Abstract
Purpose
The purpose of this study is to assess the long-term clinical complications, outcomes, and return to sport (RTS) rates in patients aged 30 or younger with a primary full-thickness arthroscopic rotator cuff repair (ARCR).
Methods
All patients who underwent a primary full-thickness ARCR at age 30 years or younger from 2003 to 2021 with a minimum of a 2-year follow-up were included. Complications, repeat surgeries, and return to sport rates were collected.
Results
32 patients underwent primary full-thickness rotator cuff repair with a mean follow-up of 9.3[2.7–17.9] years. 5(15.6%) patients had postoperative shoulder stiffness, and persistent postoperative shoulder pain was reported in 4(12.5%) patients. There were 3(9.4%) reported repair failures, with complete rotator cuff re-tears reported in 2(6.3%) shoulders and partial rotator cuff re-tear in 1(3.1%) shoulder. There were 4(12.5%) reoperations at an average of 8.7[0.65–22.7] months from primary rotator cuff repair and 2(6.3%) revision rotator cuff repairs. There was a 78.6% RTS rate at an average of 6.5[4–12] months postoperatively, with 8(72.7%) athletes returning to the sport at the same level they initially participated in pre-surgery.
Conclusion
Patients aged 30 and under who underwent full-thickness ARCR experienced promising clinical outcomes at an average 9-year follow-up.
Study Design
Retrospective Case Series; Level of Evidence, 4
Keywords: Arthroscopic rotator cuff repair, under 30, full-thickness rotator cuff tear, outcomes
Introduction
The rotator cuff comprises four muscles responsible for upper extremity movement and stabilization. The supraspinatus, infraspinatus, subscapularis, and teres minor muscles provide dynamic stabilization and facilitate abduction, internal rotation, and external rotation of the glenohumeral joint. 1 Rotator cuff injuries are typically degenerative in nature, with repetitive micro-trauma causing tendon degeneration and insufficient healing, and this most commonly occurs in the aging population. 2 However, sudden macro-trauma causes an acute tear, which is more commonly seen in younger patients and results in complete, full-thickness rotator cuff tears. 3 Acute rotator cuff pathology often presents with more significant pain and disability than more chronic etiologies. However, a precise definition of an acute insult has yet to be established. Clinical history, physical examination, and imaging findings are often used to confirm this diagnosis. 4
Recent studies have demonstrated that surgical management of acute tears, especially when the time to surgery is reduced, may be linked to better functional outcomes. 5 Acute partial-thickness or full-thickness tears <10 mm may be treated with a trial of conservative treatment that includes activity modification, NSAIDs, subacromial injections, and physical therapy before considering surgical management. 6
When surgical management is undertaken, repair can be achieved through various techniques. Although less invasive methods are often preferred, arthroscopic, mini-open, and open approaches remain valid.7,8 Despite this knowledge, few studies have reported on the outcomes of young patients undergoing arthroscopic rotator cuff repair for acute tears. A study of traumatic tears in athletes aged 30 years or less demonstrated good clinical outcomes and return to play rate with a 12-month follow-up after arthroscopic rotator cuff repair. 9 However, no studies evaluate full-thickness rotator cuff repairs in patients under 30 years of age with long-term follow-up. With an increasing incidence of rotator cuff tears in younger patients, 10 there is a newfound need for data on surgical repair in this population as the etiology of the initial injury and postoperative demands differ from the more well-studied aging population. Thus, the purpose of this study is to evaluate the long-term clinical complications, outcomes, and return to sport endpoints in patients aged 30 or younger with an arthroscopic full-thickness rotator cuff repair.
Methods
Study design
Institutional review board (IRB00091855) approval was obtained. The outcomes of patients who underwent a primary full-thickness ARCR age 30 or younger were reported using a retrospective case series design.
