My Published Algorithm for Graft Augmentation of Rotator Cuff Repairs, Used by Surgeons Worldwide
Not every rotator cuff repair will heal on its own. For patients with large tears, advanced age, significant muscle degeneration, or poor bone density, simply stitching the tendon back down may not be enough. My published framework — used by surgeons internationally — identifies who is at high risk for repair failure and when adding a graft patch can double or even triple the odds of healing.
The Problem: Rotator Cuff Repairs Don't Always Heal
Arthroscopic rotator cuff repair has transformed shoulder surgery over the past two decades. For many patients — particularly those with smaller tears and healthy muscle tissue — repair is highly effective and durable. But for larger tears, older patients, and those with certain risk factors, the reality is more complicated.
Retear rates after repair of large and massive rotator cuff tears can reach as high as 94% in some published series. That doesn't mean repair is the wrong choice — patients frequently improve even when the tendon doesn't maintain full structural integrity. But it does mean that for high-risk patients, doing a standard repair and hoping for the best is not a complete strategy. Identifying who is at high risk, and taking steps to improve their odds, is the more rigorous approach.
My co-authored algorithm, published in Arthroscopy: The Journal of Arthroscopic and Related Surgery alongside Dr. Asheesh Bedi from the University of Michigan, provides a systematic framework for exactly this decision. It has been adopted by shoulder surgeons around the world as a guide for when and how to augment a rotator cuff repair with a graft patch.
The Core Question: Who Is at High Risk for Repair Failure?
Multiple factors predict whether a rotator cuff repair will heal. Research from a large study of 603 patients identified three variables that most powerfully drive retear risk:
- Tendon retraction of 3 cm or more — increased the odds of retear by nearly 13 times
- Infraspinatus fatty infiltration grade 2 or higher — increased retear odds by nearly 3 times
- Patient age over 70 — increased retear odds by nearly 3 times
Beyond these three, other documented risk factors include a larger anteroposterior tear size (greater than 2.5 cm), low bone mineral density (osteoporosis), high-demand physical work activity, and tobacco use.
These factors don't operate in isolation — they stack. A 72-year-old with a large retracted tear and moderate muscle degeneration faces dramatically worse healing odds than a 55-year-old with a moderately retracted tear and healthy muscle. The challenge for surgeons is synthesizing all of these factors into a single, actionable preoperative prediction.
The Rotator Cuff Healing Index (RoHI): A Scoring Tool for Healing Prediction
The framework at the center of this algorithm is the Rotator Cuff Healing Index (RoHI) — a 15-point scoring system that weights the key predictive factors and generates a preoperative estimate of healing probability. The scoring is straightforward:
- Tendon retraction: 0 points for less than 1 cm; up to 4 points for 3 cm or more
- Infraspinatus fatty infiltration grade 2 or higher: 3 points
- AP tear size greater than 2.5 cm: 2 points
- Patient age over 70: 2 points
- Low bone mineral density (T-score -2.5 or worse): 2 points
- High-demand work activity: 2 points
What does the score mean in practice?
86% healing rate for patients scoring 4 or below
66% healing rate at a score of 6
38% healing rate at a score of 7
27% healing rate at a score of 10 or above
The steep drop between a score of 6 and 7 is clinically significant. In my practice, a RoHI of 7 or higher is the threshold where we seriously consider augmenting the repair with a graft patch — because at that level, nearly two-thirds of repairs will fail without additional support.
A RoHI score of 7 represents a crossover point: below it, standard repair is likely to work; at or above it, augmentation should be strongly considered to give the repair a meaningful chance of lasting structural healing.
What Is Graft Augmentation and How Does It Help?
Graft augmentation means applying a tissue patch or scaffold over the repaired tendon to reinforce it. The graft serves two purposes: it provides immediate mechanical reinforcement at the repair site, and it serves as a biological scaffold that supports tissue ingrowth and healing over time.
Several types of grafts have been studied:
- Acellular dermal allograft — human donor tissue that has been processed to remove cells, leaving the collagen scaffold intact. This is my preferred graft for augmentation. Studies show it revascularizes and remodels into tendon-like tissue with no inflammation. Biomechanical cadaveric studies have shown a 62% increased load to failure compared to standard repair, and a 22% reduction in failure rate.
