The human acellular dermal matrix (ADM) patch has emerged as a promising adjunctive option [3,10,11]. It provides a scaffold that may enhance tendon healing by facilitating cellular infiltration, neovascularization, and collagen deposition, while simultaneously reducing the mechanical load on the repaired tendon [12,13].

We read with great interest the article entitled, “Effects of tear size on outcomes after acellular dermal matrix-augmented rotator cuff repair?” by Park et al. [14]. The authors reported that ARCR with ADM patch augmentation resulted in lower retear rates (4.8% in the small and medium tear group vs. 25.0% in the large and massive tear group) and improved clinical scores across all tear sizes. Although postoperative improvements in range of motion were limited and stiffness was observed in both groups, the findings suggest that ADM can facilitate healing when applied with appropriate graft sizing and careful patient selection.

Recently, several studies have demonstrated promising clinical and radiological results without significant adverse events after ARCR with ADM patch augmentation for larger rotator cuff tears. A prospective randomized trial by Lee et al. [11] reported a retear rate of 9.1% in the ADM patch augmentation group, which was significantly lower than that in the control group (38.1%). A prospective multicenter randomized trial by Barber et al. [10] investigated the efficacy and safety of ADM patch augmentation to repair large and two-tendon rotator cuff tears. At a 2-year follow-up, 85% of patients in the augmented group had an intact cuff on magnetic resonance imaging (MRI), compared to only 40% in the control group. The augmented group also had improved functional outcome scores, and there were no complications related to the presence of the graft.

However, some important concerns have been raised about the use of ADM. A critical point on the use of ADM for augmentation of a repaired tendon is whether it can achieve biological integration with the repaired tendon over time, given that ADM is not tendon tissue. To identify remodeling patterns of integrated ADM on repaired tendon, serial follow-up MRI studies including long-term evaluation are needed. Recent studies have documented that the absence of serious adverse events such as graft rejection, infection, or foreign body reaction reinforces the safety profile of the ADM patch [4,10,11]. Despite this encouraging evidence, some reports draw attention to the adverse tissue reactions toward ADM. Rashid et al. [15] observed significant extracellular matrix disruption in repaired supraspinatus underlying ADM in four patients.

ADM patch augmentation with ARCR for large to massive rotator cuff tears may reduce retear rates, but its impact on clinical outcomes remains uncertain, as does its safety. Well-designed prospective studies are needed to clarify its clinical relevance and determine proper indications.