Technologies to Augment

Rotator Cuff Repair

Anand M. Murthi, MD*, Manesha Lankachandra, MD

KEYWORDS
 Rotator cuff repair  Platelet-rich plasma  Allograft scaffold  Synthetic scaffold  Stem cells

KEY POINTS
 The consensus of the current literature seems to be that platelet-rich plasma (PRP) may provide
some clinical benefit in rotator cuff repair, but there remains high variability among different
PRP products and preparations.
 Like PRP, the efficacy of the bone marrow aspirate concentration preparation depends on the
expression of various cytokines and signaling molecules and the product used.
 Various scaffolds and grafts, both biological and synthetic, are available to provide structural
support for the repair. Their effects and results vary depending on graft type.

Retear rates after rotator cuff repair vary widely,
depending on the tear type and size as well as
patient factors, such as age and health comor-
bidities. Earlier research has shown that pain re-
lief and satisfaction can reliably be achieved
despite tendon healing.1–3 A 2014 meta-
analysis of level I and II data showed some signif-
icant difference in some outcome measures, but
these differences did not reach clinical impor-
tance. Importantly, the influence of age and
occupation were not evaluated, and most of
the studied tears were small. Patients with intact
repairs were also found to have greater strength
than those with retears.4 The goal of surgical ro-
tator cuff repair remains a tension-free repair
that can withstand the functional demands of pa-
tients during the postoperative healing and
rehabilitative phase. Tendon to bone healing is
notoriously fickle, and the fibrous scar tissue
that creates this repair lacks the mechanical
strength and elasticity of native tendon.5,6 New
technologies seek to improve tendon to bone
healing with the addition of platelet-rich plasma
(PRP), stem cells, and biological and synthetic
grafts (Figs. 1 and 2).
After physical reattachment of rotator cuff
tendons to their insertion sites, the cells and bio-
logical factors involved in healing the repaired
bone to tendon interface derive from surround-
ing connective tissues.
PRP is an autologous blood product with
platelet concentrations greater than the baseline
values.7 It is created through plasmapheresis
whereby platelets and plasma are separated
from white blood cells (WBCs) and red blood
cells. Commercial preparation methods vary,
with varying amounts of platelets and WBCs in
the final product. Moreover, most users do not
perform cell counts on the whole blood or PRP
products to evaluate these differences clinically.
The optimal ratio of PRP products has not
been established, but a recent basic science
study does suggest that leukocyte-poor PRP
promotes more normal collagen matrix synthesis
and decreases more potentially harmful cyto-
kines and inflammatory markers than high-
leukocyte PRP preparations.8
In the perioperative setting, PRP is used to
stimulate healing at the tendon-bone interface.
In a meta-analysis of 5 studies, Chahal and

The authors declare no potential conflict of interest related to this article.

Department of Orthopaedics, MedStar Union Memorial Hospital, 3333 North Calvert Street, Suite 400, Baltimore,
MD 21218, USA
* Corresponding author. Department of Orthopaedics, MedStar Union Memorial Hospital, 3333 North Calvert
Street, Suite 400, Baltimore, MD 21218.
E-mail address: amurthi14@hotmail.com

Orthop Clin N Am 50 (2019) 103–108

https://doi.org/10.1016/j.ocl.2018.08.005
0030-5898/19/ª 2018 Elsevier Inc. All rights reserved.
104 Murthi & Lankachandra
Fig. 1. A synthetic graft outside of the body, ready to
be passed into the subacromial space through a lateral
portal.
colleagues9 showed patient-reported outcomes
were no different between the two groups and
the risk of retear was not significantly changed.
A larger meta-analysis of 11 studies also similarly
showed no difference in retear rates and patient
outcomes in patients treated with PRP and con-
trols.10 There was, however, a statistically signif-
icant reduction in retear rates with larger tears
(greater than 3 cm) that were treated with
double-row repair and PRP. A 2018 meta-
analysis of PRP and platelet-rich fibrin by Hurley
and colleagues11 showed that the use of PRP
improved tendon healing rates in tears of all
sizes. The increase in the number of studies
available for review regarding the use of PRP
products over recent years allowed the
Fig. 2. (A) The same graft now placed against the bursal side of the rotator cuff repair. (B) It is tied down against
the tendon bone interface.
investigators to subgroup PRP and platelet-rich
fibrin; they found that although the use of PRP
resulted in improved healing rates and func-
tional outcomes, the use of platelet-rich fibrin
had no beneficial effect on tendon healing or
outcomes.
A 2012 study of 37 patients also evaluated the
effects of platelet-rich fibrin on repair integrity
following rotator cuff repairs at high risk of
failure (older patients, larger tears, and higher
Goutallier scores). Retear rates were higher in
the study group versus the control group. Func-
tional outcome scores were similar in the two
groups.12
The consensus of current literature seems to
be that PRP in rotator cuff repair does provide
some clinical benefit, improving healing rates in
tears of various sizes and with variable patient
factors. That this consensus has changed consid-
erably over the past decade shows the evolving
nature of both PRP products and how they are
being used by surgeons. There are still no clear
guideline regarding the characterization of PRP
products, both in clinical use and scientific
reporting. That some PRP-related products
(platelet-rich fibrin, for example) are clearly not
beneficial also underscores the heterogeneity
of PRP preparations and the difficulty in making
generalizations regarding the use of PRP in rota-
tor cuff repair.
Similar to PRP, the use of stem cell prepara-
tions at the bone-tendon repair interface also
seeks to create a favorable milieu of chemical
signaling. Snyder and Burns’13 crimson duvet is
a well-known technique to create a collection
of stem cells and cytokines at the repair site, us-
ing similar principles as microfracture. Basic sci-
ence research in a rat model showed increased
mesenchymal stem cells in the drilling group
versus the control group, and the ultimate force
 Technologies to Augment Rotator Cuff Repair 105

