Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Patients' Preoperative Expectations Predict the Outcome of Rotator Cuff Repair"
by R. Frank Henn III, MD, et al.

Commentary & Perspective by
Thomas J. Gill, MD*,
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Posted September 2007

Surgical repair of rotator cuff tears has been shown to result in good-to-excellent clinical outcomes, even when postoperative imaging has demonstrated that up to 90% of repaired massive tears are not fully intact. Thus, when reporting "outcomes" of rotator cuff repair, it is important to differentiate between "objective" and "subjective" assessments.

There are certain variables that are traditionally believed to influence the clinical outcome of rotator cuff repairs. Perhaps the most important of these are the size of the tear, the chronicity of the tear, and the degree of fatty atrophy in the muscle belly of the torn tendon. Although larger tears can be surgically repaired, the function of the cuff itself will not always improve if there is greater than 50% fatty atrophy of the muscle belly. Nevertheless, even without objective improvements in motion and strength, patients will often report improvements in subjective clinical outcome following repair.

In addition to the anatomic factors, other aspects, such as the demographic and psychosocial attributes of patients with torn rotator cuffs, are predictive of outcome. These include age, Workers' Compensation status, occupation, comorbidities such as diabetes mellitus, and a history of smoking. The tendon quality and bone density of older patients generally are not as strong as those of younger patients, which may predispose the repair to failure even following a technically sound procedure. The healing rate in smokers is lower than that in matched nonsmoking cohorts, and patients with diabetes may struggle to regain motion following repair and have a higher incidence of adhesive capsulitis. The measured clinical outcome of rotator cuff repair in patients with active Workers' Compensation claims is also inferior to that in control groups1.

This study by Henn et al. is among the first to study the effect of patients' preoperative expectations on the clinical outcome following rotator cuff repair. The authors describe a strong correlation between the preoperative expectations of patients and their actual self-assessed outcome scores on the Simple Shoulder Test (SST), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Short Form-36 (SF-36), and visual analog scales for pain, shoulder function, and quality of life. Unfortunately, postoperative patient satisfaction was not measured in this study; it would have been interesting to know if there was a correlation between preoperative expectations and the final result. The authors concluded that, at a mean follow-up of fourteen months (range, eight to twenty-two months), preoperative expectations are the single most important predictor of both one-year performance and improvement from baseline after rotator cuff repair. However, they do acknowledge that anatomic factors such as tendon quality and repair integrity were not taken into account in their multivariate analysis.

Preoperative counseling has a major effect on the establishment of the patient-doctor relationship. Taking time to properly counsel patients on the natural history of their diagnosis, their treatment options (including nonoperative options), and the risks and benefits of potential surgical interventions will help to ensure that proper treatment plans are designed and implemented.

Preoperative counseling can also help the patient to set realistic expectations. For example, if a sixty-three-year-old laborer with a massive, chronic, retracted rotator cuff tear and high-riding humeral head expects to return to heavy lifting and construction work, then he will not typically report a favorable outcome. The same is true for a professional baseball pitcher with a torn supraspinatus, frayed infraspinatus, and nondisplaced labral tear who expects an easy return to professional baseball without any losses in velocity, control, or endurance. For the laborer, realistic expectations include relief of pain and improvement of function with the arm by the side. The baseball player should be counseled that realistic expectations include the ability to perform all activities of daily living, elimination of pain at night and with overhead reaching, and the ability to return to throwing. However, the player must not expect a "guarantee" that he or she can return to pitching at the same level or with the same velocity. In fact, the player should understand that ending his or her career might be a realistic expectation after surgical repair.

For patients with torn rotator cuffs, there are multiple predictors of surgical outcome. In considering "subjective outcomes," preoperative patient expectations do play a central role. Patients must be forewarned that they may not be able to have unlimited overhead motion and/or function or "full strength" postoperatively, especially if they are being treated for larger, chronic tears. Otherwise, even if pain is completely eliminated but motion not fully restored, their subjective outcomes will be poor. In contrast, when considering "objective" outcomes, strength, function, and range of motion are the primary outcome measures, and anatomic factors such as tendon quality, tear size, chronicity of symptoms, and fatty atrophy remain more predictive of objective outcome. Setting realistic expectations for the patient will help to ensure that objective and subjective outcomes are similar.

*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

Reference

1. Watson EM, Sonnabend DH. Outcome of rotator cuff repair. J Shoulder Elbow Surg. 2002;11:201-11.