AAOS 2025 Showdowns recap: Surgeons face off in debate on rotator cuff repair options

On the last day of the AAOS 2025 Annual Meeting, “Showdown: Augmentation of the rotator cuff repair” provided a cheeky (but studiously polite) debate, highlighting different ways to augment cuff repairs, including biologics, grafts, and other techniques. Moderated by Adil Ahmed, MD, an orthopaedic surgeon at St. Luke’s Health in Houston, the first debate pitted Rachel Frank, MD, FAAOS, a clear-eyed biologics advocate, against Albert Lin, MD, FAAOS, who was committed to grafts and patches.

Dr. Frank, who directs the Joint Preservation Program at the University of Colorado School of Medicine, is pro-biologics — but with caveats. She began by noting there is room for improvement in rotator cuff repairs.

“There’s been an explosion of publications over the last three decades with respect to rotator cuff repairs, yet our outcomes are not improving at the rate the publications suggest they should be,” she said. “So we‘re not winning the rotator cuff game. Why is that?”

Many biologics are being studied, but few are currently allowed in the United States. Dr. Frank pointed to the Regulation of Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/Ps) Small Entity Compliance Guide from the FDA. According to this guide, only minimally manipulated homologous products are currently allowed: adipose and bone marrow aspirate, platelet-rich plasma (PRP), and other blood products.

“Be cautious when you interpret the literature with respect to biologic augmentation of cuffs,” she said. “Make sure that what you’re reading is something that you can actually apply to your patients.”

PRP for rotator cuff repair is minimally invasive, is fairly inexpensive, and can help patients. Still, Dr. Frank cautioned that it has to be the right kind of tear. According to a study by Saltzman et al., for small to medium tears, solid PRP matrix applied at the tendon-bone interface can be helpful.

The literature on bone marrow aspirate is more favorable. Hernigou et al. found that mesenchymal stem cells derived from bone marrow significantly improved healing. Other options include adipose tissue and bursal cells.

“When you look at the basic science literature, it tells us we might get benefit,” Dr. Frank said. “So we’ve got PRP, we’ve got adipose, we’ve got bone marrow, we’ve got bursa. They’re all fairly cheap and easy to harvest, and they can possibly improve outcomes.”

Graft and patch augmentation
Dr. Lin, chief of shoulder surgery and codirector of the Pittsburgh Shoulder Institute at the University of Pittsburgh, eagerly picked up the gauntlet. He discussed the uncertainty associated with biologics: PRP concentration variability, the lack of actual FDA-approved stem cell products, costs, and other confounding issues.

“Rachel told you about injectable biologics,” Dr. Lin said. “Well, show me the money, or maybe the evidence. Or how about grafts and patches? Way more evidence for that.”

A study of collagen implants by Arnoczky et al. showed cellular incorporation, tissue formation and maturation, implant resorption, and biocompatibility. Another study by Schlegel at al. found that collagen scaffolds work well for intermediate and high-grade partial-thickness tears.

“I think if you have a repairable rotator cuff tear, you have to understand what the goals are,” Dr. Lin said. “Good clinical outcomes can be achieved despite healing, but if you heal, you’re going to have a better outcome, particularly strength. … This is the subject of a lot of studies right now, but I will say it’s still better than injectable stem cells, which are really not ready for prime time.”

Chronic massive rotator cuff tears: Pro-graft
For the second debate, Robert Hartzler, MD, MS, FAAOS, a surgeon at TSAOG Orthopaedics & Spine in San Antonio, represented the pro-graft/superior capsular reconstruction (SCR) camp. In his introduction, Dr. Hartzler noted that his opponent, Eric Wagner, MD, FAAOS, would be arguing for tendon transfers, which he approaches with some skepticism.

Dr. Hartzler noted that anterosuperior injuries are almost always repairable, whereas posterosuperior are “more often repairable than you would think, based on preoperative imaging characteristics.” Tension and tissue quality are important characteristics to consider. For operatively irreparable tears, he favors bridging dermis for patients with reasonable muscle. He goes to SCR in operatively irreparable scenarios where patients have bad muscle. He will do tendon transfers — occasionally.

Dr. Hartzler went on to cite case studies, starting with an acute supraspinatus tear along with a chronic subscapularis tear. “Is that subscap useless? Dr. Wagner would say yes. Is it futile? With that repair — linked double row — I would say no. This patient’s basically normal after this repair. No grafting, just doing a good repair.”

He moved swiftly into dermal allograft augmentation, citing a series of studies to show the approach’s efficacy. “There’s a strong case for dermal augmentation. More studies show these greatly improve healing rates, which we know will eventually translate into better clinical outcomes, specifically strength.”