- Bovine collagen patch — a bioinductive collagen implant derived from bovine tissue. Healing rates of 89% to 96% have been reported in clinical studies with no adverse reactions.
- Xenograft (porcine intestinal submucosa) — earlier generation grafts that showed high rates of hypersensitivity reactions (up to 20%) and have largely been supplanted by newer options.
The clinical evidence for augmentation is compelling. In a prospective randomized trial, 85% of large tears augmented with dermal allograft showed healing at one year — compared to just 40% with standard repair alone. Another study found a retear rate of only 10% with augmentation versus 26% with standard repair in large and massive tears. A systematic review of 82 integrity rates found allograft augmentation achieving 82% healing, versus 68% for xenograft and 49% for standard repair.
How the Algorithm Works in Practice
The decision tree is built on two foundational steps that flow from my broader massive rotator cuff tear management algorithm.
First: Is the shoulder a candidate for joint preservation? This requires intact or near-intact joint space (Hamada grades 1 or 2 on X-ray). Patients with significant glenohumeral arthritis are typically directed toward reverse shoulder replacement rather than repair.
Second: Is the tear repairable? If yes, the RoHI score guides whether standard repair or augmented repair is appropriate:
- RoHI below 7: Standard repair — the biological conditions favor healing without a patch
- RoHI 7 or above: Repair with graft augmentation — the risk of failure without additional support is too high to proceed with standard repair alone
For irreparable tears, augmentation alone is not sufficient. In younger patients (under 70), reconstruction options such as superior capsule reconstruction or cable reconstruction are considered. In older, lower-demand patients, partial repair with or without augmentation may be appropriate if arthritis is absent or minimal.
Two examples from the paper illustrate the algorithm in action. A 50-year-old active patient with a 3 cm retracted tear, large AP dimension, and grade 2 infraspinatus infiltration would score 9 to 11 on the RoHI — representing only a 12% to 46% chance of healing with standard repair. That patient is a clear augmentation candidate. A 72-year-old with an acute 3 cm retracted tear but no fatty infiltration would score 8 to 12 — still projecting only 28% healing without augmentation — and would similarly benefit from the patch.
What This Means for Patients
This framework has three practical implications for patients considering rotator cuff surgery.
First, not all repairs are created equal. If you have a large tear, are over 65, have been told there is significant muscle degeneration on your MRI, or have osteoporosis, you are at elevated risk for repair failure. A surgeon who does not factor these variables into the surgical plan — and does not consider augmentation — may be leaving a significant opportunity on the table.
Second, the conversation before surgery matters. The RoHI score can be calculated from your preoperative MRI and clinical information before you enter the operating room. This allows for an honest discussion about healing expectations and whether augmentation makes sense for your specific situation — rather than making that decision based on what the tissue looks like in the moment of surgery.
Third, augmentation adds cost and operative time, and carries small additional risks. It is not appropriate for every patient. But for those with a RoHI of 7 or higher — where the odds of healing without a patch fall below 40% — the evidence supports its use as a meaningful way to improve structural outcomes.
The Bottom Line
Rotator cuff repair is not a single, uniform operation. It is a family of approaches that ranges from straightforward standard repair to augmented repair with biologic patch reinforcement — and the right choice depends on a careful, individualized assessment of the patient's healing risk.
The algorithm published in Arthroscopy, and used by surgeons internationally, brings structure and evidence to that decision. By calculating the RoHI score from preoperative factors — age, tear size, retraction, muscle quality, bone density, and work demands — surgeons and patients can enter the operating room with a clear plan and realistic expectations.
If you have a large rotator cuff tear and are wondering whether your repair will hold, asking about your RoHI score and whether augmentation is appropriate for your case is exactly the right question.
Patrick J. Denard, MD is a fellowship-trained orthopedic surgeon specializing in shoulder surgery at the Oregon Shoulder Institute in Medford, Oregon. He is a co-author of "Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates," published in Arthroscopy: The Journal of Arthroscopic and Related Surgery (2022), alongside Dr. Asheesh Bedi of the University of Michigan. This framework has been adopted by shoulder surgeons internationally.
If you have a large or massive rotator cuff tear and want an expert assessment of your healing risk and surgical options, request an appointment at Oregon Shoulder Institute.
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