Skeletal Radiology

, Volume 48, Issue 1, pp 47–55 | Cite as

Graft use in the treatment of large and massive rotator cuff tears: an overview of techniques and modes of failure with MRI correlation

  • Kyle R. DuchmanEmail author
  • Dayne T. Mickelson
  • Barrett A. Little
  • Thomas W. HashII
  • Devin B. Lemmex
  • Alison P. Toth
  • Grant E. Garrigues
Review Article


Despite technical advances, repair of large or massive rotator cuff tears continues to demonstrate a relatively high rate of failure. Rotator cuff repair or superior capsular reconstruction (SCR) using a variety of commercially available grafts provides a promising option in patients with tears that may be at high risk for failure or otherwise considered irreparable. There are three major graft constructs that exist when utilizing graft in rotator cuff repair or reconstruction: augmentation at the rotator cuff footprint, bridging, and SCR. Each construct has a unique appearance when evaluated using postoperative magnetic resonance imaging (MRI), and each construct has unique sites that are predisposed to failure. Understanding the basic principles of these constructs can help the radiologist better evaluate the postoperative MRI appearance of these increasingly utilized procedures.


Rotator cuff repair Superior capsular reconstruction Rotator cuff graft Rotator cuff augmentation Rotator cuff interposition 



No external funding was utilized for the published content.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.


