OREF-funded research examines factors that affect patient satisfaction and function
Commonly held beliefs about the clinical outcomes of surgery may not always withstand scrutiny when investigators ask new questions about old assumptions. It has been widely accepted that a patient who undergoes a procedure for a rotator cuff tear does relatively well regardless of the integrity of the repair. Studies have indicated that even with recurring tears, patients report overall satisfaction, decreased pain, and better shoulder function.

William N. Levine, MD, professor and chair of clinical orthopaedic surgery at New York-Presbyterian/Columbia University Medical Center, and his colleagues revisited this idea by examining how factors such as patient age and activity level might affect satisfaction and shoulder function among patients who experience retears after rotator cuff repair.

"In general, an older population requires less physical activity for their work, sports, and daily living—a factor that may contribute to the high satisfaction level even in the presence of recurrent tears," explained Dr. Levine. "On the other hand, the younger population is more likely subject to higher physical demands, and anatomically intact repairs may be more critical in this population."

Dr. Levine's work was supported by a 2012 Orthopaedic Research and Education Foundation (OREF)/American Shoulder and Elbow Surgeons (ASES)/Rockwood Clinical Research Grant in Shoulder Care. This $50,000 grant, available to ASES members, was made possible through an endowment established by the family of Charles A. Rockwood Jr, MD.

Role of age and activities
The healing of the rotator cuff after surgical repair is primarily accomplished by the creation of scar tissue rather than a regeneration of native tendon-to-bone structures. The scar tissue does not have the same biomechanical properties of the native tissues and cannot completely restore normal functional properties. This poor healing response, as well as the underlying degenerative process associated with most tears, is a key factor contributing to the high rate of retears after surgical repair.

Given an apparent mismatch between the precarious nature of rotator cuff healing and patient-reported outcomes, Dr. Levine and his team investigated details of patient perception of treatment outcomes and identified factors associated with positive and poor results.

The researchers used ultrasonography to assess the integrity of rotator cuff repairs of 180 patients who had undergone either an arthroscopic or mini-open procedure within 1 to 5 years before the time of the study. The repairs were categorized as intact, attenuated (more than 50 percent thinning of the tendon), partial-thickness defect, or full-thickness defect. For the purpose of the study, a retear was defined as a full-thickness defect.

Each patient completed the following evaluations:

• A 10-point visual analog scale of overall satisfaction with the treated shoulder
• 10-point visual analog scales assessing activity levels at work, in sports and recreation, and at home
• An ASES self-evaluation form, which assesses perception of pain, pain medication use, degree of shoulder stability, and degree of various functional abilities
• A Simple Shoulder Test, which assesses perception of comfort and functional abilities

Patients were divided into three groups based on age at the time of the study: younger than 55 years, 55 to 65 years, and older than 65 years.

A clearer picture of patient satisfaction
In 2014, Dr. Levine's team published its results in "Factors affecting satisfaction and shoulder function in patients with a recurrent rotator cuff tear" in The Journal of Bone & Joint Surgery.

"Contrary to commonly held belief, we found that rotator cuff retear in younger patients is not well-tolerated," said Dr. Levine. "Patient satisfaction is not good; patient function is not as good, and even in the older population, there's clearly a difference between those who have healing and those who do not."

Comparing only patients with retears, the researchers found that the self-reported outcomes of satisfaction and function were poorer among younger patients than older patients. When each outcome measure was compared between the retear and no retear groups, the differences in outcomes were greater in younger patients, and those differences decreased gradually with age.

The researchers also noted that a greater workplace activity level was associated with poorer satisfaction and shoulder function. But contrary to the group's expectations, higher recreational and home activity levels were associated with better satisfaction and function. Although the reason for this phenomenon is unknown, the researchers speculate that the discrepancy could be related to changes in activities following repair or to the sensitivity of the measurement method.

"At least for now, we can say confidently that there is a real age-related outcome that had not been previously identified," said Dr. Levine, "and that it's not fair to tell patients, 'If you have a retear, it won't be a big deal. You'll have pain relief and you'll be okay.' This may also suggest that it's more important to obtain durable repair integrity and to implement more tailored rehabilitation in younger patients than in older patients."

Critical funding
Dr. Levine expressed gratitude to OREF for supporting his investigation, and opines that OREF has been a major contributor to the advancement of orthopaedics.

"The funding from OREF was critical," he said. "Without it, we wouldn't have been able to have our patients return to complete the evaluations, and therefore we wouldn't have been able to perform the study at the level and quality we felt necessary.

 "For orthopaedic surgeons, tinkering is at the heart of what we do. We're fixing. We're always trying to make things a little bit better. OREF, as a major contributor to advancing our field, deserves the support of the entire orthopaedic community."

Jay D. Lenn is a contributing writer for OREF. He can be reached at communications@oref.org