Patient identification
Patients were identified from a query of the administrative database at a single academic institution from 2003 to 2021 using the Current Procedural Terminology code 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair). All patients with a minimum 2-year follow-up who underwent arthroscopic surgical repair of a completely torn rotator cuff were identified. Clinic and hospital records were reviewed to determine if the patient met the eligibility criteria for inclusion in the study. Patients aged 30 years or younger who underwent primary arthroscopic surgical repair of a full-thickness rotator cuff tear as confirmed on preoperative MRI and intraoperative arthroscopic imaging were considered for inclusion. Exclusion criteria were patients with surgical procedures other than rotator cuff repair for complete rotator cuff tear (i.e., partial tears felt to be “significant”), patients undergoing a revision of a prior rotator cuff surgery on the same shoulder, or patients who did not have 2-year follow up.
Surgical technique
Indications for each rotator cuff repair procedure were collected. All patients were treated by either fellowship-trained sports medicine, fellowship-trained shoulder/elbow, or general orthopedic surgeons at a single academic institution. Overall patient health, including vascular status and ability to adhere to postoperative rehabilitation protocols, was assessed individually and used to determine patient appropriateness for surgery. The rotator cuff repairs were performed arthroscopically, but surgical approaches were not standardized for this study, so operative data was collected to control this during the analysis.
Data collection
Baseline patient demographic information, including age, sex, body mass index (BMI), smoking status, hand dominance, and the interval between the date of injury and the date of surgery, was collected. Operative reports were reviewed to record surgical factors, including whether the injury was traumatic or chronic, the rotator cuff muscles torn, the suture technique utilized (single or double row), and the number of sutures used for cuff repair. Concomitant procedures and intraoperative complications were also collected from operative reports. Progress notes were reviewed for postoperative complications, reports of repair failure, and repeat surgery. Repair failure was evaluated through either postoperative (at least 6 months) MRI or as noted during additional surgeries performed after the primary rotator cuff repair. Complications included stiffness, infection, wound dehiscence, persistent shoulder, partial re-tear, complete re-tear, deltoid detachment, or reoperation.
For this study, stiffness was defined as any medical or surgical treatment for a restricted range of motion, including reoperation, physical therapy, or corticosteroids (oral or intra-articular). Superficial wound infection or wound dehiscence was identified by the prescription of antibiotics in response to documented wound concerns or a clear description of gross wound abnormalities. All episodes of deep infection required a return to the operating room for irrigation and debridement. Persistent shoulder pain was defined as continued pain with activities for at least 6 months postoperatively. Evidence of ipsilateral rotator cuff re-tear was evaluated through either postoperative (at least 6 months after surgery) MRI or as noted during additional surgeries performed after the primary rotator cuff repair.
Patients were contacted regarding their ability to return to sport postoperatively and to report if they had any complications or reoperations. If they returned to sport, their subjective level of return to play (better, same or worse) was asked. Once patients agreed to participate, informed consent was obtained. Study data was collected and managed using Research Electronic Data Capture (REDCAP) (Vanderbilt University), a secure web-based software platform hosted at OrthoCarolina Research Institute. 11
Statistical analysis
Descriptive statistics were calculated for all continuous and categorical variables. Continuous variables are reported as mean [range], and categorical variables as frequencies with percentages. All statistical analysis was performed using SAS/STAT software, Version 9.4 of the SAS System for Windows (SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA). An a priori power analysis was not performed because all eligible patients were included in the study.
Results
Demographic and intraoperative data
There were 28,787 ARCRs performed from 2003 to 2021, and of those, 208 (0.7%) were performed on patients aged 30 and under. After inclusion and exclusion criteria were applied, 32 patients were included in the final analysis (Figure 1.). Two patients were excluded due to lacking the 2-year patient follow-up and were unable to be contacted. 32 patients aged 30 years and younger underwent primary full-thickness rotator cuff repair, 29(90.6%) were male, and the average age of the cohort was 25.1[9–30] years (Table 1.) The average body mass index (BMI) was 28.2 ± 5.8 kg/m2, and the mean follow-up was 9.3[2.7–17.9] years. For patients with traumatic tears, the time from initial injury to surgery was 11.8[0.4–148.6] months. There were 9(28.1%) patients who smoked cigarettes at the time of surgery (Table 1.).
