Commonly, the use of patches in the rotator cuff surgery can be identified in two different settings: augmentation of repair or as gap-spanning devices. We prefer to use patches for augmentation only, particularly in case of large to massive tears with degenerative tendons that may be less likely to heal. In cases where the tear appears irreparable, retracted, and associated with a severe (grade IV) muscle atrophy, the use of patch as bridging in our view is not suitable because there are problems related to securing the graft to the native patient’s tissue, and moreover it is not likely that it can be repopulated and function as muscle-tendon unit.

We also prefer to augment with patches in the setting of revision repairs in cases without a severe grade of muscle atrophy.

We use biological patches because we believe that it could be able to increase early strength of repair, provide a biological network for cellular ingowth, and not induce a foreign-body reaction, thereby not interfering with the healing process.

Advanced glenohumeral osteoarthritis/rotator cuff tear arthropathy is a relative contraindication because these patients may get significant stiffness and inadequate pain relief.

We use the augmentation patch associated with the suture anchors technique for rotator cuff repair. Patients are under general anaesthesia and positioned in a lateral decubitus position. The arm is prepped and draped sterilely. A standard posterior portal to the glenohumeral joint is established, and diagnostic arthroscopy is done. Then an anterior and two lateral portals are made. Associated lesions, if detected, are treated simultaneously, after which attention is turned to the rotator cuff. The stump of tendon is identified and debrided minimally, then it is pulled with a grasper toward the greater tuberosity to assess if a direct repair is possible. Sometimes, in case of massive retracted V-shape tear, marginal convergence sutures could be necessary as first step. The tendons are mobilised enough to bring the edge back to the native footprint on the greater tuberosity. Then we start the repair. We use a single row repair with triple loaded suture anchors. According to the size of tear, two or three anchors are inserted on the greater tuberosity at a distance where the repairing cuff is not overtensioned. Two of three sutures of anchors are passed directly through the tendon, then arthroscopic knots are tied to secure the tendon to the greater tuberosity (Fig. 1). The strands of these sutures are cut. One limb of suture that remains from each anchor is retrieved outside the lateral cannula and passed through the lateral margin of the patch. The size of patch is then measured, and the graft is cut and prepared on the back table. Medially on the rotator cuff three sutures are passed – one anteromedial, one in the middle, and one posteromedial – and retrieved from anterior cannula, percutaneously through the Neviaser portal and from posterior cannula, respectively. One limb of these three sutures is retrieved from lateral cannula and passed through the medial margin of the patch. The limbs coming from each suture are knotted with a Mulberry knot over the surface of the patch. Different suture colors can help during these steps. Once all the sutures are passed through the patch, the patch is pushed gently through the lateral cannula and the other limb of sutures (that outside the anterior cannula, Neviaser portal, posterior cannula and the other two sutures coming through the anchors that remain all the time outside the skin) are pulled by an assistant so that the patch is introduced in the subacromial space and on the cuff. In this phase, any twist of suture should be avoided (Fig. 2a–e). Once the patch is on the cuff, any single suture is retrieved from lateral, anterior or posterior cannula and are tied (Figs. 3 and 4).