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Original Article|Articles in Press

Female Sex and Higher Infraspinatus Fatty Infiltration Are Linked to Dissatisfaction at a Minimum Follow-Up of 4 Years after Arthroscopic Repair of Massive Rotator Cuff Tears

Open AccessPublished:May 12, 2023DOI:https://doi.org/10.1016/j.asmr.2023.03.016

      Purpose

      To evaluate patient satisfaction at a minimum of 4 years after arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCT), to identify preoperative and intraoperative characteristics associated with satisfaction, and to compare clinical outcomes between satisfied and dissatisfied patients.

      Methods

      A retrospective review on prospectively collected data was conducted on ARCRs of MRCTs performed at 2 institutions between January 2015 and December 2018. Patients with a minimum 4-year follow-up, preoperative and postoperative data, and primary ARCR of MRCTs were included for analysis. Patient satisfaction was analyzed according to patient demographics, patient-reported outcome measures (American Shoulder and Elbow Surgeons score [ASES], visual analog scale [VAS] for pain, Veteran Rands 12-item health survey [VR-12], and Subjective Shoulder Value [SSV]), range of motion (forward flexion [FF], external rotation [ER], and internal rotation [IR]), tear characteristics (fatty infiltration, tendon involvement, and tear size), and clinical significant measures (minimal clinical important difference [MCID], substantial clinical benefit [SCB], and patient-acceptable symptomatic state [PASS]) for ASES and SSV. Rotator cuff healing was also assessed with ultrasound in 38 patients at final follow-up.

      Results

      A total of 100 patients met the study’s criteria. Overall, 89% of patients were satisfied with ARCR of a MRCT. Female sex (P = .007) and increased preoperative infraspinatus fatty infiltration (P = .005) were negatively associated with satisfaction. Those in the dissatisfied cohort had significantly lower postoperative ASES (80.7 vs 55.7; P = .002), VR-12 (49 vs 37.1; P = .002), and SSV scores (88.1 vs 56; P = .003), higher VAS pain (1.1 vs 4.1; P = .002) and lower postoperative range of motion in FF (147° vs 117°; P = .04), ER (46° vs 26°; P = .003), and IR (L2 vs L4; P = .04). Rotator cuff healing did not have an influence on patient satisfaction (P = .306). Satisfied patients were more likely to return to work than dissatisfied patients (97% vs 55%; P < .001).

      Conclusion

      Nearly 90% of patients who undergo ARCR for MRCTs are satisfied at a minimum 4-year follow-up. Negative preoperative factors include female sex and increased preoperative infraspinatus fatty infiltration, but no association was observed with rotator cuff healing. Furthermore, dissatisfied patients were less likely to report a clinically important functional improvement.

      Introduction

      Massive rotator cuff tears (MRCT) can be difficult to manage. Retear rates are high, which may affect patient satisfaction.
      • Bushnell B.D.
      • Connor P.M.
      • Harris H.W.
      • Ho C.P.
      • Trenhaile S.W.
      • Abrams J.S.
      Retear rates and clinical outcomes at 1 year after repair of full-thickness rotator cuff tears augmented with a bioinductive collagen implant: A prospective multicenter study.
      Although one might expect repair integrity to influence patient experience, this has been inconsistently documented, as satisfaction can be achieved despite a negative or suboptimal physiological outcome.
      • Fermont A.J.M.
      • Wolterbeek N.
      • Wessel R.N.
      • Baeyens J.P.
      • de Bie R.A.
      Prognostic factors for successful recovery after arthroscopic rotator cuff repair: A systematic literature review.
      This discrepancy is supported by Barnes et al., who retrospectively reviewed satisfaction and repair integrity in 150 patients undergoing either mini-open or arthroscopic rotator cuff repair (ARCR) and found no consistent relationship between the two.
      • Barnes L.A.F.
      • Kim H.M.
      • Caldwell J.M.
      • et al.
      Satisfaction, function and repair integrity after arthroscopic versus mini-open rotator cuff repair.
      With the shift toward value-based care, there is growing interest in evaluating patient satisfaction after common procedures, such as ARCR.
      • Holzer-Fleming C.
      • Tavakkolizadeh A.
      • Sinha J.
      • Casey J.
      • Moxham J.
      • Colegate-Stone T.J.
      Value-based healthcare analysis of shoulder surgery for patients with symptomatic rotator cuff tears—Calculating the impact of arthroscopic cuff repair.
      It has been reported that female sex, younger age, and poor rotator cuff quality contribute to dissatisfaction after ARCR.
      • Cho N.S.
      • Rhee Y.G.
      The factors affecting the clinical outcome and integrity of arthroscopically repaired rotator cuff tears of the shoulder.
      ,
      • Tashjian R.Z.
      • Bradley M.P.
      • Tocci S.
      • Rey J.
      • Henn R.F.
      • Green A.
      Factors influencing patient satisfaction after rotator cuff repair.
      These studies, however, are single-center case series with limited follow-up and are not specific to ARCR of MRCTs.
      The purposes of this study were 1) to evaluate patient satisfaction at a minimum of 4 years after arthroscopic repair (ARCR) of massive rotator cuff tears (MRCT), 2) to identify preoperative and intraoperative characteristics associated with satisfaction, and 3) to compare clinical outcomes between satisfied and dissatisfied patients. Our hypothesis was that satisfied patients would have less preoperative fatty infiltration and higher rates of postoperative rotator cuff healing.