Figure 1.
CONSORT (Consolidated Standards of Reporting Trials) diagram for outcomes of full thickness rotator cuff repair in patients 30 and younger.
Table 1.
Demographics.a.
| N = 32 | |
|---|---|
| Male | 29(90.6%) |
| Female | 3(9.4%) |
| Age at surgery, y | 25.1[9–30] |
| BMI, kg/m2 | 28.2[16.1–40.2] |
| Follow-up, years | 9.3[2.7–17.9] |
| Current smoker | 9(28.1%) |
| Former smoker | 2(6.3%) |
| Never smoker | 21(65.6%) |
| Months between injury and surgery | 11.8[0.4–148.6] |
Data are presented as mean [range] or n (%). Abbreviations: BMI, body mass index.
There were 25(78.1%) traumatic injuries to the rotator cuff and 7(21.9%) tears due to chronic injury/unknown. Chronic injury/unknown was defined as patients who failed conservative management after greater than four months and patients who had no known inciting injury or pathology. 15(46.9%) rotator cuff repairs were performed on the patient's dominant side (Table 2.). Ten patients experienced a sports-related injury, 7 had a work-related injury, 4 had a motor vehicle-related injury, 2 had a traumatic dislocation and 1 patient had a physical altercation leading to a shoulder injury. An isolated supraspinatus tendon tear was diagnosed in 18(56.3%) patients, an isolated infraspinatus tendon tear was found in 1(3.1%) patient, and an isolated subscapularis tendon tear was identified in 2(6.3%) patients. There were 7(21.9%) shoulders with a supraspinatus + infraspinatus tear, 2(6.3%) with a supraspinatus + subscapularis tear, 1(3.1%) had an infraspinatus + teres minor tear, and 1(3.1%) with a supraspinatus + infraspinatus + teres minor tear (Table 2.).
Table 2.
Operative data. a
| N = 32 | |
|---|---|
| Traumatic injury | 25(78.1%) |
| Chronic injury/unknown | 7(21.9%) |
| Surgery on dominant side | 15(46.9%) |
| Supraspinatus tear only | 18(56.3%) |
| Infraspinatus tear only | 1(3.1%) |
| Subscapularis tear only | 2(6.3%) |
| Supraspinatus + Subscapularis Tear | 2(6.3%) |
| Infraspinatus + Teres Minor Tear | 1(3.1%) |
| Supraspinatus + Infraspinatus Tear | 7(21.9%) |
| Supraspinatus + Infraspinatus + Teres Minor Tear | 1(3.1%) |
| Single row repair | 14(43.8%) |
| Double row repair | 18(56.3%) |
| Mean medial row suture anchor N | 1.75[1–3] |
| Mean lateral row suture anchor N | 1.73[1–2] |
| Mean single row suture N | 2[1–5] |
Data are presented as mean [range] or n (%).
14(43.8%) shoulders were repaired with a single row technique and 18(56.3%) shoulders were repaired with a double row technique. The number of sutures used for the rotator cuff repairs is reported in Table 2. The concomitant procedures performed with rotator cuff repair were subacromial decompression 23(71.9%), labral repair 5(15.6%), and bicep tenodesis 5(15.6%) (Table 3.). Additional concomitant procedures are outlined in Table 3.
Table 3.
Concomitant procedures. a
| N = 32 | |
|---|---|
| Subacromial decompression | 23(71.9%) |
| AC ligament resection | 2(6.3%) |
| Capsular release | 1(3.1%) |
| Labral repair | 5(15.6%) |
| Labral debridement | 4(12.5%) |
| Biceps tenodesis | 5(15.6%) |
| Biceps debridement | 1(3.1%) |
| Distal clavicle excision | 3(9.4%) |
| HAGL repair | 2 (6.3%) |
| Manipulation under anesthesia | 2(6.3%) |
| Microfracture of glenoid | 3(9.4%) |
Data are presented as mean [range] or n (%). Abbreviations: AC, acromioclavicular; HAGL, humeral avulsion of glenohumeral ligament.
