Rotator Cuff Reconstruction Using Biceps Tendon Autograft Versus Acellular Dermal Allograft: A Systematic Review and Meta-analysis of Clinical Outcomes.

BACKGROUND: Massive rotator cuff tears impose a challenge in shoulder surgery because of high failure rates and poor tendon healing. Augmentation using biological grafts emerged as a solution to enhance surgical outcomes; they provide structural reinforcement, while biceps tendon autografts offer native biological integration. The comparative effectiveness of these 2 techniques remains unclear. HYPOTHESIS/PURPOSE: We hypothesized that both techniques would provide comparable clinical outcomes, but differences may exist in graft integrity and complication rates. The purpose was to evaluate clinical outcomes, functional improvement, and graft healing rates after rotator cuff repair using human dermal (HD) allograft versus biceps tendon autograft augmentation. STUDY DESIGN: Meta-analysis and systematic review; Level of evidence, 4. METHODS: A meta-analysis was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were identified through a comprehensive search of the PubMed, Embase, Scopus, and Cochrane Library databases. Studies comparing HD allografts and biceps tendon autografts for rotator cuff repair were included. Outcome measures included the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS), range of motion (ROM), acromiohumeral distance (AHD), and retear rates. A random-effects model was used to analyze pooled data, and heterogeneity was assessed using the I2 statistic. RESULTS: Seventeen observational studies involving 613 patients were included, comparing long head of the biceps tendon (LHBT) autograft (n = 322) and acellular HD allograft (n = 291). Both techniques demonstrated substantial improvements across functional, pain, and radiological outcomes. For functional recovery, the pooled standardized mean difference (SMD) in ASES scores was higher in the LHBT autograft group (SMD, 2.35 [1.63 to 3.07]) compared with the HD allograft group (SMD, 1.65 [1.40 to 1.90]). However, subgroup differences were not statistically significant (P = .07). Pain outcomes showed marked improvement in both groups, with LHBT autograft demonstrating a greater reduction (VAS SMD, -2.25 [-2.89 to -1.61]) compared with HD allograft (SMD, -1.89 [-2.22 to -1.56]; P = .32). ROM also improved, with forward elevation SMDs of 0.92 (LHBT) and 0.65 (HD), and external rotation SMDs of 1.08 and 0.22, respectively. AHD increased in both groups (LHBT SMD, 1.38; HD SMD, 1.13), with no significant intergroup differences observed. CONCLUSION: Both LHBT autograft and acellular HD allograft augmentation for massive rotator cuff repair showed improvements in function, pain, ROM, and AHD, with comparable retear rates. Despite heterogeneity among studies, HD allograft procedures appear to yield predictable clinical outcomes, although comparisons with the unaugmented rotator cuff repair literature remain necessary.