      Methods

      Study Design

      A retrospective review was conducted of a prospective database to identify patients who underwent ARCR of a MRCT at two institutions between January 2015 and December 2018. This study’s protocol was approved December 17, 2020, by the Salus Institutional Review Board (protocol #102). Inclusion criteria included a primary ARCR, intraoperative rotator cuff tear confirmation of a MRCT, defined as at least 5 cm in size,
      • DeOrio J.K.
      • Cofield R.H.
      Results of a second attempt at surgical repair of a failed initial rotator-cuff repair.
      or complete tear of 2 tendons,
      • Gerber C.
      • Fuchs B.
      • Hodler J.
      The results of repair of massive tears of the rotator cuff.
      and minimum 4-year follow-up. Exclusion criteria were a previous rotator cuff surgery and lack of baseline or postoperative functional outcome data. All patients had undergone surgery for rotator cuff tears identified clinically and/or via imaging for pain and/or weakness that was significantly interfering with their quality of life.

      Surgical Technique

      Surgeries were performed by two fellowship-trained shoulder surgeons (P.D., R.G.). All repairs were performed under general anesthesia and interscalene block, and the patient was placed in the lateral decubitus (P.J.D.) or beach chair (R.G.) position, per surgeon preference. The biceps tendon was either tenodesed or tenotomized at the surgeon’s discretion. A limited acromioplasty with preservation of the coracoacromial ligament was routinely conducted. An anterior interval slide in continuity was routinely performed for mobilization. Posterior interval slides were added as needed (Table 2). If at least 75% coverage of the greater tuberosity was possible, a double-row repair was undertaken unless the construct was felt to be under too much tension, in which case, a single row or single row with rip-stop repair was performed instead. Partial repair was performed if tears were deemed irreparable. Complete repair was achieved in 92% and 100% of the satisfied and dissatisfied cohorts, respectively.
      Postoperatively, patients were immobilized in a sling for 6 weeks. At 6 weeks, passive forward flexion and external rotation were allowed. Active range of motion and strengthening began 3 months after surgery. Unrestricted return to activities was deferred until 6 to 12 months postoperatively.

