2015 ISAKOS Biennial Congress ePoster #2406

Graft Utilization in the Repair of Large-to-Massive Rotator Cuff Tears: A Systematic Review

Ivan Wong, MD, FRCSC, MACM, Dip. Sports Med, Halifax, NS CANADA
T. Duncan Smith, MD, Halifax, Nova Scotia CANADA
Devin Ferguson, BSc, Halifax, Nova Scotia CANADA
Matthew Lewington, MD, FRCSC, Halifax, NS CANADA

Dalhousie University, Halifax, Nova Scotia, CANADA

FDA Status Not Applicable

Summary: A systematic review assessing the use of graft augmentation for the treatment of large-to-massive rotator cuff tears.




Current treatment options for large (3-5cm) to massive (>5cm) rotator cuff tears provide reductions in patient pain, but re-tear rates continue to be high. Surgeons have used several strategies including synthetic and biologic grafts to augment or bridge rotator cuff repairs. Multiple reviews exist summarizing these products, however, no systematic reviews or metaanalyses have been performed.


To systematically review the existing literature and analyze reported outcomes to ascertain the utility of using grafts to treat large or massive rotator cuff tears.


A systematic electronic search of PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) was employed. The search strategy included terms relating to or describing the rotator cuff and grafting procedures for large-to-massive tears. Reference lists of reviews and eligible studies were hand searched for additional citations that may not have been captured by our search strategy. Studies had to be available in English. Subjects had to be human. There was no restriction on date of publication. Each study had to report at least one validated clinical shoulder score with a published minimal clinically important difference. Shoulder scores had to be reported for a preoperative and a postoperative value. Two review authors independently assessed the risk of bias of included studies by adhering to the Down and Blacks instrument.


Eighteen studies fit the inclusion criteria. Most were case series or cohort studies. There were two prospective randomized studies identified. Repair techniques were either arthroscopic or open. Both augmentation and bridging techniques were used. Nine studies utilized dermal allograft tissue. Of those, 6 were human tissue and 3 were of porcine origin. Three studies used porcine small intestine submucosa. Four studies used autograft tissue. Finally, 2 studies use synthetics.

Sample sizes varied greatly. Human allograft studies had between 5-42 subjects; xenografts reported on between 9-30 subjects; autografts studied between 24-68 subjects; and synthetics reported on between 21-41 subjects.

Where reported, patient satisfaction and failure rates varied. Human allograft satisfaction ranged from 79-100% and failure rates were between 14-40%. Xenografts had between a 90-96% satisfaction rate, and failure rates varied between 0-100%. Autografts had between a 17-42% failure rate. Patient satisfaction was not reported for autograft studies. Synthetics had a 10% failure rate; again patient satisfaction was only reported in one study (90%). Outcome measures varied greatly and included range of motion, strength, VAS pain, PENN, Constant-Murley, ASES, WORC, Flex-SF, and DASH(W) scores.


There are no prospective, well-powered, randomized studies specifically focused on massive tears. As well, there are no prospective, well-powered, randomized studies focused on bridging of any sized rotator cuff tear. Reported outcome measures are varied, making direct comparison and metaanalysis difficult. In general, patients seem to be satisfied following the use of these techniques, and report lower pain post-operatively than pre-operatively. Re-tear rates vary. This can be partially explained by low subject numbers (and lack of adequate power) for some of the studies. In general, bridging has a higher failure rate than augmentation.