Effect of BMAC-PRP augmentation on repair of large rotator cuff tears: a clinical evaluation among different age groups.

The use of orthobiologic augmentation, including platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), has gained increasing attention in rotator cuff repair; however, evidence supporting their combined use remains limited and inconsistent. This prospective randomized controlled study evaluated the clinical efficacy of PRP and combined PRP with BMAC (BMAC + PRP) following arthroscopic repair of large full-thickness rotator cuff tears (3-5 cm). A total of 93 patients were allocated into three groups: control (n = 33), PRP (n = 30), and BMAC + PRP (n = 30). Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score (primary outcome), visual analogue scale (VAS), and Constant score at baseline, 3 months, and 6 months. To address baseline imbalances, propensity score-based overlap weighting (ATO) and weighted ANCOVA were performed. All groups demonstrated significant improvement in pain and functional outcomes over time. In unadjusted analyses, early differences were observed at 3 months; however, after adjustment using overlap weighting and baseline covariates, no statistically significant differences were observed between groups at 6 months for ASES, VAS, or Constant scores. Exploratory age-stratified analyses suggested potential trends toward improved outcomes in patients aged > 55 years in the BMAC + PRP group, although these findings were attenuated after adjustment and should be interpreted cautiously. These findings indicate that, despite theoretical biological complementarity, the addition of BMAC to PRP does not confer clinically meaningful short-term benefit after repair of large rotator cuff tears. The results challenge the assumption of additive efficacy in combined orthobiologic strategies and underscore the need for biologically stratified trials to identify patient subsets that may derive benefit. Longer-term and mechanistically integrated studies are required to define the role of combined biologic augmentation in tendon regeneration.Trial registration: The patients were registered in the institutional board registry of Hallym University Medical Center (registry number 138-82-02667). The study was registered with the International Standard Randomized Controlled Trial Number (ISRCTN) 69,088,783.