      Study Variables

      Patients were divided into two cohorts based on their reported satisfaction at the latest follow-up. Satisfaction was determined with a binary “yes/no'' question. Patients responded to the following question, “Are you satisfied with your shoulder?”
      • Tashjian R.Z.
      • Bradley M.P.
      • Tocci S.
      • Rey J.
      • Henn R.F.
      • Green A.
      Factors influencing patient satisfaction after rotator cuff repair.
      . Demographic factors included age, follow-up, gender, worker’s compensation, and tobacco use. Active range of motion (ROM) and patient-reported outcomes (PROs) were documented at baseline and postoperatively. ROM was measured for forward flexion (FF), external rotation (ER), and internal rotation (IR) by the two treating surgeons (P.D., R.G.). Internal rotation was numerically scaled based on the nearest spinal level achieved with the thumb (T10 = 10, T12 = 12, L2 = 14, L4 = 16, S1 = 18, hip = 20). PROs included American Shoulder and Elbow Surgeons score (ASES), visual analog scale for pain (VAS), Veterans Rand 12-Item questionnaire (VR-12), and Subjective Shoulder Value (SSV). Clinically significant measures included minimal clinical important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for ASES and SSV.
      • Cvetanovich G.L.
      • Gowd A.K.
      • Liu J.N.
      • et al.
      Establishing clinically significant outcome after arthroscopic rotator cuff repair.
      Patients reaching or exceeding the values established by Cvetanovich et al. were recorded in both cohorts.
      Preoperatively, fatty infiltration of the rotator cuff was assessed with magnetic resonance imaging (MRI) based on the Goutallier classification.
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.
      According to Gouttalier et al., grade 2 and above translated to irreversible muscle damage. Patients were, thus, divided into 2 groups based on fatty infiltration grade, with those with grade 0 and 1 in one group and grade 2 and above in another. Tendon tear pattern was classified on the basis of intraoperative appearance, according to the Collin classification, which provides patterns A to E.
      • Collin P.
      • Matsumura N.
      • Lädermann A.
      • Denard P.J.
      • Walch G.
      Relationship between massive chronic rotator cuff tear pattern and loss of active shoulder range of motion.
      This classification was modified to include pattern type F to describe a massive tear that consists of the entire subscapularis, supraspinatus, and infraspinatus tendons. Additionally, intraoperative tear size was measured in centimeters (cm) in the anteroposterior (AP) and mediolateral (ML) dimensions. Postoperative construct integrity was examined via ultrasound by each surgeon (P.J.D., R.G.) to determine healing per the Sugaya classification. Healing was further classified as complete (all tendons), partial (one or tendons), or nonhealing (no tendon healing).

      Statistical Analysis

      Two-sample t-tests were used to compare continuous variables (PROs and ROM). Categorical variables displayed as proportions were compared with Chi-squared tests. These variables include demographic characteristics, cuff integrity, surgery-related factors, concomitant procedures, need for revision, and clinically significant measures. Data analysis was performed on the basis of patient availability for each variable, regardless of whether the total number of patients was reached. P values under .05 were considered statistically significant. Multivariate logistic regression analysis was conducted to determine factors affecting satisfaction by inputting significant variables derived from univariate analysis using the stepwise forward method. All analyses were performed with R (version 4.2.1) and RStudio (version 2022.07.1) software. A power analysis was performed for satisfaction rate, based on a binary question, resulting in a minimum sample size of 73 patients.

