Scientific developments and clinical applications utilizing biologic augmentation for rotator cuff repair: a systematic review
Embargo Date
2025-02-07
OA Version
Citation
Abstract
BACKGROUND: The radiology failure rate of arthroscopic rotator cuff repair varies between 11-94%. Despite the advances that have been made in the surgical technique, recurrent tear continues to pose a significant problem. Biologic augmentation with 1. Implanted scaffolds, 2. Biologic injections, and 3. Marrow stimulation have the potential to strengthen the suture-tendon junction and enhance the cellular environment within the joint to encourage healing of native tissue, thereby improving surgical repair outcomes.
PURPOSE: This systematic review will discuss three major categories of RCR augmentation in both preclinical and clinical settings.
STUDY DESIGN: Systematic Review
METHODS: A systematic review of the past 10 years of the PubMed database was completed using PRISMA guidelines. Studies were classified as preclinical or clinical, and then further subdivided by augmentation category: grafts/scaffolds, injectable biologics, and marrow induction. This resulted in 87 studies as follows: 42 graft/scaffolds- 12 clinical and 30 preclinical; 37 injectable biologics-7 clinical and 30 preclinical; and 8 marrow induction- 6 clinical and 2 preclinical.
RESULTS: Preclinically, a scaffold enhanced the healing potential of a torn, native rotator cuff tendon, with most included studies being biologically-based augmentation techniques demonstrating benefit in load-to-failure, stiffness, and strength. No study indicated a detriment to the repaired rotator cuff. Data on graft-based constructs were limited, with two autograft studies displaying inconsistent results. The majority of included preclinical studies exhibited improved enthesis maturation score and superior histological organization. All twelve clinical studies utilized scaffolds and indicated limited adverse implant-related complications with similar or improved patient-reported outcome measures compared to control repairs. Clinically, grafts/scaffolds and marrow stimulation have demonstrated positive outcomes when augmenting rotator cuff repairs. Preclinical injectables included a wide range of substances such as transforming growth factor β3, erythropoietin, bone marrow & adipose derived mesenchymal stem cells and platelet rich plasma with ozone. Preclinically, the most used injectable was stem cell-based biologics; it was found to have improved load-to-failure and histological findings. The most common findings for preclinical injectables were increased load-to-failure (51.7%) and improved collagen histological quality (31%). Clinically, platelet rich plasma and adipose-derived mesenchymal stem cells have shown potential to enhance rotator cuff repair results with further optimization of delivery methods, such as incorporation within a fibrin matrix. Lastly, marrow stimulation is promising both histologically and mechanically, demonstrating thicker collagen bundles and greater mean load-to-failure in rabbit models. Clinically, marrow stimulation has demonstrated variable but overall positive outcomes when augmenting rotator cuff repairs. Marrow stimulation techniques have demonstrated significant post-operative reduction in pain and improvement in function. Deep marrow venting significantly reduces retear rate relative to stand-alone single-row or double-row repair with limited adverse effects. Vented anchors demonstrated improved ossification and bone density at the anchor site, but no clinically significant difference in outcomes or retear rate.
CONCLUSION: Recent advances in 1. Grafts and scaffolds, 2. Injectable biologics, and 3. Marrow stimulation have helped promote the cellular environment within the joint and demonstrate favorable results in both preclinical and clinical settings. Clinically, grafts and scaffolds have proven to be safe and effective in treating rotator cuff tears, offering a promising means to improve rotator cuff repair load-to-failure, stiffness, and strength. Incorporation of injectable biologics into RCRs has shown the potential for enhanced healing of the biologic intra/extra cellular environment. There are a wide range of biologic compositions, preparation processes, and delivery methods in use. Though additional clinical data is needed, pre-clinical and clinical studies suggest injectable biologics may improve tendon quality and patient outcomes. Finally, marrow stimulation has demonstrated very high healing rates in primary rotator cuff repair and is promising in this setting. Current evidence demonstrates that microfracture and marrow-venting techniques may have a positive impact on healing and retear rate, while vented anchors have muted impact relative to non-vented anchors. Though available evidence is limited and more research is needed, findings to date suggest marrow stimulation techniques may be an inexpensive, simple technique to consider in qualifying patients to prevent rotator cuff retears.