AAOS: Strong recommendation for "bioinductive tendon implants to augment rotator cuff repair"

Recently the AAOS updated its clinical practice guidelines, including those for the management of rotator cuff injuries.The 2025 CPG contains a strong recommendation for the use of bioinductive implants during rotator cuff repair, as it may reduce the chances of retear and improve patient-reported outcomes.

Let's take a look at the two papers quoted as support for this recommendation

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

and

An isolated bioinductive repair vs sutured repairfor full-thickness rotator cuff tears: 2-year resultsof a double blinded, randomized controlled trial 

Both of studies used Regeneten, a patch made of purified type I collagen derived from bovine (cow) Achilles Tendon marketed by Smith and Nephew. The authors of both studies acknowledged support from the company. 

The first study compared transosseous equivalent (TOE) repairs of medium to large cuff tears randomized at surgery after the TOE repair to repair alone or to TOE repair with a bovine collage patch placed over the repaired tendon, stretching 5- to 10-mm lateral to the footprint, and fixed to the tendon with 5-8 absorbable anchors and to the bone with 1 to 3 PEEK (polyether ether ketone) anchors. In the Control group, there were 16 retears in 62 subjects (25.8%); in the bovine collage patch group, there were 5 retears in 60 subjects (8.33%).While the retear rate was lower in the bovine collage patch group, up to a year after surgery there were no differences in the ASES scores between the two groups.

In the second study patients with small/medium (2.5 cm) full thickness supraspinatus tears and intact rotator cable were randomized to arthroscopic transosseous-equivalent repair or debridement after which the bovine collage patch was placed on top of the tear, overlapping the bone-tendon junction. The patch was secured with tendon anchors and 2 bone anchors. No structural tendon repair was carried out.

Measured via a 6-month biopsy, highly organized, parallel bundles of collagen, without inflammation, were present in all bovine collage patch patients, whereas poorly organized, nonparallel collagen fibers were present in 24/30 (80%) of control patients, with 28/30 having minimal to mild inflammation.  All bovine collage patch patients had 100% healing on MRI at 12 and 24 months measured as gap fill-in; the gap fill-in for the controls was not reported. The bovine collage patch group returned to work significantly faster (median 90 days vs. median 163.5 days) than the control group. 

Compared with the control group, the bovine collage patch group had higher American Shoulder and Elbow Surgeons and Constant-Murley Shoulder scores at each evaluation, less pain at 6 and 12 months, and greater satisfaction at 12 and 24 months. 

At two years after surgery, the ASES scores for the bovine collage patch and Control were 88 and 80; for the Constant Scores were 88 and 78. In each group, both measures were improved by 100% of the minimal clinically important difference (MCID).

Here are a few other recent articles relating to the use of Regenetin in rotator cuff surgery. These articles were not mentioned in the "current practice guidelines"

Economic value. Two studies attempted to assess the economic value of Regeneten, but did not evaluate patient reported clinical outcomes.

Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears Average cost of treatment $32,213 without Regeneten, $54,459 with Regeneten (additional cost 69%). Did not assess patient reported outcomes or revision rates for patients without or with the patch. While using "healing" as the study endpoint, the authors point out that there is lack of agreement on what constitutes healing or retearing after a cuff repair based on magnetic resonance imaging, ultrasound, or arthrogram. Evidence was not presented that "healing" by imaging correlated with better clinical outcomes .

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy. Average cost of treatment €4650 without Regeneten, €7828 with Regeneten (additional cost 68%). Study limitations the same as those for the report above.

Complications: The one study that compared clinical outcomes of repairs without and with Regeneten found an eight-fold increase in postoperative stiffness in the Regeneten group. All reoperations were in the Regeneten group.

Increased stiffness and reoperation rate in partial rotator cuff repairs treated with a bovine patch: a propensity-matched trial found that postoperative stiffness was observed in the first 12 weeks in 8 of 32 patients in the patch group compared with 1 of 32 patients in the control group. Six patients in the patch group underwent reoperations compared with no patients in the control group. All 6 reoperations in the patch group were performed to address stiffness. The authors concluded that patients in the patch group had a significantly higher rate of postoperative stiffness. In the majority of patients in whom shoulder stiffness developed, reoperation was required. It seems possible that this stiffness may be related to overstuffing the subacromial space by the graft as well as associated scarring in the humeroscapular motion interface.

A report of revision because of bursitis and rice bodies in a Regeneten-treated cuff repair.

Subacromial-Subdeltoid Bursitis With Rice Bodies After Rotator Cuff Repair With a Collagen Scaffold Implant: A Case Report. reported a case of subacromial-subdeltoid bursitis with rice bodies after rotator cuff repair with a Smith + Nephew REGENETEN bovine-derived bioinductive collagen scaffold implant. After debridement, the patient recovered well and made a full return to work and recreational activities.

