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William N. Levine, MD

Revisiting rotator cuff repairs

William N. Levine, MD OREF/ASES/Rockwood Clinical Research Grant in Shoulder Care
Research Summary
Research topic: Examining how factors such as patient age and activity level might affect the degree of satisfaction and shoulder function among patients with retears after rotator cuff repair.

Research results: Contrary to the commonly held belief that all patients who’ve undergone rotator cuff tear repair fare well, younger patients reported less function and lower satisfaction with their results than older patients.

Patient care application of results: Understanding that it might be more important to obtain durable rotator cuff repair integrity and to implement more tailored rehabilitation in younger patients than in older patients

Simplified patient care application: More durable repair and tailored rehabilitation for younger rotator cuff tear patients


Revisiting rotator cuff repairs

With funding from OREF, researcher examines factors that affect patient satisfaction and function
Jay D. Lenn

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.

“This idea is based on literature that primarily included older patients who were likely less active,” stated William N. Levine, MD, professor and chair of clinical orthopaedic surgery at New York-Presbyterian/Columbia University Medical Center. Dr. Levine and his colleagues revisited this idea by examining how factors, particularly patient age and activity level, might affect the degree of satisfaction and shoulder function among patients with 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.”

His investigation 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.

The 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 the key factor contributing to the high rate of retears after surgical repair.

Given the precarious nature of rotator cuff healing, reported overall patient satisfaction and shoulder function are somewhat surprising. Dr. Levine and his team teased out 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 a series of evaluation forms:

  • 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, 55 to 65, and older than 65.

    A clearer picture of patient satisfaction
    Dr. Levine’s team published their results in 2014 in The Journal of Bone & Joint Surgery (volume 96, issue 2). “What we found ultimately,” stated Dr. Levine, “contrary to the commonly held belief, is that rotator cuff re-tear in younger patients is not well tolerated. 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.”

    When comparing only patients with retears, the researchers found that the self-reported outcomes of satisfaction and function were poorer among the younger patients than the 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 the differences in outcomes decreased gradually with age.

    With regard to activity levels, the researchers found 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 conjectured that the discrepancy could be related to changes in activities following repair or to the sensitivity of the measurement method.

    Dr. Levine stated, “At least for now, we can say confidently that there is a real age-related outcome that had not been previously identified and that it’s not fair to tell patients, ‘Well, if you have a retear, it won’t be a big deal. You’ll have pain relief and you’ll be okay.’ And 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 his gratitude to OREF for supporting his investigation. “The funding from OREF was critical. 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.”

    Dr. Levine also believes that OREF has been a major contributor to advancing orthopaedics. “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

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