      Results

      Preoperative Factors

      One hundred patients met the study’s criteria and, thus, were included in the analysis (Table 1). Overall, 89% of patients were satisfied at final follow-up of mean of 64 months postoperation. Females were less likely to be satisfied with the procedure (P = .007). Otherwise, there were no differences in satisfaction based on demographics. These variables included preoperative MRI and postoperative ultrasound in both cohorts. There were 49 patients who had preoperative MRIs, with 42 belonging to the satisfaction group and 7 to the dissatisfaction group. At the latest follow-up, 38 patients returned for ultrasound with 32 and 6 being satisfied and dissatisfied patients, respectively.
      Table 1Baseline Characteristics of MRCT Patients: Satisfied Versus Dissatisfied
      Patient DemographicsSatisfied (n = 89)Dissatisfied (n = 11)P
      Age
       years (mean, SD)628.7639.6.646
      Follow-up
       months (mean, SD)648.9629.4.462
      Gender
       male (n, %)6169%327%.007
      Worker's Compensation
       yes (n, %)1011%19%.830
      Smoker
       yes (n, %)78%19%.896
      MRCTs, massive rotator cuff tears. Bolded value indicates significant difference.
      Compared to the satisfied group, dissatisfied patients demonstrated significantly lower preoperative ER (35° vs 49°; P = .049) and a higher grade (at least grade 2) of IS fatty infiltration (100% vs 51%; P = .016) (Tables 2 and 3). Intraoperatively, tear size and tear pattern were comparable between groups. Concomitant procedures were statistically similar between groups (P > .05).
      Table 2Tendon Integrity and Surgery-Related Factors of MRCT Patients: Satisfied Versus Dissatisfied
      Satisfied (n = 89)Dissatisfied (n = 11)P
      n%n%
      Fatty Infiltration (Goutallier grade)
      grade ≥ 2 (n)%grade ≥ 2 (n)%
       Supraspinatus atrophy2255%571%.417
       Infraspinatus atrophy2051%7100%.016
       Subscapularis atrophy1032%467%.112
      Tear Characteristics
      Tear size
       Medial-Lateral
      ≤ 3 cm2950%546%.956
      3-5 cm2035%436%
      ≥ 5 cm916%218%
       Anterior-Posterior
      ≤ 3 cm2034%655%.418
      3-5 cm2136%327%
      ≥ 5 cm1831%218%
       Tendons Involved
      Type A710%19%.263
      Type B710%00%
      Type C2129%218%
      Type D2129%218%
      Type F1723%654%
      Repair Technique
       Posterior Slide45%19%.509
      Fixation Construct
       Single Row2441%546%.201
       Double Row2542%218%
       Rip Stop1017%436%
      Repair
       Complete repair8292%11100%.335
      Concomitant Procedures
       Distal clavicle excision33%00%.536
       Biceps tenodesis6775%873%.854
       Biceps tenotomy11%00%.724
       Others2023%00%.079
      MRCTs, massive rotator cuff tears.
      Table 3Baseline PROs and ROM of MRCT Patients: Satisfied Versus Dissatisfied
      Satisfied (n = 89)Dissatisfied (n = 11)P
      MeanStd. Dev.MeanStd. Dev.
      Patient Reported Outcomes
       VAS Pain5.12.25.62.3.535
       ASES40.820.732.620.1.250
       VR-1237.08.938.312.9.771
       SSV37.322.133.226.7.651
      Range of Motion
       Active FF, °1274011646.477
       Active ER at Side, °49203521.050
       Active IR (spinal level)163172.242
      ASES, American Shoulder and Elbow Surgeons; ER, external rotation; FF, forward flexion; IR, internal rotation; MRCT, massive rotator cuff tear; PROs, patient reported outcomes; ROM, range of motion; SSV, Subjective Shoulder Value; VAS, visual analog scale; VR-12, Veterans RAND 12. Bolded value indicates significant difference.
      Preoperative ER and sex were included in the multivariate analysis (Table 4). A 1-degree increase in ER at baseline correlated with a 3% increase in likelihood of achieving satisfaction (P = .07). Furthermore, sex significantly correlated with satisfaction. Males are 4.8× more likely to be satisfied than females after ARCR for MRCT (P = .03).
      Table 4Multivariate Analysis of Factors Associated with Patient Satisfaction
      Coefficient EstimateP ValueOR (95% CI)
      Active ER at side, °0.029.07211.029 (0.997-1.062)
      Sex (male)1.567.03224.793 (1.142-20.121)
      ER, external rotation; OR, odds ratio. Bolded value indicates significant difference.

