Massive rotator cuff tears: biceps tendon autograft or dermal allograft?

Polish version: Masywne uszkodzenie stożka rotatorów — ścięgno bicepsa czy przeszczep skórny?

A meta-analysis of reconstruction for massive rotator cuff tears does not establish a clearly superior graft material. Both long head of biceps tendon autograft and acellular dermal allograft were associated with improved pain, function and motion. All included studies were observational, however, and surgical techniques varied substantially.

Why this study matters

Massive tears can be difficult to repair durably when there is marked retraction, poor tissue quality or muscle atrophy. Biological augmentation and reconstruction may help address inadequate coverage or structural integrity. Biceps autograft avoids donor material and may preserve biological continuity with the patient’s tissues, while dermal allograft offers material with predictable dimensions and mechanical properties. Robust comparisons have been limited.

Review methods

Alhussain and colleagues followed PRISMA and searched PubMed, Embase, Scopus and the Cochrane Library. Seventeen observational studies included 613 patients: 322 treated with biceps tendon autograft and 291 with acellular dermal allograft.

Outcomes included ASES, VAS pain, range of motion, acromiohumeral distance and structural failure. The groups encompassed superior capsular reconstruction, repair augmentation and bridging grafts, rather than one identical operation performed across centres.

Main results

Both strategies produced substantial postoperative improvement. Standardised mean differences for ASES were 2.35 with biceps autograft and 1.65 with dermal allograft; the between-subgroup difference was not statistically significant (P = 0.07).

VAS pain improved considerably in both groups, without a significant difference between techniques (P = 0.32). Elevation, external rotation and acromiohumeral distance also improved, without convincing evidence favouring one strategy.

No significant difference in structural failure was demonstrated. Failure rates varied widely between studies, however, and definitions and imaging surveillance were inconsistent.

Clinical interpretation for an orthopaedic surgeon

Both approaches can yield good results in selected patients, but current evidence does not support routinely preferring one material. Selection still depends on tear pattern, tendon quality, availability and condition of the biceps tendon, muscle atrophy and fatty infiltration, prior surgery, patient expectations and surgeon experience.

These studies did not simply compare otherwise identical reconstructions using different grafts. Differences may reflect operative design, indications and patient selection as well as material properties.

Limitations

• All 17 studies were observational; there were no randomized comparisons.
• Definitions of a massive tear varied by defect size or number of involved tendons.
• Superior capsular reconstruction, augmentation and bridging are biomechanically different procedures.
• Fatty infiltration, retraction, subscapularis integrity, graft thickness, associated procedures and rehabilitation were inconsistently reported.
• Failure was usually assessed with MRI, but some studies used ultrasound or clinical criteria.

Implications for practice

The review supports individual selection rather than assuming that one graft is inherently better. Biceps autograft was not clearly inferior in the available clinical data, but absence of a significant difference does not establish equivalence. Optimal treatment for particular tear patterns and comparative long-term outcomes remain uncertain. Prospective, preferably randomized studies with standardised techniques and eligibility criteria are needed.

References

• Poboży T, Kielar M, Miąskiewicz J. Ultrasound-guided biodegradable subacromial spacer implantation in a patient with massive irreparable rotator cuff tears. Wideochir Inne Tech Maloinwazyjne. 2019;14(1):145-148. DOI: 10.5114/wiitm.2018.77555. This report concerns a different treatment for the same clinical problem: a massive irreparable rotator cuff tear.
• Alhussain AH, Alzahrani MT, Aljaafri ZA, et al. Rotator Cuff Reconstruction Using Biceps Tendon Autograft Versus Acellular Dermal Allograft: A Systematic Review and Meta-analysis of Clinical Outcomes. Orthop J Sports Med. 2026;14(8):23259671261470960. DOI: 10.1177/23259671261470960. PubMed.

The meta-analysis was published on 24 August 2026. The full text is legally available in PubMed Central.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.