Report of revisions because of reactive bursitis: Revision arthroscopic surgery after rotator cuff repair with a collagen graft: histologic evaluation of biopsy specimens from two patients.

Comment: The use of "biologics" in rotator cuff surgery is of interest clinically, scientifically, and economically. From what has been reported, bovine collagen patches can enhance the healing of certain cuff tears. However, their impact on the outcomes perceived by the patient (patient reported outcomes, PROs) appears to vary according to the type of tear being treated. The best results seem to be for small tears with an intact rotator cuff cable. The value to patients with other tear types has yet to be rigorously evaluated. 

Thus, the clearest patient-perceived value is in carefully selected small/medium tears with an intact rotator cable; the broader value proposition (medium–large repairs, partial tears) still needs longer-term PROs, complication surveillance, and transparent cost-effectiveness that includes PROs, not just imaging.

Thinking through the options

Western Bluebirds

Orcas Island

2021

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Progression of asymptomatic degenerative rotator cuff tears - is the 'cable' relevant?

Patterns of tear progression for asymptomatic degenerative rotator cuff tears

These authors studied 139  full-thickness rotator cuff tears with a mean subject age of 63.3 years and follow-up duration of 6.0 years/

Ninety-six (69.1%) of the tears demonstrated integrity of the anterior 3 mm of the supraspinatus tendon (the 'cable').

Fifty (52.1%) of the tears with intact anterior 3 mm of the supraspinatus tendon showed >5mm progression of tear width at a median of 3.2 years from enrollment. 

Twenty nine (67.4%) of tears with disruption of anterior 3 mm of the supraspinatus tendon showed >5mm progression of tear width at a median of 2.2 years from enrollment.

They concluded that the integrity of the anterior 3 mm of the supraspinatus had no effect on the magnitude of enlargement.

Comment: It is not surprising that degenerative cuff tears continue to degenerate. The significance of the 'anterior rotator cuff cable' remains undefined. 

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Supraspinatus rotator cuff tears - the importance of the anterior cable

Characteristics of small to medium-sized rotator cuff tears with and without disruption of the anterior supraspinatus tendon

This study compared the baseline function and results of arthroscopic cuff repair in 112 shoulders with small and medium-sized full-thickness cuff tears with complete supraspinatus disruption compared with those with an intact anterior supraspinatus tendon.

Shoulders with anterior supraspinatus disruption had greater mean tear width, length, and area and greater supraspinatus muscle degenerative changes compared with shoulders with an intact anterior supraspinatus tendon. 

There was no difference in tendon healing rates or functional results of repair, so this distinction may not have importance in surgical decision making.

See a related study on the anterior cuff cable posted here.

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Consultation for those who live a distance away from Seattle.

**Check out the new Shoulder Arthritis Book - click here.**

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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The anterior rotator cuff cable

The Biomechanical Relevance of Anterior Rotator Cuff Cable Tears in a Cadaveric Shoulder Model

This paper builds on the classical paper of Harryman and Clark, showing that the cuff insertion is not a homogeneous sheath, but rather a complex intersection of many fibers in at least 5 different layers. They also showed that the 'anterior cable' (the anterior 1 cm of the insertion immediately posterior to the biceps tendon) is not just a thickened aspect of the supraspinatus tendon, but also a means by which the supraspinatus inserts around the biceps tendon into the lesser tuberosity, providing special strength and importance to this aspect of the tendon.For that reason a defect in the the anterior aspect of the tendon is of greater consequence than a defect of the tendon behind the anterior aspect of the cable. Here's a figure from the Harryman and Clark article.

These authors used 12  human cadaveric shoulders to compare equivalently sized supraspinatus cuts of either the anterior rotator cuff cable (n = 6) or the adjacent rotator cuff crescent (n = 6). Under loading the gap distance of large cable tears was significantly greater than that of large crescent tears (median gap distance, 1.3 mm) (p = 0.002), a finding that supports the importance of the anterior cable.

Comment: This is an excellent anatomical/biomechanical study. The authors' statement of the clinical relevance may not, however, necessarily follow: "Clinicians should consider early repair of rotator cuff cable tears, which may need surgical intervention to address their biomechanical pathology. In contrast, surgical treatment may be more safely delayed for rotator cuff crescent tears." It is unclear whether the repair of an acute tendon tear of the crescent should be delayed, just as it is unclear that the repair of a failed anterior cable should be rushed if conditions are not favorable for a durable repair.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, rotator cuff surgery, 'ream and run essentials' and consultation for shoulder arthritis.

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