      Postoperative Factors

      Satisfied patients achieved higher postoperative values in PROs, including VAS, ASES, VR-12, and SSV (P < .05) (Table 5). Likewise, postoperative values in ROM were significantly higher in the satisfied group (FF 147° vs 117°; ER 46° vs 26°; IR 14 vs 16; P < .05).
      Table 5Outcomes at a Minimum of 4 Years Postoperatively: Satisfied Versus Dissatisfied Patients after ARCR of MRCTs
      Patient-reported outcomes≥ 4-Year OutcomesPChange From BaselineP
      Satisfied (n = 89)Dissatisfied (n = 11)Satisfied (n = 89)Dissatisfied (n = 11)
      MeanStd. Dev.MeanStd. Dev.MeanStd. Dev.MeanStd. Dev.
       VAS pain1.12.14.12.5.002-4.02.4-1.63.0.034
       ASES80.726.955.720.2.00239.329.523.823.6.081
       VR-1249.012.337.19.1.00211.512.6-1.212.8.013
       SSV88.115.656.027.4.00350.224.727.440.1.109
      Range of motion
       Active FF (°)1472111741.0402245160.280
       Active ER at side (°)46192518.003−123−925.328
       Active IR (spinal level)144163.040−24−12.253
      Return to work
       yes (n, %)8696.6%654.5%.000
      ARCR, arthroscopic rotator cuff repair; ASES, American Shoulder and Elbow Surgeons; ER, external rotation; FF, forward flexion; IR, internal rotation; MRCT, massive rotator cuff tear; SSV, Subjective Shoulder Value; VAS, visual analog scale; VR-12, Veterans RAND 12. Bolded values indicate significant difference.
      There was no association between tendon healing and satisfaction. Complete healing was higher in the dissatisfied group (5 of 6, or 83%), compared to the satisfied group (16 of 32, or 50%), but this difference did not reach statistical significance (P = .306) (Table 6). A significantly higher proportion of satisfied patients were able to return to work compared to dissatisfied patients (97% vs 55%; P < .001).
      Table 6Rate of Tendon Healing
      Tendon HealingSatisfied (n = 32)Dissatisfied (n = 6)P
      Nonhealing3 (9%)0 (0%).306
      Partial healing13 (41%)1 (17%)
      Complete healing16 (50%)5 (83%)
      n = 39.
      One complication was observed. In the dissatisfied group, one patient had an anchor pullout in the early postoperative protocol and was revised to reverse shoulder arthroplasty (RSA) 2 months postoperatively. In addition, two dissatisfied patients underwent revision to RSA for persistent pain and limited function 18 months postoperatively. In the satisfied group, one patient underwent RSA prior to final follow-up for progression of glenohumeral arthritis, and another required open reduction and internal fixation for an unrelated proximal humerus fracture.

      Clinically Significant Measures

      A significantly higher proportion of satisfied patients achieved SCB and PASS for ASES compared to the dissatisfied cohort (SCB 84% vs 45%; P < .01; PASS 65% vs 18%; P < .01) (Table 7). Although the percentage of satisfied patients reaching MCID for ASES was higher, this did not reach significance (MCID 89% vs 73%; P = .14). For SSV, all measures were significantly different between cohorts (P < .01). A higher proportion of satisfied patients reached these thresholds for MCID (96% vs 64%), SSV (88% vs 45%), and PASS (80% vs 18%).
      Table 7MCID, SCB, and PASS for ARCR of MRCT: Satisfied Versus Dissatisfied
      Satisfied (n = 89)Dissatisfied (n = 11)P
      ASES
      MCID7989%873%.14
      SCB7584%545%<.01
      PASS5865%218%<.01
      SSV
      MCID8596%764%<.01
      SCB7888%545%<.01
      PASS7180%218%<.01
      ARCR, arthroscopic rotator cuff repair; ASES, American Shoulder and Elbow Surgeons; MCID, minimal clinical important difference; MRCT, massive rotator cuff tear; PASS, patient acceptable symptomatic state; SCB, substantial clinical benefit; SSV, Subjective Shoulder Value.

