Leukocyte-poor platelet-rich plasma reduces retear risk after arthroscopic rotator cuff repair: a meta-analysis with mechanistic and economic evaluation

Rotator cuff repair (RCR) is one of the most common orthopedic procedures, yet 20%-40% of repairs fail structurally within two years, leading to pain, functional decline, and costly revision surgery. Platelet-rich plasma (PRP) has been proposed to enhance tendon-bone healing, but prior reviews frequently pooled heterogeneous formulations as a homogeneous intervention, producing conflicting conclusions. This review aimed to clarify formulation-specific effects within the PRP literature and, where benefit is observed, examine the biological rationale and practical economic implications for surgical adoption. A systematic review and meta-analysis were conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed and Embase were searched through July 2025 for comparative clinical studies of intraoperative PRP augmentation during arthroscopic RCR with imaging-confirmed retear outcomes. Risk of bias was assessed using Risk of Bias 2 tool (randomized controlled trials) and Risk Of Bias In Nonrandomized Studies-I (nonrandomized studies). Random-effects models (restricted maximum likelihood; Hartung-Knapp) pooled risk ratios (RRs) for structural failure and, secondarily, mean differences in patient-reported outcome measures (PROMs). Prespecified subgroups included PRP formulation, tear size, and follow-up duration; sensitivity analyses excluded high-risk and atypical studies. Publication bias was evaluated with Egger's regression and trim-and-fill. A pragmatic U.S. payer-perspective cost-consequence model estimated revision-related economic impact using pooled absolute risk reduction, number needed to treat, amortized per-case PRP setup costs, and reported reoperation rates after RCR. Twenty-one studies (1,279 patients) were synthesized. PRP reduced retear risk with moderate heterogeneity (RR: 0.74, 95% confidence interval [CI]: 0.55-0.99; I≈ 29%). Across formulations, LP-PRP demonstrated the clearest reduction. Inclusion of one critically biased trial increased heterogeneity (I= 53.3%), whereas its exclusion yielded a precise, homogeneous estimate (RR: 0.37, 95% CI: 0.19-0.73; I= 0%). Benefit was most evident in medium-sized tears (RR: 0.68, 95% CI: 0.48-0.96). PROMs did not improve consistently. Publication-bias diagnostics suggested small-study effects (Egger P = .017); trim-and-fill (k= 8) yielded an exploratory adjusted RR of 0.91 (95% CI: 0.69-1.19). Using an absolute risk reduction of 11.8% (number needed to treat 9) for LP-PRP, economic modeling projected substantial reductions in structural failures, with cost neutrality or net savings achievable under low-cost preparation strategies when scaled by reported revision probabilities. Leukocyte-poor PRP augmentation during arthroscopic RCR is associated with reduced structural retear rates, with the most consistent benefit observed in medium-sized tears and no reliable improvement in PROMs. The economic value of LP-PRP is conditional rather than uniform and depends on revision probability and preparation cost. When applied using low-cost preparation methods, LP-PRP may achieve cost neutrality or modest savings, supporting selective adoption as a structural safeguard rather than a symptomatic modifier.