperative; Preop, preoperative.

RCR Rates

Seventeen studies^** reported on RCR rates (10 studies, PA^{4-7,23,24,27,32,43,48}; 7 studies, BMS^{21,30,31,36,44,46,53}) (Table 7). No significant difference was observed between groups when comparing the retear rate between groups (P = .88).

Table 7

RCR Rates ^a

Study (Year)	Retear Rate
Patch
Barber et al⁴ (2012)	3/22 (13.6)
Bryant et al⁵ (2016)	18/31 (58.1)
Cai et al⁵ (2018)	7/51 (13.7)
Camacho Chacon et al⁷ (2024)	0/30 (0)
Iannotti et al²³ (2006)	11/15 (73.3)
Ide et al²⁴ (2017)	1/16 (6.3)
Kim et al²⁷ (2024)	3/29 (10.3)
Lee et al³² (2022)	2/22 (9.1)
Ruiz et al⁴³ (2024)	5/60 (8.3)
Snow et al⁴⁸ (2023)	4/18 (22.2)
Total	54/294 (18.4)
BMS
Hong et al²¹ (2024)	6/103 (5.8)
Lapner et al³¹ (2021)	9/34 (26.5)
Lapner et al³⁰ (2023)	16/75 (21.3)
Milano et al³⁶ (2013)	18/35 (51.4)
Ruiz et al⁴⁴ (2021)	5/36 (13.9)
Shibata et al⁴⁶ (2023)	8/24 (33.3)
Yang et al⁵³ (2025)	3/56 (5.4)
Total	65/363 (17.9)
P	0.88

Retears are reported as the number of retears/total number of patients (%). BMS, bone marrow stimulation.

Discussion

The results of this systematic review demonstrate that patients undergoing RCR with BMS can be expected to achieve similar outcomes to those receiving RCR with PA. While both PA and BMS have demonstrated improvements over RCR alone in RCTs, no previous study has directly compared their effectiveness. The authors hypothesized that there would be no significant difference in outcomes between patients undergoing RCR with PA and RCR with BMS.

The findings suggest comparable outcomes for both augmentation techniques across all PROs. It is also important to note that there was no difference in retear rates between groups. This may be attributed to the fact that the efficacy of both PA and BMS can vary depending on tear size and surgical technique. Future research stratifying patients by tear size and surgical technique is crucial to discern potential differences between these interventions within specific subgroups. Additionally, no studies have directly compared PA and BMS; therefore, a head-to-head RCT of PA and BMS is suggested to further evaluate any superiority between the augmentations.

When evaluated independently, both treatment groups demonstrated excellent improvement from pre- to postoperative, to a similar degree. Of the 9 reports evaluating RCR with BMS, 7 reported significant improvements in patients from preoperative to the latest follow-up.^{30,31,39,44,46,50,53} Seven of the 11 reports, in which studies examined RCR with PA, found significant improvement from preoperative to the latest follow-up.^{2,6,7,27,32,43,48} This finding provides another area of future research for a cost-utilization analysis directly comparing both techniques given the equal improvement in clinical outcomes within their respective groups. Previous cost-effectiveness analyses have demonstrated that PA can be cost-effective and, despite its higher initial cost, yield long-term savings that can offset this expense because of significantly reduced revision risk.^41,45 Regarding the cost-effectiveness of BMS as an augmentation for RCR, a systematic review found a positive cost profile.⁵⁷ Given the present study's findings, observing equal outcomes between PA and BMS, it may be fair to say that BMS is more cost-effective than PA.

The findings of the present systematic review stipulate the potential comparative effect of the biological enhancing ability of BMS in recruiting mesenchymal stem cells and growth factors, and PA's immediate mechanical reinforcement as a bioinductive scaffold at the repair site. It is believed that the recruitment of mesenchymal stem cells from the bone marrow to the tendon-bone interface creates an enriched environment that promotes angiogenesis, modulates inflammation, and facilitates organized collagen synthesis. Ultimately, in theory, these stem cells and growth factors promote the regeneration of the tendon and surrounding structures.⁸ PA, on the other hand, acts to distribute tensile forces to reduce the stress at the repair site, thereby protecting the healing tendon during the early postoperative period. As scaffolds, the patches may also act to facilitate cellular infiltration and organized collagen deposition. However, the function of PA during RCR may vary depending on the graft position and fixation technique of the repair. Despite the different mechanisms of the 2 augmentation techniques, the present systematic review demonstrates positive clinical outcomes, supporting the action of both techniques to promote a more organized fibrocartilaginous tissue at the enthesis.

The strengths of this study include a comprehensive systematic review of Level 1 and Level 2 studies performed by 2 independent reviewers. The limitations of this study should also be noted. Among the 20 studies included, 9 were Level 1 evidence.^{5,7,27,30,36,39,43,44,53} No studies directly compared clinical outcomes of RCR with PA and RCR with BMS; therefore, a meta-analysis of the literature could not be performed. Given the absence of a meta-analysis, a power analysis of the pooled studies was not performed either. Significant heterogeneity was observed in the included studies in surgical technique, follow-up periods, rehabilitation protocols, augmentation types, and tear grades. In particular, studies utilized several different patches or BMS drilling techniques to augment the repair. It is yet to be understood which patch for RCR works best and which BMS drilling technique optimizes the outcomes of patients after RCR. This reflects the significant variability observed in the specific augmentation type utilized in each respective study. Future studies are suggested to compare the varying patch types and different BMS techniques to assess whether there is any difference in outcomes dependent on the augmentation type. Furthermore, there was significant heterogeneity in the inclusion criteria for rotator cuff tear sizes of the patients in each included study. Smaller tears may lead to better postoperative outcomes as compared with larger-sized tears. Therefore, given that the studies included patients with small to massive tears with various representations of each augmentation group in the pooled analysis, it is important to consider the tear size heterogeneity when evaluating the outcomes of the present study. Because of the high variability in tear type across studies, a subanalysis categorizing results by tear type could not be performed. In addition, because of significant variability in the BMS technique and patch type, it similarly prevented a subanalysis on this topic from being performed. Follow-up times were also variable between study groups. Overall, the heterogeneous nature of these studies serves as a confounding factor in the comparison of these 2 treatment groups.

Conclusion

Patients undergoing RCR with PA or BMS have demonstrated similar improvements in both patient-reported and functional outcomes. Further randomized controlled studies are needed to directly compare these 2 RCR augmentation groups and compare different patch types and different BMS techniques.

Footnotes

Final revision submitted March 29, 2026; accepted April 5, 2026.

One or more of the authors has declared the following potential conflict of interest or source of funding: E.C.M. has received support for other professional activities and intellectual property royalties from Zimmer Biomet Holdings; he is on the board of directors for AOSSM. C.M. is a family member of E.C.M. R.M.F. has received support for other professional activities from the Joint Restoration Foundation, Inc, Stryker, Smith and Nephew, Elsevier, Bodycad USA Corp, and Arthrex; she is a committee member of AOSSM.

ORCID iD

Joseph J. Lim

Notes

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