      Discussion

      The primary finding of this study was that ARCR of MRCT led to a satisfaction rate of 89% at a minimum 4 years of follow-up. Negative preoperative factors include female sex, limited preoperative ER, and increased IS fatty infiltration. Postoperatively, satisfied patients had higher ROM and PROs, despite identifying complete healing in only half of the cases. Moreover, the revision rate to RSA was low, but more commonly seen with dissatisfied patients. These findings may have implications for patient counseling and the overall management of MRCTs.
      Patient satisfaction appears to be overall high following rotator cuff repair of a MRCT.
      • Fermont A.J.M.
      • Wolterbeek N.
      • Wessel R.N.
      • Baeyens J.P.
      • de Bie R.A.
      Prognostic factors for successful recovery after arthroscopic rotator cuff repair: A systematic literature review.
      ,
      • Barnes L.A.F.
      • Kim H.M.
      • Caldwell J.M.
      • et al.
      Satisfaction, function and repair integrity after arthroscopic versus mini-open rotator cuff repair.
      ,
      • Tashjian R.Z.
      • Bradley M.P.
      • Tocci S.
      • Rey J.
      • Henn R.F.
      • Green A.
      Factors influencing patient satisfaction after rotator cuff repair.
      ,
      • Rousseau T.
      • Roussignol X.
      • Bertiaux S.
      • Duparc F.
      • Dujardin F.
      • Courage O.
      Arthroscopic repair of large and massive rotator cuff tears using the side-to-side suture technique. Mid-term clinical and anatomic evaluation.
      ,
      • Razmjou H.
      • Holtby R.
      Impact of rotator cuff tendon reparability on patient satisfaction.
      Razmjou et al. reported on 145 patients 2 years following ARCR for all tear sizes and noted that 83% of MRCTs were very or somewhat satisfied.
      • Razmjou H.
      • Holtby R.
      Impact of rotator cuff tendon reparability on patient satisfaction.
      Similarly, Rousseau et al. reported an 88% satisfaction rate, which included very satisfied and satisfied patients, in a study of 50 ARCR of MRCTs retrospectively reviewed at midterm follow-up.
      • Rousseau T.
      • Roussignol X.
      • Bertiaux S.
      • Duparc F.
      • Dujardin F.
      • Courage O.
      Arthroscopic repair of large and massive rotator cuff tears using the side-to-side suture technique. Mid-term clinical and anatomic evaluation.
      However, they did not stratify on the basis of tear size. In this study, analysis was limited to MRCTs and observed a satisfaction rate of 89%. This corroborates with the previous studies in demonstrating the generally high rate of patient satisfaction with ARCR of MRCTs. The large cohort size also provided the opportunity to evaluate factors associated with satisfaction.
      According to the present study, females and patients with preoperative limited ER or increased infraspinatus fatty infiltration preoperatively were most likely to be dissatisfied. Although the link to patient sex has been described,
      • Nabergoj M.
      • Bagheri N.
      • Bonnevialle N.
      • et al.
      Arthroscopic rotator cuff repair: Is healing enough?.
      ,
      • Chung S.W.
      • Park J.S.
      • Kim S.H.
      • Shin S.H.
      • Oh J.H.
      Quality of life after arthroscopic rotator cuff repair.
      other reports have not reported differences based on sex.
      • Razmjou H.
      • Holtby R.
      Impact of rotator cuff tendon reparability on patient satisfaction.
      ,
      • Youm T.
      • Murray D.H.
      • Kubiak E.N.
      • Rokito A.S.
      • Zuckerman J.D.
      Arthroscopic versus mini-open rotator cuff repair: A comparison of clinical outcomes and patient satisfaction.
      In this analysis, males were nearly 5 times more likely to be satisfied postoperatively. Kim et al. and Tashijan et al. associated young age with lower rates of satisfaction.
      • Tashjian R.Z.
      • Bradley M.P.
      • Tocci S.
      • Rey J.
      • Henn R.F.
      • Green A.
      Factors influencing patient satisfaction after rotator cuff repair.
      ,
      • Kim H.M.
      • Caldwell J.M.E.
      • Buza J.A.
      • et al.
      Factors affecting satisfaction and shoulder function in patients with a recurrent rotator cuff tear.
      Older age has been linked to poor tissue quality, worse functional outcomes, and multiple tendon involvement, but not with satisfaction.
      • Cho N.S.
      • Rhee Y.G.
      The factors affecting the clinical outcome and integrity of arthroscopically repaired rotator cuff tears of the shoulder.
      ,
      • Chung S.W.
      • Park J.S.
      • Kim S.H.
      • Shin S.H.
      • Oh J.H.
      Quality of life after arthroscopic rotator cuff repair.
      ,
      • Gulotta L.V.
      • Nho S.J.
      • Dodson C.C.
      • Adler R.S.
      • Altchek D.W.
      • MacGillivray J.D.
      Prospective evaluation of arthroscopic rotator cuff repairs at 5 years: Part II—Prognostic factors for clinical and radiographic outcomes.
      Conversely, younger patients have higher preoperative expectations with postoperative functional outcomes.
      • Cole B.J.
      • Cotter E.J.
      • Wang K.C.
      • Davey A.
      Patient understanding, expectations, and satisfaction regarding rotator cuff injuries and surgical management.
      Interestingly, the present study suggested a link between higher preoperative ER and satisfaction. Although the multivariate P value was not significant (P = .07), each 1-degree increase of ER translated to a 3% increase in likelihood of reaching satisfaction. This is consistent with the study by Manaka et al., who reported that preoperative stiffness, defined as <120° total (internal plus external rotation at 90° of abduction), negatively influenced functional recovery time,
      • Manaka T.
      • Ito Y.
      • Matsumoto I.
      • Takaoka K.
      • Nakamura H.
      Functional recovery period after arthroscopic rotator cuff repair: Is it predictable before surgery?.
      which is contrary to the findings by Fermont et al.
      • Fermont A.J.
      • Wolterbeek N.
      • Wessel R.N.
      • Baeyens J.P.