Complications and outcomes
No intraoperative complications were reported. 5(15.6%) patients had postoperative shoulder stiffness (Table 4.). There were 3(9.4%) repair failures reported, with complete rotator cuff re-tears reported in 2(6.3%) shoulders and a partial rotator cuff re-tear reported in 1(3.1%) shoulder. Of the patients who experienced repair failure, 2(6.3%) underwent a double row repair technique and 1(3.1%) underwent a single row repair technique. None of the repair failures were traumatic in nature. Persistent postoperative shoulder pain was reported in 4(12.5%) patients. There were 4(12.5%) reoperations at an average of 8.7[0.65–22.7] months from primary rotator cuff repair (Table 4.). Of the 4 reoperations, 2(6.3%) were patients who had a revision rotator cuff repair, 1(3.1%) had a lysis of adhesions, and 1(3.1%) had a biceps tenodesis with subacromial debridement and revision acromioplasty.
Table 4.
Complications and outcomes data. a
| N = 32 | |
|---|---|
| Stiffness | 5(15.6%) |
| Complete retear | 2(6.3%) |
| Partial retear | 1(3.1%) |
| Persistent pain | 4(12.5%) |
| Reoperation | 4(12.5%) |
| Time from surgery to reoperation, mo | 8.7[0.65–22.7] |
Data are presented as mean [range] or n (%). Abbreviations: SSI, superficial skin infection.
One patient had four additional reoperations after their initial ARCR for a massive rotator cuff tear with retraction repair. The first reoperation was a revision open rotator cuff repair performed 5 months postoperatively and the second reoperation was an irrigation and debridement 2 weeks after that for delayed wound infection. About 12 years later, they had a traumatic massive re-tear at the workplace with an upper trunk brachial plexopathy. They underwent a revision ARCR that was only partially repaired due to moderate arthritis. Lastly, they had a reverse total shoulder arthroplasty a year later for an irreparable rotator cuff tear with early rotator cuff tear arthropathy and glenohumeral arthritis.
Return to sport
There were 14 patients who participated in a sport preoperatively (Table 5.). Of those 14, 11(78.6%) patients returned to sport at an average of 6.5[4–12] months postoperatively. 8(72.7%) athletes returned to the sport at subjectively the same level they originally participated in pre-surgery. The level of play pre-surgery and whether patients were contact athletes or overhead athletes is outlined in Table 5.
Table 5.
Return to sport data. a
| N = 32 | |
|---|---|
| Participated in sports preoperatively | 14(43.8%) |
| Overhead athlete | 5 (35.7%) |
| Contact athlete | 7(50%) |
| Level of play pre-surgery: recreational | 7(50%) |
| Level of play pre-surgery: competitive | 7(50%) |
| RTS | 11 (78.6%) |
| Months to RTS | 6.5[4–12] |
| Subjective level RTS: Same | 8(72.7%) |
| Subjective level RTS: Better | 1(3.1%) |
| Subjective level RTS: Worse | 2(6.3%) |
| Reason for not returning to sport, shoulder related | 3(9.4%) |
Data are presented as mean [range] or n (%). Abbreviations: RTS, return to sport.
Discussion
In this study, patients aged 30 and under who underwent a full-thickness ARCR demonstrated a 9.4% reported repair failure rate, 12.5% reoperation rate, and a 78.6% return to sport rate at an average 9-year follow-up. The prevalence of full-thickness ARCR in patients 30 and under with at least two-year follow up at this single academic institution was exceedingly rare, comprising 0.11% of all ARCR performed. This is the only study to report outcomes of full-thickness ARCR in the younger population with long-term follow-up.