  1. 1.
    Iyengar JJ, Samagh SP, Schairer W, Singh G, Valone FH 3rd, Feeley BT. Current trends in rotator cuff repair: surgical technique, setting, and cost. Arthroscopy. 2014;30(3):284–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227–33.CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86-a(2):219–24.CrossRefPubMedGoogle Scholar
  4. 4.
    Jung HJ, Sim GB, Bae KH, Kekatpure AL, Chun JM, Jeon IH. Rotator cuff surgery in patients older than 75 years with large and massive tears. J Shoulder Elbow Surg. 2017;26(2):265–72.CrossRefPubMedGoogle Scholar
  5. 5.
    Rhee YG, Cho NS, Yoo JH. Clinical outcome and repair integrity after rotator cuff repair in patients older than 70 years versus patients younger than 70 years. Arthroscopy. 2014;30(5):546–54.CrossRefPubMedGoogle Scholar
  6. 6.
    Kim SJ, Kim SH, Lee SK, Seo JW, Chun YM. Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity. J Bone Joint Surg Am. 2013;95(16):1482–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Choi CH, Kim SK, Cho MR, Baek SH, Lee JK, Kim SS, et al. Functional outcomes and structural integrity after double-pulley suture bridge rotator cuff repair using serial ultrasonographic examination. J Shoulder Elbow Surg. 2012;21(12):1753–63.CrossRefPubMedGoogle Scholar
  8. 8.
    Toussaint B, Schnaser E, Bosley J, Lefebvre Y, Gobezie R. Early structural and functional outcomes for arthroscopic double-row transosseous-equivalent rotator cuff repair. Am J Sports Med. 2011;39(6):1217–25.CrossRefPubMedGoogle Scholar
  9. 9.
    Hanusch BC, Goodchild L, Finn P, Rangan A. Large and massive tears of the rotator cuff: functional outcome and integrity of the repair after a mini-open procedure. J Bone Joint Surg (Br). 2009;91(2):201–5.CrossRefGoogle Scholar
  10. 10.
    Kilcoyne KG, Guillaume SG, Hannan CV, Langdale ER, Belkoff SM, Srikumaran U. Anchored transosseous-equivalent versus anchorless transosseous rotator cuff repair: a biomechanical analysis in a cadaveric model. Am J Sports Med. 2017;45(10):2364–71.CrossRefPubMedGoogle Scholar
  11. 11.
    Tashjian RZ, Hoy RW, Helgerson JR, Guss AD, Henninger HB, Burks RT. Biomechanical comparison of transosseous knotless rotator cuff repair versus transosseous equivalent repair: half the anchors with equivalent biomechanics? Arthroscopy. 2018;34(1):58–63.CrossRefPubMedGoogle Scholar
  12. 12.
    Meisel AF, Henninger HB, Barber FA, Getelman MH. Biomechanical comparison of standard and linked single-row rotator cuff repairs in a human cadaver model. Arthroscopy. 2017;33(5):938–44.CrossRefPubMedGoogle Scholar
  13. 13.
    Quigley RJ, Gupta A, Oh JH, Chung KC, McGarry MH, Gupta R, et al. Biomechanical comparison of single-row, double-row, and transosseous-equivalent repair techniques after healing in an animal rotator cuff tear model. J Orthop Res. 2013;31(8):1254–60.CrossRefPubMedGoogle Scholar
  14. 14.
    Barber FA, Drew OR. A biomechanical comparison of tendon-bone interface motion and cyclic loading between single-row, triple-loaded cuff repairs and double-row, suture-tape cuff repairs using biocomposite anchors. Arthroscopy. 2012;28(9):1197–205.CrossRefPubMedGoogle Scholar
  15. 15.
    Charles MD, Christian DR, Cole BJ. The role of biologic therapy in rotator cuff tears and repairs. Curr Rev Musculoskelet Med. 2018;11(1):150–61.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Gillespie RJ, Knapik DM, Akkus O. Biologic and synthetic grafts in the reconstruction of large to massive rotator cuff tears. J Am Acad Orthop Surg. 2016;24(12):823–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Ferguson DP, Lewington MR, Smith TD, Wong IH. Graft utilization in the augmentation of large-to-massive rotator cuff repairs: a systematic review. Am J Sports Med. 2016;44(11):2984–92.CrossRefPubMedGoogle Scholar
  18. 18.
    Weeks KD 3rd, Dines JS, Rodeo SA, Bedi A. The basic science behind biologic augmentation of tendon-bone healing: a scientific review. Instr Course Lect. 2014;63:443–50.PubMedGoogle Scholar
  19. 19.
    Lewington MR, Ferguson DP, Smith TD, Burks R, Coady C, Wong IH. Graft utilization in the bridging reconstruction of irreparable rotator cuff tears: a systematic review. Am J Sports Med. 2017;45(13):3149–57.CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Washburn R 3rd, Anderson TM, Tokish JM. Arthroscopic rotator cuff augmentation: surgical technique using bovine collagen bioinductive implant. Arthrosc Tech. 2017;6(2):e297–301.CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    Ciampi P, Scotti C, Nonis A, Vitali M, Di Serio C, Peretti GM, et al. The benefit of synthetic versus biological patch augmentation in the repair of posterosuperior massive rotator cuff tears: a 3-year follow-up study. Am J Sports Med. 2014;42(5):1169–75.CrossRefPubMedGoogle Scholar
  22. 22.
    Proctor CS. Long-term successful arthroscopic repair of large and massive rotator cuff tears with a functional and degradable reinforcement device. J Shoulder Elbow Surg. 2014;23(10):1508–13.CrossRefPubMedGoogle Scholar
