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Scientific Articles   |    
Factors Affecting Satisfaction and Shoulder Function in Patients with a Recurrent Rotator Cuff Tear
H. Mike Kim, MD1; Jon-Michael E. Caldwell, MD2; John A. Buza, MD2; Leslie A. Fink, MD2; Christopher S. Ahmad, MD2; Louis U. Bigliani, MD2; William N. Levine, MD2
1 Department of Orthopaedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, 30 Hope Drive, EC089, Hershey, PA 17033
2 Department of Orthopaedic Surgery, New York-Presbyterian Hospital/Columbia University Medical Center, 622 West 168th Street, PH-11, New York, NY 10032. E-mail address for W.N. Levine: wnl1@columbia.edu
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Investigation performed at New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY

A commentary by Robert Tashjian, MD, is linked to the online version of this article at jbjs.org.



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2014 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2014 Jan 15;96(2):106-112. doi: 10.2106/JBJS.L.01649
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Abstract

Background: 

It is widely accepted that most patients treated with rotator cuff repair do well regardless of the integrity of the repair. The purpose of this cross-sectional study was to reexamine this concept and identify the factors affecting the outcomes of patients with a recurrent tear.

Methods: 

A cohort of patients who had been treated with rotator cuff repair completed a survey regarding satisfaction with the operatively treated shoulder, physical activity, and shoulder function. Ultrasonography was performed to determine rotator cuff integrity. Patients were divided into three age categories: younger than fifty-five years, fifty-five to sixty-five years, and sixty-six years or older. The relationships of the outcomes to patient age, repair integrity, and other demographic factors were analyzed.

Results: 

Forty-seven (26%) of the 180 enrolled patients had a retear, defined as a full-thickness defect. In each age category, the satisfaction, ASES (American Shoulder and Elbow Surgeons), and SST (Simple Shoulder Test) scores in the retear group were significantly poorer than those in the no-retear group (p < 0.05). Within the retear group, all three scores were significantly better in the oldest age category (p < 0.05); there were no significant differences among the age categories within the no-retear group (p > 0.05). Simple regression analysis showed that younger age, a Workers’ Compensation claim, and lower education level were significant predictors of poorer scores in patients with a retear (p < 0.05). Multiple regression analysis of the retear group showed that (1) lower education level and a Workers’ Compensation claim were independent predictors of a poorer satisfaction score; (2) lower education level, younger age, and a Workers’ Compensation claim were independent predictors of a poorer ASES score; and (3) lower education level was the only independent predictor of a poorer SST score (p < 0.01 for all).

Conclusions: 

The presence of a retear negatively affected the clinical outcomes following rotator cuff repair. This finding refutes the widely held concept that patients typically do well regardless of the repair integrity following rotator cuff repair. In patients with a retear, nonanatomic factors including younger age, lower education level, and a Workers’ Compensation claim were associated with poorer outcomes.

Level of Evidence: 

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Peer Review 

This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Benjamin JF Dean
    Posted on January 17, 2014
    How does cuff integrity affect outcome?
    Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK

    I read the well-designed study by Kim et al. showing that cuff integrity influences clinical outcome after rotator cuff repair surgery with great interest. The abstract states that “It is widely accepted that most patients treated with rotator cuff repair do well regardless of the integrity of the repair” which I think is not entirely accurate. Several studies have shown that the integrity of the rotator cuff is an important predictor of outcome in patients undergoing rotator cuff repair surgery[1-3]. One explanation is that the studies which have not demonstrated this finding may be making type-2 statistical errors; an example of this may be the recent trial by Kukkonen et al.[4]. However an alternative and very plausible explanation is that the patients’ conscious awareness of having suffered a re-tear may influence the outcome via central mechanisms. The authors mention subject blinding but do not specify if any of the patients knew if they had suffered a ‘re-tear’ prior to enrolling in the study; it would be interesting to know if this was the case?

    REFERENCES
    1. Vastamaki M, Lohman M, Borgmastars N. Rotator cuff integrity correlates with clinical and functional results at a minimum 16 years after open repair. Clinical orthopaedics and related research 2013;471(2):554-61.
    2. Kluger R, Bock P, Mittlbock M, et al. Long-term survivorship of rotator cuff repairs using ultrasound and magnetic resonance imaging analysis. The American journal of sports medicine 2011;39(10):2071-81.
    3. Yoo JH, Cho NS, Rhee YG. Effect of postoperative repair integrity on health-related quality of life after rotator cuff repair: healed versus retear group. The American journal of sports medicine 2013;41(11):2637-44.
    4. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J 2014;96(1):75-81.

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