“The Box" allograft augmentation for at risk rotator cuff repairs

Background Rotator cuff tears are a challenging problem for orthopedic surgeons, especially those with at risk features. Because of this it is imperative to establish reliable methods to maximize patient outcomes and mitigate the risk of retears. Biologic augmentation with acellular dermal allograft (DAA) has been proposed to improve tendon healing and structural integrity. This study describes a novel arthroscopic technique utilizing DAA augmentation with a box-configuration transosseous-equivalent canopy construct and reports early clinical outcomes. Methods A retrospective review was performed on patients who underwent arthroscopic RCR with DAA augmentation using a box-configuration construct between January 2021 and October 2025 by two surgeons at a single institution. Preoperative MRI was evaluated to classify tear size, tissue quality and tendon retraction. Clinical outcomes assessed included postoperative pain, range of motion, retear rate, and complications. Results Eleven patients underwent RCR with DAA augmentation. Mean age was 59.5 years (range, 51–72) with a mean BMI of 27.6. Seven repairs (63.6%) were revision procedures. Ten tears (90.9%) were full thickness, with a median of two tendons involved and a median Patte retraction grade of 2. Mean follow-up was 7.2 months. Postoperatively, ROM remained excellent in 5 patients (45.5%) and improved in 6 patients (54.5%). Pain improved completely in 9 patients (81.8%) and partially in 2 (18.2%). No postoperative infections were observed or reoperations. Conclusion Arthroscopic RCR with DAA augmentation using a box-configuration canopy construct demonstrated favorable early clinical outcomes and a low complication rate in a cohort with a high proportion of revision repairs. Larger prospective studies with longer follow-up are needed to further evaluate the durability and clinical benefits of this technique.