to failure was significantly higher in the drilling

group at 4 and 8 weeks.14 A similar study in rab-
bits also showed increased force to failure at 8
and 16 weeks, and histologic analysis showed
thicker collagen bundles and more fibrocartilage
in the microfracture group.15
In humans studies, clinical outcomes have
been similar in patients undergoing microfrac-
ture or other marrow-stimulating tech-
niques.16–18 Milano and colleagues17 reported
on 80 patients, 40 who were randomized to
receive microfracture with rotator cuff repair
and 40 patients who underwent cuff repair
alone. At a mean follow-up of roughly 2 years,
Constant scores were similar in the two groups.
There was no difference in healing rates be-
tween the two groups, though subgroup analysis
did show better healing rates for large tears in
the microfracture group. Taniguchi and col-
leagues18 also showed improved repair integrity
in large and massive cuff tears using bone
marrow stimulation, despite similar results be-
tween groups in small and medium tears.
Mesenchymal stem cells from bone marrow
can also be collected and concentrated from Fig. 4. Bone marrow aspirate harvest from the greater
bone marrow and injected back at the site of tuberosity. A Jamshidi needle is used through a lateral
repair (Fig. 3). Like PRP, there are multiple sys- portal; no other incisions are necessary.
tems from multiple companies. Like PRP, the ef-
ficacy of the bone marrow aspirate concentration
preparation depends on the expression of stem cells in the setting of chronic rotator cuff
various cytokines and signaling molecules. tear.
The site of harvest of these bone marrow cells Although mesenchymal stem cells from bone
also varies. Bone marrow aspirate is commonly marrow concentrate can differentiate into
harvested from the greater tuberosity (Fig. 4), tendon cells, the clinical significance of this
which minimizes donor site morbidity and in- finding in rotator cuff surgery is unclear. Animal
creases surgical time. However, Hernigou and studies have shown that the bone marrow–
colleagues19 showed that bone marrow aspirate derived cells were active at the site of repair,
from this site might have fewer mesenchymal but results regarding improvement in the me-
chanical strength of the repair are mixed.20–22
In humans, 2 recent studies show decreased
retear rates in both primary and revision settings
using bone marrow aspirate.19,23
In addition to maximizing the biological com-
ponents of the repair, various scaffold and
grafts, both biological and synthetic, are avail-
able to provide structural support for the repair.
This support becomes especially important
when patient factors result in poor-quality tissue
at the site of repair. Neviaser and colleagues24
initially described the use of graft material in ro-
tator cuff repair in the 1970s to bridge in irrepa-
rable repair. This idea has recently been taken
further with the idea of superior capsular recon-
struction; but graft material is more commonly
used to reinforce a repair with poor quality tis-
Fig. 3. Bone marrow aspirate concentrate injected sue, rather than to bridge a gap between tendon
into and around the synthetic graft and repair. and bone. The use of grafts as scaffolds can
106 Murthi & Lankachandra
generally be split into products that use biolog-
ical material, usually human or animal extracel-
lular matrix, and those that use synthetic
materials.
In vitro research has shown that the structural
makeup and mechanical properties of both bio-
logical and synthetic grafts is relatively dissimilar
from native rotator cuff tendon. Smith and col-
leagues25 evaluated 7 scaffolds, comparing their
mechanical properties with a cadaver supraspi-
natus tendon. Synthetic grafts fared better in
load to failure tests when compared with biolog-
ical grafts, but neither matched native supraspi-
natus tendon. The investigators suggested that
one reason for this dissimilarity may lie in the
origin of these grafts for uses outside of the
shoulder, and further research into grafts
designed to mimic the rotator cuff tendons
may hold promise.
Histologic studies show evidence of increased
cell adhesion and proliferation, depending on
the graft type.26 Arnoczky and colleagues27
recently performed a retrospective study of 7
patients who underwent rotator cuff procedures
with a bovine collagen graft and then underwent
a repeat surgery with biopsy. At 5 weeks, bi-
opsies showed host fibroblasts within the
collagen implant. At 8 weeks, there was further
host incorporation within the implant with linear
organization of the host collagen fibers. At
3 months, biopsies showed further host incorpo-
ration of the implant as well as implant degrada-
tion. At 6 months, the remnants of the implant
were gone and the tissue samples had the orga-
nized appearance of tendon, densely organized
with parallel bundles of collagen fibers. In this
study, at no point was there inflammatory or
foreign body reaction within the sampled tissue.
