Bone-marrow-based augmentation in rotator cuff repair—from microfracture to bone marrow aspirate concentrate

Abstract Rotator cuff tears are a major cause of shoulder dysfunction, and relatively high rates of rotator cuff re-tear persist despite surgical advancements, particularly in patients with poor biological healing potential. Bone-marrow-based augmentation techniques, specifically bone marrow stimulation (BMS) and bone marrow aspirate concentrate (BMAC), have been introduced to enhance the biological environment at the repair site, potentially improving outcomes. Bone marrow stimulation, commonly achieved through microfracture, stimulates the release of growth factors and mesenchymal stem cells (MSCs) from the bone marrow to promote tendon-to-bone integration. Although simple and cost-effective, clinical results for BMS augmentation in rotator cuff repair (RCR) are mixed, with most recent meta-analyses not demonstrating a clinically significant superiority over conventional RCR. Augmentation with BMAC offers a more sophisticated approach, concentrating MSCs and anti-inflammatory cytokines to directly enhance the healing process. Preclinical studies have shown promising results with BMAC augmentation, demonstrating improved tendon integrity and biomechanical strength. The existing clinical studies suggest BMAC may reduce re-tear rates and enhance tendon healing, although outcomes are not yet universally optimal. The current evidence highlights the potential of these techniques, particularly as a potential treatment option in biologically challenging cases. However, the variability in clinical outcomes underscores the need for further research to refine these methods and establish their role in routine clinical practice.