Outcomes Following Rotator Cuff Repair: Are We Doing Better?

Introduction

Ever since the first description over 200 years ago, rotator cuff tears have fascinated orthopedic surgeons. As surgeons moved away from simply identifying rotator cuff tears, focus moved toward treatment of these often debilitating injuries. The first English-language description of an open rotator cuff repair technique, now over 100 years ago, has been followed by a rapid evolution of changing management strategies, operative techniques, and postoperative protocols. The development of diagnostic imaging modalities, including arthrography and magnetic resonance imaging (MRI), has helped fuel this rapid evolution, as have advances in shoulder arthroscopy, which was first described nearly 85 years ago. These developments led to debates about the optimal treatment of rotator cuff tears, which initially compared open and arthroscopically driven miniopen repair techniques and eventually all-arthroscopic repair techniques. With continued technologic advances, debates have moved toward comparison of specific suture repair techniques, including single- and double-row techniques, with the most recent studies investigating the role of biologic agents or augmentations in rotator cuff repair.

Today, it is estimated that over 250,000 rotator cuff repairs are performed annually in the United States, with a dramatic increase in the number of rotator cuff repair procedures over the last decade. Similarly, the number of peer-reviewed publications on the rotator cuff has increased, with a nearly exponential increase in publications over the last 30 years, with rotator cuff–specific publications dominating recent clinical shoulder literature. Although the volume and breadth of literature are impressive, at times it seems as though more questions are raised than answers provided. This, at least in part, may be attributable to the difficulty in defining a successful rotator cuff repair. Defining success is complicated by the fact that there is great inconsistency throughout the literature when reporting surgical indications, particularly important given the high number of asymptomatic rotator cuff tears, and outcomes. Multiple outcomes are available for assessment of the shoulder. This includes patient-reported outcome measures as well as various imaging parameters to assess repair integrity. However, there has been a lack of consistency for assessment of strength and function. Although quality of life may improve after rotator cuff repair, other parameters, including maintenance of the structural integrity of the rotator cuff repair following surgery, have yielded less satisfying results. Despite the high volume of procedures and publications, evaluating the success of rotator cuff repair is hindered by inconsistent reporting of important variables throughout the literature. Although these shortcomings have been acknowledged and suggestions made to improve reporting, questions undoubtedly remain. This chapter evaluates the current best evidence available to better answer the question at the crux of rotator cuff repair surgery: Are we doing better?

Assessing Outcomes Following Rotator Cuff Repair Surgery

Patient-Reported Outcome Measures

Rotator cuff repair outcomes are typically reported using patient-reported outcome measures in combination with the structural integrity of the repair typically reported using MRI, sonography, or computed tomographic (CT) arthrography. With respect to patient-reported outcome measures, it has been suggested that validated measures, including a general health outcome measure, a general shoulder outcome measure, a rotator cuff–specific outcome measure, and an activity measure, be used to perform the highest level of assessment. The relatively recent addition of an activity measure is particularly useful because limiting upper-extremity activity may artificially increase patient-reported outcome measures that place less emphasis on function but are of historical relevance. The following will provide a brief overview of the most frequently used validated patient-reported outcome measures applicable to rotator cuff repair in order to better understand the results of rotator cuff repair surgery. Additionally, we discuss the role of advanced imaging in assessing the structural integrity of the rotator cuff following repair and the influence structural integrity may have on outcomes.

General Health Outcome Measures

General health outcome measures allow comparison of patients with various conditions across medical specialties and within a variety of populations. These measures are important to rotator cuff repair outcomes because they allow comparison with other conditions. The Medical Outcomes Study 36-Item Short Form Healthy Survey (SF-36) and abbreviated Medical Outcomes Study 12-Item Short Form Healthy Survey (SF-12) are the most frequently used general health outcome measures in the orthopedic and general health literature and have been validated in a variety of languages and formats. The components of the SF-36 and SF-12 allow for calculation of a physical and mental component score, allowing comparison of health-related quality of life between a variety of disciplines and disease processes.

General Shoulder Outcome Measures

General shoulder outcome measures assess the role the shoulder specifically has on quality of life. Limiting evaluation to the anatomic region of interest eliminates other variables, including concomitant disease processes in other organ systems, which may affect general health outcome measures. Historically, general shoulder outcome measures have a long track record with widespread use, allowing comparison of outcomes for patients with a variety of shoulder conditions. We have selected several of the most frequently cited and validated general shoulder outcome measures to expand on below.

The Constant score, or Constant-Murley score as frequently referenced, provided one of the first dedicated shoulder outcome measures. Although predated by the nonvalidated University of California Los Angeles shoulder score, the Constant score became the standard for future validations. The Constant score’s applicability to rotator cuff repair outcomes rests primarily on the range of motion and strength testing components, both of which are heavily weighted in calculation of the score. However, poor interrater reliability and inconsistencies in strength measurements have called into question the utility of the Constant score. Still, the widespread use of the score throughout the shoulder literature cannot be questioned.

The American Shoulder and Elbow Surgeons (ASES) score was created by the research committee of the ASES in order to standardize shoulder outcomes for the purpose of comparative and multiinstitutional research. It has been validated for evaluation of rotator cuff disease and has been shown to have excellent reliability. Unlike the Constant score, the ASES score lacks a physical exam component and places a heavy emphasis on pain in calculation of the composite score. Because of this, there is some concern that patients with high functional status where pain is not the primary concern, such as athletes, may not be distinguished.

The Simple Shoulder Test (SST) consists of 12 yes-or-no questions, all equally weighted, in order to provide a shoulder outcome measure with minimal patient time requirements. Despite the inherent simplicity of the test, the SST has been validated for patients with rotator cuff disease while serving to be less burdensome for patients than more robust general shoulder outcome measures that may require more time for data acquisition.

The Disabilities of the Arm, Shoulder and Hand (DASH) score was developed in an attempt to better assess upper extremity disability using a single questionnaire. Although the entire upper extremity as a whole is evaluated, the DASH has been validated for assessment of rotator cuff repair outcomes. Although the assumption that the DASH score is a generalized upper extremity outcome measure may limit its use within the shoulder literature, the correlation and subsequent validation of the DASH with a wide variety of shoulder pathologies should only further serve to strengthen its use in the shoulder literature.

Rotator Cuff–Specific Outcome Measures

There are two disease-specific outcome measures designed for rotator cuff pathology, including the Western Ontario Rotator Cuff (WORC) Index and the Rotator Cuff Quality of Life score. To date, the WORC Index has been used more extensively and has undergone more vigorous validation, with some suggesting that it is the most responsive to detecting changes in outcomes following rotator cuff repair surgery. Although disease-specific outcome measures are important tools, the more widespread use of general shoulder outcome measures that have been further validated to specifically assess rotator cuff disease, including the ASES, SST, and DASH, has limited the adoption of rotator cuff–specific outcome measures.

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