Rotator cuff augmentation: Surgeons need to understand how to select the best procedure

Rotator cuff repair remains challenging, with approximately one in four cases failing to heal. Larger tears, fatty degeneration, and retraction are major predictors of failure. Failed repairs also carry a significant economic burden, with costs in the United States estimated at nearly $438.9 million over two years. Several options exist for augmentation, including dermal allograft, xenografts, and synthetic patches. The holy grail for augmentation is technical ease, biologic augmentation, and structural strength.

Dermal allografts
Dermal allograft augmentation has the most consistent evidence base. Techniques include using onlay grafts and passing sutures through the graft. The latter is more technically complex and adds structural support. In a 2024 study, Nuvoli and colleagues demonstrated that outcomes after dermal allograft augmentation remained durable at a mean follow-up of six years. Healing rates improved to 60% to 85% compared with 40% in standard repair, and rates of intact cuff were reported as high as 90%. Economic analyses, including work by Quigley and colleagues in 2022 and Silva and colleagues in 2024, have confirmed cost-effectiveness at approximately $14,000 per quality-adjusted life year, with increased direct costs offset by reduced revisions.

Xenografts
Initial porcine xenografts were associated with poor healing and hypersensitivity. A 2025 meta-analysis by Oettl and colleagues confirmed no improvement in healing and a threefold increase in complications with use of porcine xenografts, factors that led to their abandonment.

More recently, a bovine-derived implant has been marketed as bio-inductive and has gained significant market share. Although it does not provide structural strength, the technical adoption is straightforward. A randomized, controlled trial by Angel and colleagues in 2023 showed lower retear rates (8.3% versus 25.8%) but no significant difference in clinical outcomes at one year. However, a recent randomized, controlled trial sponsored by Smith & Nephew found no significant difference in retear rates at six months after surgery and was terminated prior to two-year follow-up.

Synthetic patch
Synthetic augmentation provides structural support with a goal of biomechanically improving the weak link in rotator cuff repair — the suture tendon interface. Several options with FDA approval exist, such as the BioBrace (ConMed) and SpeedPatch (ZuriMed Inc). The latter uses a novel technique to interlock a nonwoven polyester patch directly into tendon tissue. In 2023, Meyers and colleagues demonstrated in ovine models that this device nearly tripled ultimate tensile strength compared with standard repair; however, further clinical studies are required to determine whether healing will ultimately improve.

Selecting the right procedure
Although augmentation improves healing rates, it is more expensive than other options — necessitating an evidence-based algorithm for augmentation to properly identify patients at risk for failure.

The Rotator Cuff Healing Index (ROHI) provides a validated tool to stratify risk. The scoring system includes points assigned for age, tear size, fatty infiltration of the infraspinatus, bone mineral density, and level of work. As points increase, the likelihood of rotator healing declines. For instance, with 4 points or fewer, the chance of rotator cuff healing is more than 90%. At 5 points, the chance of healing is approximately 70%, and at 7 points the chance of healing is approximately 40%. According to Jackson et al., a ROHI score of 7 or greater as a threshold could help surgeons identify patients who may benefit most from graft augmentation. However, lower or higher thresholds may be considered based on patient-specific considerations.

Rotator cuff augmentation should be guided by risk stratification. ROHI provides one tool to preoperatively stratify risk and determine the need for augmentation. At this time, no one augmentation approach perfectly accomplishes the goals of speed, improved biology, and structural support. Currently, the largest amount of evidence supports the use of dermal allograft. Further research is needed to compare augmentation approaches and develop predictive models with the goal of individualized treatment.

Leonard Stokes, BS, is a fourth-year medical student and research fellow at the Oregon Shoulder Institute in Medford, Oregon.

Patrick J. Denard, MD, is an orthopaedic surgeon specializing in shoulder surgery at the Oregon Shoulder Institute in Medford, Oregon.