Which Biologics Does Dr. Raffo Add During Surgery, and When?

Overview

Several biologic techniques are added to a surgery already being done, rather than sold as a standalone office treatment — a collagen implant placed on a repaired tendon, PRP injected at the repair site, marrow-venting holes drilled to release healing cells, or a concentrate of bone marrow layered onto the construct. Dr. Raffo uses each of these selectively, based on tear or tissue characteristics, not as a routine add-on to every case. This page explains what each one is, where the evidence for it is real, and where it is still unproven.

Who this is for

This page is for patients who are already candidates for a rotator cuff repair or a meniscal repair and want to understand the biologic add-ons that might be discussed at the time of surgery, rather than patients considering an office-based injection as their primary treatment — that decision is covered on the PRP page. It applies most directly to patients undergoing a rotator cuff repair, a partial-thickness rotator cuff tear repair, a Regeneten-augmented repair, or a meniscal repair, including meniscus root repair. None of these add-ons change whether surgery is indicated in the first place; they are refinements layered onto an operation the patient needs regardless.

How I approach it

I think about surgical biologics as tools that address a specific weakness in a specific case, not as a package deal. Regeneten is the one I use most and with the most confidence, because it has an actual Level I randomized trial behind it. In that RCT of transosseous-equivalent cuff repair with or without the bioinductive collagen implant, radiographic retear at roughly 12 months was 8.3% with the implant versus 25.8% without — a two-thirds relative reduction that held up at two years (12.3% versus 35.1%) (Ruiz Ibán, Arthroscopy 2024; ASES 2024). I tell every patient the honest caveat in the same breath: in that same trial, patient-reported outcome scores did not differ between groups — Constant-Murley 76.7 versus 81.7, ASES 75 versus 80, neither reaching significance (Ruiz Ibán, Arthroscopy 2024). The implant reliably improves what the MRI shows. It has not yet been shown to improve how the patient feels at two years. I still use it, because a structurally intact tendon is a reasonable thing to want for its own sake, especially in a younger patient with decades of shoulder use ahead, but I don't oversell the patient-facing benefit.

PRP at the time of cuff repair is a narrower call for me. In a randomized trial specifically in large and massive tears, patients who received intraoperative PRP had better tendon-to-bone MRI signal at three months and better pain and function scores at 12 months, though the trial was not powered to prove a retear-rate difference on its own (Jo et al., AJSM 2013). That is a more favorable picture than PRP has for standalone tendinopathy, and I think the difference makes sense: at the time of repair, PRP is being placed directly at a freshly prepared healing surface rather than injected into an intact, chronically degenerated tendon. I discuss PRP augmentation with patients who have large or massive tears, where the biological healing challenge is greatest, more than I do with smaller, lower-risk tears.

Marrow venting at meniscal repair is a technique I reach for when a patient is having an isolated repair without a concurrent ACL reconstruction, because ACL surgery itself produces a version of the same biologic effect. In a cohort of 109 inside-out meniscal repairs, isolated repairs augmented with marrow venting achieved survivorship comparable to repairs done alongside ACL reconstruction — 86% at two, three, and five years for the vented isolated repairs versus 94% at two to three years and 87% at five years for the ACL-reconstruction group, with no significant difference between them (Dean et al., AJSM 2017). The logic is that an ACL reconstruction floods the joint with marrow elements from tunnel drilling, and an isolated meniscal repair doesn't get that exposure unless it's created deliberately. I add marrow venting routinely to isolated meniscal repairs for exactly this reason.

BMAC is the biologic I use least often and describe most carefully, because its name invites confusion with stem cell transplantation, which it is not. BMAC is a concentrate made from a patient's own bone marrow aspirate, drawn intraoperatively and spun down to concentrate its cellular and growth-factor content — nothing is cultured, expanded, or derived from a donor. In a randomized trial adding BMAC to cuff repair, the structural retear rate fell sharply — 18% versus 57% on Sugaya grading — but clinical failure rates were nearly identical between groups (16% versus 15%) and patient-reported outcomes did not differ (Cole et al., AJSM 2023). I present that result to patients exactly as it reads: a real structural signal, no proven functional benefit yet, and a treatment I reserve for larger tears in patients with reduced biological healing potential rather than something I add by default.

Risks and honest tradeoffs

Each of these techniques adds a small amount of time and, in most cases, a modest add-on expense to the primary operation, without materially changing the risk profile of the surgery itself. Regeneten and PRP have not shown increased complication rates compared with repair alone in the trials cited above. Marrow venting adds a brief drilling step at the intercondylar notch and has a low reported rate of augmentation-related adverse events. BMAC requires an additional aspiration, typically from the iliac crest, which adds temporary local soreness at the aspiration site beyond what the primary surgery already involves. None of these techniques are risk-free substitutes for a well-executed repair — they are additions to one, and none of them have been shown to change whether the underlying repair holds up if the repair technique itself is inadequate. Cost is also a real consideration: several of these add-ons, particularly BMAC and certain PRP protocols, are not reliably covered by insurance even when the underlying surgery is, and patients should ask specifically what their plan covers before assuming a biologic add-on is included.

Alternatives I considered

For a rotator cuff repair where the tissue quality is genuinely poor rather than merely average, an alternative to layering on more biology is to change the surgical plan itself — a more robust suture-bridge construct, a different anchor pattern, or, in select irreparable tears, a different operation entirely, as discussed on the rotator cuff repair page. For an isolated meniscal repair in a patient who declines marrow venting, meticulous preparation of the tear bed and vascularized rim remain the primary drivers of healing, and venting is additive rather than essential.

Biologics used