Augmentation for rotator cuff repair - clinical use patterns and limited patient access: the American Shoulder and Elbow Surgeons bio-advocacy work group survey.

Background: Over the last decade, treatment algorithms of rotator cuff pathology have increasingly included various forms of augmentation of rotator cuff repair (RCR). This study aimed to quantify real-world clinical patterns for RCR augmentation and provide consensus statements for clinical practice and payor consideration. It was our hypothesis that augmentation would be popular amongst surgeons, especially for reduction in retear rates, and that a high percentage of respondents would also identify restrictions to access. Material and methods: The American Shoulder and Elbow Surgeons Advocacy Committee distributed a 12-question digital survey to all current members of American Shoulder and Elbow Surgeons. The survey evaluated current surgical techniques and augmentation usage, limitations on augmentation access, target patients for augmentation selection, and desired clinical outcomes. Questions were analyzed as either frequency of response or as a rank average with 95% confidence intervals. Results: The survey was sent to 1,210 surgeons, and 103 surgeons participated in the survey (8.5% response rate). The survey revealed the following: (1) use of RCR augmentation is reported by 76.2% and 85.1% of surgeons for partial-thickness tears (PTT) and full-thickness tears (FTT), respectively. However, 74.5% of surgeons indicate that they have limited or variable access to augmentation options. (2) A bioinductive collagen implant (BCI) is the most preferred form of augmentation for PTT (52.5% of respondents), while both the BCI (45.5%) and human dermal allograft augmentation (45%) are most preferred for FTT.(3) The decision to use augmentation is largely based on positive clinical outcomes (9.4/10) and a defined target patient population (8.4/10), with the most critical outcome being a lower retear rate for both PTT (7/10) and FTT (8/10). (4) For PTT, patient comorbidities (7/10) are of greatest concern and are the most impactful criteria for the decision to use augmentation (6/10). For FTT, poor tendon quality (8.6/10) and increasing tear size (2.9-9.1/10) are of greatest concern, with tear size indicated as the most impactful criteria for selecting augmentation (7.6/10). Conclusion: This expert-opinion survey confirmed the growing popularity of RCR augmentation and the significant limitations in access faced by surgeons and their patients. BCI and human dermal allograft were the most popular augmentation options. Surgeons identify multiple factors as important to decision-making for implant use, including positive clinical outcomes, low retear rates, defined patient populations, patient comorbidities, poor tendon quality, and tear size. Research in this area continues to expand, but additional work on payor approval remains to ensure appropriate access to this technology.