To heal or not to heal, is it really that important? That is the question that we often ask ourselves and struggle with when surgically treating patients with a rotator cuff tear. The answer to this question is at the base of many surgical and nonsurgical decisions made in the treatment of these tears. Our decision to utilize a particular surgical repair construct is based on our belief regarding whether anatomic healing of a rotator cuff repair affects postoperative clinical outcomes.
Despite our surgical fascination with healing, most studies have failed to show that anatomic healing makes an important difference with regard to outcomes—possibly it does with regard to strength and motion, but not with regard to self-assessed patient functional outcomes1. Also, the authors of several studies have reported the durability of functional improvement despite healing failure over a long duration of follow-up2,3. Despite such data, revision procedures for failed rotator cuff repairs are not uncommon, supporting findings that clinical failures do occur. Both Kim et al. and Namdari et al. have attempted to further analyze the subset of patients who fail to heal after arthroscopic rotator cuff repair and to define which patients are at potential risk for not turning their “failure” into a clinical success story.
Namdari et al. performed a retrospective review of sixty-one patients who failed to achieve healing after arthroscopic rotator cuff repair. This cohort of patients was identified within a larger group of 212 patients from several prior published studies who underwent imaging after rotator cuff repair. The authors categorized the patients who had anatomic failure of the repair into those with clinical failure (an ASES [American Shoulder and Elbow Surgeons] score of <80) and those with clinical success (an ASES score of ≥80), and they evaluated factors associated with clinical success or failure. A multivariate regression analysis confirmed that a labor-intensive occupation, a lower preoperative SST (Simple Shoulder Test) value, and poorer preoperative active external rotation were associated with clinical failure. Multiple other variables including age were not identified as significantly associated with clinical failure.
Kim et al. performed a retrospective review of 180 patients who underwent arthroscopic, mini-open, or open rotator cuff repair, utilizing outcome questionnaires evaluating satisfaction, activity level, and functional outcomes (ASES and SST scores) as well as ultrasonography to assess repair integrity. They identified retears in 26% of the patients. Individuals with a retear had poorer levels of satisfaction and functional outcomes compared with those with a healed repair. They subdivided the patients with a retear according to age and determined that those older than sixty-five years of age had better SST, ASES, and VAS (visual analog scale) satisfaction scores compared with younger patients. There was no difference in scores among age groups in the patients with a healed repair. Multiple regression analysis showed that lower education level, younger age, and the presence of a Workers’ Compensation claim were significantly associated with poorer outcomes in the retear group.
Both studies are compromised by incomplete follow-up and the retrospective nature of the study designs. Nevertheless, both studies fill a void in our understanding of outcomes after rotator cuff surgery. Healing does seem to matter with regard to outcomes, and many of our prior studies evaluating the effect of healing may have been biased toward older patients who had less labor-intensive occupations. Fortunately, failure to heal is less common in young, active patients. However, if these patients do not heal, the data in these studies suggest that they will likely have an inferior result. Utilization of a biomechanically superior construct combined with slower rehabilitation may be most important in this age and activity group to optimize healing; although these patients are the most likely to heal, they have also the most to lose if they have a failure.