He cited another study, by Ruiz et al., which showed collagen implants, in medium to large posterosuperior rotator cuff tears, reduced retear rates after 12 months by 66%. Moving on to SCR, one of several studies showed that dermal allograft SCR for irreparable posterosuperior tear improved function for at least two years.

Lower trapezius transfer
Dr. Wagner, director of upper-extremity research at Emory University, weighed in on lower trapezius transfer (LTT), noting that the procedure is easier than most people think.

“One thing that holds people back from doing the lower trap is that they are intimidated by the actual procedure,” said Dr. Wagner. “But I think it’s probably simpler than some of the stuff Rob just showed you.”

He believes muscle quality is one of the best indicators of whether cuff repair will succeed or fail. “When you look at the RoHI [Rotator Cuff Healing Index], the muscle is one of the biggest parts of it,” he said. “When you don’t have muscle, your chance of healing really goes down.”

Dr. Wagner pointed to a study from Gusnowski et al., which showed that LTT improves patient-reported outcomes, restoring strength even when there is significant fat infiltration. He also explained that harvesting the tendon is relatively easy, and the outcomes are quite good. To close out, he described the algorithm his team uses to care for patients.

“If they have good tendon and muscle, do interval releases, maybe add some BMAC [bone marrow aspirate concentrate] or PRP,” Dr. Wagner said. “But if they do not have a good tendon, that’s when I consider augmentation. If they have good muscle but no good tendon, maybe a structural graft plus augmentation. But if they don’t have good muscle, my augmentation preference is a larger transfer. I think this works and provides predictable outcomes.”

Josh Baxt is a freelance writer for AAOS Now.

References 

1. McElvany MD, McGoldrick E, Gee AO, et al. Rotator cuff repair: Published evidence on factors associated with repair integrity and clinical outcome. Am J Sports Med. 2015;43(2):491-500. doi:10.1177/0363546514529644
2. Saltzman BM, Jain A, Campbell KA, et al. Does the use of platelet-rich plasma at the time of surgery improve clinical outcomes in arthroscopic rotator cuff repair when compared with control cohorts? A systematic review of meta-analyses. Arthroscopy. 2016;32(5):906-918. doi:10.1016/j.arthro.2015.10.007
3. Hernigou P, Flouzat Lachaniette CH, Delambre J, et al. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: A case-controlled study. Int Orthop. 2014;38(9):1811-1818. doi:10.1007/s00264-014-2391-1
4. Arnoczky SP, Bishai SK, Schofield B, et al. Histologic evaluation of biopsy specimens obtained after rotator cuff repair augmented with a highly porous collagen implant. Arthroscopy. 2017;33(2):278-283. doi:10.1016/j.arthro.2016.06.047
5. Schlegel TF, Abrams JS, Bushnell BD, et al. Radiologic and clinical evaluation of a bioabsorbable collagen implant to treat partial-thickness tears: A prospective multicenter study. J Shoulder Elbow Surg. 2018;27(2):242-251. doi:10.1016/j.jse.2017.08.023
6. Kantanavar R, Lee IE, Rhee SM, et al. Outcomes of arthroscopic single-row repair alone vs. repair with human dermal allograft patch augmentation in patients with large to massive, posterosuperior rotator cuff tears: A retrospective comparative study. J Shoulder Elbow Surg. 2024;33(4):823-831. doi:10.1016/j.jse.2023.08.002
7. Lee GW, Kim JY, Lee HW, et al. Clinical and anatomical outcomes of arthroscopic repair of large rotator cuff tears with allograft patch augmentation: A prospective, single-blinded, randomized controlled trial with a long-term follow-up. Clin Orthop Surg. 2022;14(2):263-271. doi:10.4055/cios21135
8. Cha EDK, Shultz K, Chan K, et al. Longitudinal efficacy of acellular dermal allograft following superior capsular reconstruction of irreparable rotator cuff tears. J Orthop. 2022;33:31-36. doi:10.1016/j.jor.2022.06.012
9. Ruiz Ibán MÁ, García Navlet M, Moros Marco S, et al. Augmentation of a transosseous-equivalent repair in posterosuperior nonacute rotator cuff tears with a bioinductive collagen implant decreases the retear rate at 1 year: A randomized controlled trial. Arthroscopy. 2024;40(6):1760-1773. doi:10.1016/j.arthro.2023.12.014
10. Burkhart SS, Pranckun JJ, Hartzler RU. Superior capsular reconstruction for the operatively irreparable rotator cuff tear: Clinical outcomes are maintained 2 years after surgery. Arthroscopy. 2020;36(2):373-380. doi:10.1016/j.arthro.2019.08.035
11. Gusnowski E, Wagner E, McRae S, et al. Lower trapezius tendon transfer for massive irreparable rotator cuff tears improves outcomes in patients with high grade fatty infiltration of teres minor. JSES Int. 2024;9(1):296-300. doi:10.1016/j.jseint.2024.11.014