      • de Bie R.A.
      Prognostic factors for recovery after arthroscopic rotator cuff repair: a prognostic study.
      While in this study univariate analysis of infraspinatus fatty infiltration was directly linked to lower satisfaction, tendon involvement was not impactful. Multiple studies have reported that fatty infiltration leads to lower postoperative PROs.
      • Fermont A.J.M.
      • Wolterbeek N.
      • Wessel R.N.
      • Baeyens J.P.
      • de Bie R.A.
      Prognostic factors for successful recovery after arthroscopic rotator cuff repair: A systematic literature review.
      ,
      • Shin S.J.
      • Lee J.
      • Ko Y.W.
      • Park M.G.
      Evaluation of rotator cuff repair using Korean Shoulder Scoring System.
      ,
      • Chung S.W.
      • Kim J.Y.
      • Kim M.H.
      • Kim S.H.
      • Oh J.H.
      Arthroscopic repair of massive rotator cuff tears.
      Shin et al. reported that patients with grade 3 or higher IS fatty infiltration had lower KSS outcomes scores.
      • Shin S.J.
      • Lee J.
      • Ko Y.W.
      • Park M.G.
      Evaluation of rotator cuff repair using Korean Shoulder Scoring System.
      Similarly, Shon et al. reported that dissatisfied patients had higher teres minor fatty infiltration preoperatively in a cohort of 31 patients treated with arthroscopic partial repair for large to massive cuff tears.
      • Shon M.S.
      • Koh K.H.
      • Lim T.K.
      • Kim W.J.
      • Kim K.C.
      • Yoo J.C.
      Arthroscopic partial repair of irreparable rotator cuff tears.
      This high grade of fatty infiltration has been implicated in limited functional improvement postoperatively.
      With regard to function, the best results following ARCR of MRCTs are achieved with complete repairs.
      • Denard P.J.
      • Jiwani A.Z.
      • Lädermann A.
      • Burkhart S.S.
      Long-term outcome of arthroscopic massive rotator cuff repair: The importance of double-row fixation.
      Satisfaction is often linked to the degree of functional improvement patients are able to attain.
      • Tashjian R.Z.
      • Bradley M.P.
      • Tocci S.
      • Rey J.
      • Henn R.F.
      • Green A.
      Factors influencing patient satisfaction after rotator cuff repair.
      ,
      • Razmjou H.
      • Holtby R.
      Impact of rotator cuff tendon reparability on patient satisfaction.
      Significantly higher PROs and ROM in satisfied patients were observed postoperatively in this study. Similarly, Razmjou and Holtby, and O’Holleran et al. reported lower ASES scores and higher VAS pain scores postoperatively in dissatisfied patients at 2-year follow-up.
      • Razmjou H.
      • Holtby R.
      Impact of rotator cuff tendon reparability on patient satisfaction.
      ,
      • OʼHolleran J.D.
      • Kocher M.S.
      • Horan M.P.
      • Briggs K.K.
      • Hawkins R.J.
      Determinants of patient satisfaction with outcome after rotator cuff surgery.
      Similar to other reports, we found no relationship between patient outcomes and tendon healing. Generally, infiltration is directly linked to tendon healing.
      • Bushnell B.D.
      • Connor P.M.
      • Harris H.W.
      • Ho C.P.
      • Trenhaile S.W.
      • Abrams J.S.
      Retear rates and clinical outcomes at 1 year after repair of full-thickness rotator cuff tears augmented with a bioinductive collagen implant: A prospective multicenter study.
      ,
      • Fermont A.J.M.
      • Wolterbeek N.
      • Wessel R.N.
      • Baeyens J.P.
      • de Bie R.A.
      Prognostic factors for successful recovery after arthroscopic rotator cuff repair: A systematic literature review.
      ,
      • Jensen A.R.
      • Taylor A.J.
      • Sanchez-Sotelo J.
      Factors influencing the reparability and healing rates of rotator cuff tears.
      This is particularly important to consider in the setting of MRCT, where nonhealing rates are high, and functional outcomes are reportedly lower than other tear sizes.
      • Bushnell B.D.
      • Connor P.M.
      • Harris H.W.
      • Ho C.P.
      • Trenhaile S.W.
      • Abrams J.S.
      Retear rates and clinical outcomes at 1 year after repair of full-thickness rotator cuff tears augmented with a bioinductive collagen implant: A prospective multicenter study.
      ,
      • Rousseau T.
      • Roussignol X.
      • Bertiaux S.
      • Duparc F.
      • Dujardin F.
      • Courage O.
      Arthroscopic repair of large and massive rotator cuff tears using the side-to-side suture technique. Mid-term clinical and anatomic evaluation.
      ,
      • Chung S.W.
      • Kim J.Y.
      • Kim M.H.
      • Kim S.H.
      • Oh J.H.
      Arthroscopic repair of massive rotator cuff tears.
      Healing, nonetheless, has not been implicated with satisfaction in MRCTs, which concurs with our study findings.
      • Fermont A.J.M.
      • Wolterbeek N.
      • Wessel R.N.
      • Baeyens J.P.
      • de Bie R.A.
      Prognostic factors for successful recovery after arthroscopic rotator cuff repair: A systematic literature review.
      ,
      • Nho S.J.
      • Brown B.S.
      • Lyman S.
      • Adler R.S.
      • Altchek D.W.
      • MacGillivray J.D.
      Prospective analysis of arthroscopic rotator cuff repair: Prognostic factors affecting clinical and ultrasound outcome.
      Rousseau et al. reported a satisfaction rate of 88% and an intact RCR identified via ultrasound in 56% of cases at a mean follow-up of 38.6 months after ARCR of large and MRCT.
      • Rousseau T.
      • Roussignol X.
      • Bertiaux S.
      • Duparc F.
      • Dujardin F.
      • Courage O.
      Arthroscopic repair of large and massive rotator cuff tears using the side-to-side suture technique. Mid-term clinical and anatomic evaluation.
      Patients with retears experienced significant improvement in Constant score compared to their preoperative status. Their findings correlated with Jost et al., who reported that failure of healing following open repair of MRCTs did not preclude improvement in pain and function.
      • Jost B.
      Long-term outcome after structural failure of rotator cuff repairs.