The is a paucity of human studies on host
response to synthetic scaffolds, but a canine
study showed improved biomechanical function
at 12 weeks. In this study, 8 dogs underwent
bilateral shoulder surgery, with one side
repaired and the other repaired and augmented
with a polymer scaffold. At time zero, repair with
augmentation increased load to failure; at
12 weeks, there was less tendon retraction and
greater cross-sectional area. Histologic samples
at 12 weeks also showed fibrous tissue ingrowth
with an overall compatible host response.28 A
similar study in rats using a polycarbonate poly-
urethane patch showed no inflammatory
response at 6 weeks as well as significant host
tissue ingrowth.29 Regarding the initial repair
strength using a synthetic scaffold, a small
cadaver study showed the ultimate load to fail-
ure was improved by 25% for rotator cuff repairs
augmented with a polyhydroxyalkanoate mesh.
There was no difference in gap formation after
cyclic loading.
Human studies show generally favorable out-
comes with the use of biological grafts. In one of
the few randomized controlled trials, Barber and
colleagues30 showed American Shoulder and
Elbow Surgeons (ASES) and Constant scores
were improved and cuff integrity was better
maintained in patients who underwent repair
plus augmentation with dermal allograft of their
large (2 tendons) rotator cuff tears versus those
who underwent repair alone. Intact repairs
were found in 85% of the augmentation group
versus 40% of the control group at a mean of
14 months postoperatively. The investigators
also note that operative time was generally
increased by 30 to 60 minutes in the augmenta-
tion group.
Other retrospective studies using biological
grafts for bridging augmentation, especially in
the setting of massive rotator cuff tears, also
show good results. In a study of 45 patients
with massive rotator cuff tears treated arthro-
scopically with a regenerative tissue matrix allo-
graft augmentation using a bridging construct,
Wong and colleagues31 show improved Univer-
sity of California, Los Angeles and ASES scores
as well as improved functionality at 2 years post-
operatively. The average postoperative ASES
score in this group was 84.1, and it is important
to note that the technique used in this report
involved bridging deficient rotator cuff tendons
rather than augmenting tendon to bone repair.
In a study of 24 patients with massive rotator
cuff tears treated using a mini open technique
with regenerative tissue matrix allograft, Gupta
and colleagues32 showed improved the Short
Form 12 (SF-12) and ASES scores at 3 years post-
operatively. The mean ASES scores improved
from 66.6 to 88.7, and the mean SF-12 scores
improved from 48.4 to 56.8. Neither of these re-
ports had control groups, and it is important to
note that the surgical technique used involved
bridging a bone to tendon gap versus purely
an augmentation of a tenuous repair.
In a revision setting, Petri and colleagues33
showed significant improvement in the func-
tional portion of the ASES after open, revision,
biological patch augmentation. Patient satisfac-
tion in this series was also high, with no patients
requiring further surgery. In a larger review of 24
patients undergoing revision open rotator cuff
repair with dermal allograft augmentation,
10 patients had MRI evidence of a retear
at 50 months.34 Based on ASES and simple
assessment numeric evaluation (SANE) scores,
 Technologies to Augment Rotator Cuff Repair
excellent results were achieved in 24% of pa-
tients, good in 13%, fair in 21%, and poor in
42%. Interestingly, this study compared these
outcomes with historical control of revision sur-
gery without augmentation and found no signif-
icant improvements.
For synthetic scaffolds, one of the only studies
with a control group compared open rotator cuff
repair, repair with a collagen scaffold, and repair
with a synthetic scaffold. The polypropylene
patch augmentation of rotator cuff repair
demonstrated significant improvement in the
36-month outcome in terms of function,
strength, and retear rate.35 Other case series
as well have shown decreased pain, increased
range of motion, and improvement in patient-
reported outcomes.36–38 Even in revision set-
tings, case series have shown good results with
synthetic grafts. Although retear rates in this
population remain high, shoulder outcome
scores significantly improved.39
Recent technology may allow improved heal-
ing rates in both simple and complex rotator cuff
repair surgery. Understanding the nuances of bi-
ologics and grafting can allow surgeons to
choose the appropriate augmentation tech-
niques and products in their primary and revision
rotator cuff repair patients. Many of these newer
technologies still need to be studied in a pro-
spective fashion to allow for a thorough under-
standing of their role in improved outcomes
while factoring in the potential for added cost
and risks.
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