  23. 23.
    Giannotti S, Ghilardi M, Dell’osso G, Magistrelli L, Bugelli G, Di Rollo F, et al. Study of the porcine dermal collagen repair patch in morpho-functional recovery of the rotator cuff after minimum follow-up of 2.5 years. Surg Technol Int. 2014;24:348–52.PubMedGoogle Scholar
  24. 24.
    Boutsiadis A, Chen S, Jiang C, Lenoir H, Delsol P, Barth J. Long head of the biceps as a suitable available local tissue autograft for superior capsular reconstruction: “the Chinese way”. Arthrosc Tech. 2017;6(5):e1559–66.CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Kokubu T, Mifune Y, Inui A, Kuroda R. Arthroscopic rotator cuff repair with graft augmentation of fascia Lata for large and massive tears. Arthrosc Tech. 2016;5(6):e1235–8.CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Steinhaus ME, Makhni EC, Cole BJ, Romeo AA, Verma NN. Outcomes after patch use in rotator cuff repair. Arthroscopy. 2016;32(8):1676–90.CrossRefPubMedGoogle Scholar
  27. 27.
    Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy. 1994;10(4):363–70.CrossRefPubMedGoogle Scholar
  28. 28.
    Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92(15):2544–56.CrossRefPubMedGoogle Scholar
  29. 29.
    Gupta AK, Hug K, Berkoff DJ, Boggess BR, Gavigan M, Malley PC, et al. Dermal tissue allograft for the repair of massive irreparable rotator cuff tears. Am J Sports Med. 2012;40(1):141–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Ono Y, Davalos Herrera DA, Woodmass JM, Boorman RS, Thornton GM, Lo IK. Graft augmentation versus bridging for large to massive rotator cuff tears: a systematic review. Arthroscopy. 2017;33(3):673–80.CrossRefPubMedGoogle Scholar
  31. 31.
    Mohana-Borges AV, Chung CB, Resnick D. MR imaging and MR arthrography of the postoperative shoulder: spectrum of normal and abnormal findings. Radiographics. 2004;24(1):69–85.CrossRefPubMedGoogle Scholar
  32. 32.
    Gyftopoulos S, Guja KE, Subhas N, Virk MS, Gold HT. Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears. J Shoulder Elbow Surg. 2017;26(12):2067–77.CrossRefPubMedGoogle Scholar
  33. 33.
    Spielmann AL, Forster BB, Kokan P, Hawkins RH, Janzen DL. Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals—initial experience. Radiology. 1999;213(3):705–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Crim J, Burks R, Manaster BJ, Hanrahan C, Hung M, Greis P. Temporal evolution of MRI findings after arthroscopic rotator cuff repair. AJR Am J Roentgenol. 2010;195(6):1361–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Roy JS, Braen C, Leblond J, Desmeules F, Dionne CE, MacDermid JC, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. Br J Sports Med. 2015;49(20):1316–28.CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Lo IK, Burkhart SS. Double-row arthroscopic rotator cuff repair: re-establishing the footprint of the rotator cuff. Arthroscopy. 2003;19(9):1035–42.CrossRefPubMedGoogle Scholar
  37. 37.
    Trantalis JN, Boorman RS, Pletsch K, Lo IK. Medial rotator cuff failure after arthroscopic double-row rotator cuff repair. Arthroscopy. 2008;24(6):727–31.CrossRefPubMedGoogle Scholar
  38. 38.
    Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med. 2010;38(4):664–71.CrossRefPubMedGoogle Scholar
  39. 39.
    Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83.Google Scholar
  40. 40.
    Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8(6):599–605.CrossRefPubMedGoogle Scholar
  41. 41.
    Ji X, Bi C, Wang F, Wang Q. Arthroscopic versus mini-open rotator cuff repair: an up-to-date meta-analysis of randomized controlled trials. Arthroscopy. 2015;31(1):118–24.CrossRefPubMedGoogle Scholar
  42. 42.
    Narvani AA, Imam MA, Polyzois I, Sarkhel T, Gupta R, Levy O, et al. The “pull-over” technique for all arthroscopic rotator cuff repair with extracellular matrix augmentation. Arthrosc Tech. 2017;6(3):e679–87.CrossRefPubMedCentralPubMedGoogle Scholar
  43. 43.
    Burkhart SS, Denard PJ, Adams CR, Brady PC, Hartzler RU. Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff repair. Arthrosc Tech. 2016;5(6):e1407–18.CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Cummins CA, Murrell GA. Mode of failure for rotator cuff repair with suture anchors identified at revision surgery. J Shoulder Elbow Surg. 2003;12(2):128–33.CrossRefPubMedGoogle Scholar
  45. 45.
    Denard PJ, Brady PC, Adams CR, Tokish JM, Burkhart SS. Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft. Arthroscopy. 2018;34(1):93–9.CrossRefPubMedGoogle Scholar

Copyright information

© ISS 2018

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryDuke University Medical CenterDurhamUSA
  2. 2.Proliance Orthopaedics and Sports MedicineIssaquahUSA
  3. 3.OrthoCarolinaRock HillUSA
  4. 4.RadsourceRaleighUSA

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