      Limitations

      This study is not without limitations. One is the use of a binary satisfaction question, which could lead to unbalanced cohorts. A small number of patients in one cohort may predispose to type I or II statistical errors. Furthermore, the retrospective nature of this study is a limitation. Given that these are the outcomes of two large-volume shoulder surgeons, the results could vary if the same procedure is performed by less experienced surgeons. Also, many patients did not return for ultrasound, which may influence postoperative healing analysis. Other variables, such as education level or psychosocial parameters, proven in other studies to influence patient expectations, and, therefore, satisfaction, could have also been integrated at the study’s inception.
      • Fermont A.J.M.
      • Wolterbeek N.
      • Wessel R.N.
      • Baeyens J.P.
      • de Bie R.A.
      Prognostic factors for successful recovery after arthroscopic rotator cuff repair: A systematic literature review.
      ,
      • Ravindra A.
      • Barlow J.D.
      • Jones G.L.
      • Bishop J.Y.
      A prospective evaluation of predictors of pain after arthroscopic rotator cuff repair: Psychosocial factors have a stronger association than structural factors.

      Conclusion

      Nearly 90% of patients who undergo an ARCR for a MRCT are satisfied at a minimum 4-year follow-up. Negative preoperative factors include female sex and increased preoperative infraspinatus fatty infiltration, but no association was observed with rotator cuff healing. Furthermore, dissatisfied patients were less likely to report a clinically important functional improvement.

      Supplementary Data

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