The authors point out that rotator cuff repair surgery is frequently unsuccessful, "Re-tear or non-healing of a surgically repaired rotator cuff is common"
They sought to determine the relationship between preoperative and intra-operative factors and re-tear rate following rotator cuff repair in 1962 consecutive patients having primary arthroscopic single row rotator cuff repair by an individual surgeon.
The mean anteroposterior tear length was 1.8 ± 1.0cm (range = 0.3 - 10.0cm), and the mean mediolateral tear length was 1.6 ± 0.9cm (range = 0.4 - 8.0cm). The mean value of their resultant product (tear size area) was 3.7 ± 5.1cm2 (range = 0.2 - 64.0cm2).
Patients were assessed by ultrasonography at 6-month follow-up. Re-tear was defined as present if a full- or partial-thickness defect was visible as a hypoechoic gap on ultrasound.
14% (271/1691) of the repairs had failed by 6 months after surgery.
The data indicated that following rotator cuff repair there was
a 4-fold increase in re-tear rate as AP tear size increased from 1cm to 3cm;
a 8-fold decrease when comparing case number 1000 with case 3000 (i.e. cases done later in the series did better);
a 2-fold increase as patient age increased from 50 to 70; and
a 3-fold increase when comparing surgery performed in public hospital versus private hospital.
The predictive effect of anteroposterior tear length and patient age and case number in contributing to re-tear was additive.
The authors attribute the independent effect of case number to increased experience and less aggressive rehabilitation. This suggests that the "learning curve" continues, even for an experienced surgeon performing thousands of repairs.
The authors suggest that the effect of public vs private hospital site of surgery may be explained by factors including
- disparate patient factors such as socioeconomic status
- younger surgeons assisting in rotator cuff repairs under supervision of the senior author in the public hospital.
- superior equipment including arthroscopes and screens,
- more experienced staff (given the higher number of repairs performed within the private hospital) - the free availability of a preoperative rehabilitation education clinic to private patients.
They created a predictive model for outcomes for this surgeon. Example predictions: a 50 year-old with an anteroposterior tear size of 1cm who was the 2000th surgical case has a 2% chance of a re-tear/ failure to heal at six months, while a 70 year old with a 3cm tear who was case number 1000 has a 34% chance of re-tearing.
Comment: This large study by an individual very high volume surgeon is informative. It is of note that the cuff tears in this series were small (average <2 cm in AP dimension). The failure rates presented cannot be generalized to larger tears or to repairs performed by less experienced surgeons. This study did not compare the patient reported outcomes of failed and successful repairs.
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