Rotator cuff repair has high failure rates. Augmentation techniques aim to improve healing biology but evidence is limited. Steroid injections impair healing while diabetes control and smoking cessation may optimize patient factors. Footprint preparation requires care to not weaken fixation. Patch augmentation shows promise with lower re-tear rates in some studies compared to historical controls, but evidence is mainly from lower quality studies. Further high-quality research is needed to establish the role of augmentation techniques like platelet-rich plasma, stem cells, and scaffolds.

1. Can we improve rotator
cuff tendon biology and
is augmentation
helpful?
Mr Adnan Saithna, Consultant Sports Injury Knee and Shoulder
Surgeon based at Southport, Ormskirk and Renacres Hospitals

2. The role for improving biology..
• High failure rates, particularly for massive tears
• Widely reported figures of 20-90%
• How can we optimise the biology:
 Avoid treatments that impair biology
 Optimise the repair
 Optimise patient factors
 Augmentation
 PRP
 Stem Cells
 Patches

3. SR:Effect of glucocorticoids
Mechanical properties of tendon, Dean et al

4. Effect of glucocorticoids
• significant negative effects on tendon cells in vitro, including reduced cell
viability, cell proliferation and collagen synthesis
• There is increased collagen disorganisation and necrosis as shown by in vivo
studies
• Directly affects microvascularisation of the footprint, Bonneviale et al
• 48 patients
 Angiogenesis assessed by CD34 immunostaining from intra-op biopsy at repair
 Correlated with success of repair at 1 year
 Glucocorticoid injection significantly reduces CD34 staining (and microvascularity of
footprint) 10% vs 16%
 Microvascularity correlates with success of cuff healing after repair

5. 16%
14%
4%
Association between rate of microvascularisation and Sugaya grade

6. Footprint preparation:
Radiofrequency ablation
• Ficklcherer, et al. Arthroscopy 2014
• Supraspinatus repair in 189 rats
 Footprint either decorticated, untreated or treated with RFA
• Biomechanics of repair
 Mean load to failure significantly reduced in RFA group
 No diff decorticated/untreated
• Histological
 Significantly reduced type II collagen in RFA group compared to others

7. Crimson duvet
Snyder et al, TSES, 2009

8. RCT, Microfracture, Milano et al, Arthroscopy 2013
40 patients in each arm
Significantly improved healing rate in large tears (65 vs
52 %)
No difference in small tears
No difference in constant score
Similar findings Jo et al , AJSM 2013

9. Optimising patient factors:
Smoking and cuff repair
Systematic Review, Santiago-Torres,AJSM 2014
• Nicotine delays tendon to bone healing in rat model with lower load to
failure at 10 and 28 days
• Clinical outcomes
 3 studies
 Balyk et al and Mallon et al show significantly worse clinical scores (ASES, UCLA)
in smokers at 6 months and 1 year post-op
 In contrast Prasad showed no difference
• structural integrity (MRI/USS)
 4 studies
 Neyton significantly reduced healing on MRI at 16 months
 Thashijan et al and Dhanjari et al showed trend to inferior outcomes in smokers on
USS
 Nho et al, no difference on USS

10. Diabetic control
• Cho et al, AJSM 2015
• Cohort study
• Diabetic patients with post-operative Hba1c more than 7% greater than pre-
op value classified as poor control
• Cuff re-tear rate defined by MRI significantly higher (43%) in poorly
controlled diabetics than in good control (26%) p<0.001

11. Vitamin D
Ryu, AJSM 2015
• Cohort study
• 91 patients
• No association between Vitamin D levels, clinical scores and structural
outcomes

12. PRP: Systematic Review of Meta
Analyses
Saltzman et al, Arthroscopy 2016
• The current highest level of evidence suggests that PRP use at the time of
arthroscopic rotator cuff repair does not universally improve re-tear rates or
affect clinical outcome scores.
• However, the effects of PRP use on re-tear rates trend toward beneficial
outcomes if evaluated in the context of the following specific variables:
 use of a solid PRP matrix
 application of PRP at the tendon-bone interface
 in double-row repairs
 and with small- and/or medium-sized rotator cuff tears.

13. Stem cells in tendon disorders
Systematic Review: Pas et al BJSM 2017
• No high quality evidence found for the therapeutic use of stem cells for
tendon disorders (including cuff repair).
• The use of stem cell therapy for tendon disorders in clinical practice is
currently not advised.
• Kim et al AJSM 2017
 MSCs loaded in fibrin glue
 Cohort study
 No clinical differences at 28 months
 MRI retear rate 28% vs 14% p<0.001

14. Human Dermal Matrix Augmentation
RCT, Barber et al, Arthroscopy 2012

16. Augmentation associated with better
scores at mean f/up 24 months
• The ASES score improved from 48.5 to 98.9 in group 1 and from 46.0 to 94.8
in group 2. (P = .035).
• The Constant score improved from 41.0 to 91.9 in group 1 and from 45.8 to
85.3 in group 2. (P = .008).
• No difference in UCLA score

17. Outcomes after patch use
SR: Steinhaus, Arthroscopy 2016
• 24 included studies (19 level IV)
• When categorized by graft type, the rates of complete re-tears were
synthetic: 15.0% (33 of 220), xenograft: 42.0% (50 of 119), and allograft: 9.9%
(7 of 71)
• Overall, the complication rate was 3.5% (12 of 340) including 1 severe
inflamm reaction, 2 x cystic change HH, 1 deep infection
• Failure rates seem low compared to previously reported rates for large tears
but broad inclusion criteria and predominantly cohort series
 Some studies included smaller tears
 Differing lengths of follow up
 Broad inclusion criteria
 Weak evidence

18. Future directions
• MSC/biomolecule (BMP-7) loaded hydrogels and synthetic scaffolds have
shown promise in animal studies
• However, a cautious approach must be adopted as animal models have
limitations. Eg. Rat model – much higher healing rates, limited fatty
degeneration, different morphology and loading

19. Summary
• Avoid steroid injections
• Counsel diabetics and smokers
• Some evidence for footprint preparation but avoid compromising fixation
• PRP/MSCs insufficient evidence to currently support a role
• Patch augmentation – some evidence but mainly Level IV only. More
comparative studies required
• Animal studies should be interpreted with caution (as learned from PRP)