After full-thickness repair, there was a 9.4% reported repair failure rate, with complete rotator cuff re-tears in 6.3% of shoulders and partial rotator cuff re-tear in 3.1% of shoulders. This study evaluated repair failure through either postoperative (at least 6 months) MRI or as noted during additional surgeries performed after the primary rotator cuff repair. However, due to the inability to image for cuff healing in all patients, the true failure rates in this population remain unknown. The reported re-tear rate in this study is similar to a study by Godinho et al. that found a 9.5% re-tear rate in patients with a mean age of 57.2 after full-thickness ARCR at 10-year follow-up. 12 Thus, the repair failure rate in patients under 30 may be similar to the older population. Regarding active patients, a study by Scanaliato et al. reported a 7.4% re-tear rate in active military patients under 40 at 8-year follow-up. 13 Despite this, they were traumatic re-tears compared to our study, which had reported repair failures. 13 Although the postoperative demands in younger patients after ARCR differ, especially in athletes, from the older population, which constitutes the majority of patients who undergo rotator cuff repairs, the failure rate remains similar. The patients included in the current study had a relatively high rate of smoking, and the patients who had repair failures were all smokers. Smoking is a known risk factor for rotator cuff repair failure due to its effects on healing,3,14 so the ARCR repair failure rate in young non-smokers may be lower than the reported failure rate of this study.
The 12.5% reoperation rate and 6.3% revision ARCR rate in the current study are comparable to the older ARCR population, which found reoperation rates after ARCR of 3.8%–15.4% at 5 and 10-year follow-ups.15,16 For athletes, studies report a 2%–8% revision rate for all rotator cuff tear types, paralleling the current study's revision rates.9,17–21 The reoperations included in this study involved lysis of adhesions, and 15.6% of patients experienced more than 6 months of postoperative stiffness. The incidence of postoperative shoulder stiffness is highly variable in the literature, ranging from 2% to 28%, 20 with an increased time to rehabilitation as a risk factor. 21 The highly variable rates of postoperative stiffness after ARCR should be further evaluated.
This study found a 78.6% return to sport (RTS) rate at an average of 6.5[4–12] months postoperatively, with 72.7% of athletes returning to the sport at the same level they initially participated in pre-surgery. These rates are consistent with the RTS rates seen in studies of the older ARCR population (80%–90%)17,22,23 and similar to full-thickness ARCR in athletes (75%–80%).18,24,25 The only other study evaluating outcomes in patients under 30 noted an 85% RTS and only 50% returning to the same or higher level of sport at a mean 5.8 months after partial-thickness ARCR. 9 However, the N included in the study was small (n = 20), making it difficult to interpret. Our study had a slightly higher N (n = 32), indicating the results in the current study may be more representative.
The rates of RTS to the same level played pre-surgery are highly variable in the literature.9,19,20,22,26–28 A systematic review of RTS after ARCR found that, on average, 76% (42–100%) of the athletes returned to equal or higher pre-injury levels. 29 However, other studies evaluating RTS in athletes after ARCR have noted a lower RTS rate to the previous level, with 61.5% of competitive athletes RTS to the previous level 25 and a 25% RTS rate to the previous level in professional athletes. 26 It should be noted that half of the athletes in the current study were recreational. Recreational athletes may experience higher RTS levels after ARCR than competitive athletes, with the rates of RTS decreasing as the activity level increases.18,25,26 The average time to return to play in the current series was 6.5 months and consistent with previous studies that evaluate RTP in athletes after ARCR (6–8 months),15,17,23,27 a systematic review of RTS after ARCR for all tear types (6.8 ± 1.7 months), 29 and a systematic review of full-thickness tears (4.8–14 months). 28
Though this is the first study to evaluate the surgical and return to sport outcomes for patients aged 30 and under with full-thickness ARCR, it has limitations. Although rotator cuff injuries are uncommon in our patient population, our small sample size limits analysis. Small sample sizes can result in large fluctuations of percentages regarding outcomes, so results should be interpreted with caution, and larger studies should be conducted. This is a retrospective study with a long follow-up. In effect, this study possesses the confounding limitations and variable data capture inherent to all retrospective reviews. Patient-reported outcomes were not reported due to a lack of patient participation, limiting this series’ ability to comment on this population's subjective and functional outcomes. The rotator cuff tear size was unable to be collected. Thus, this series cannot correlate outcomes with the size of repair. Postoperative imagining was not obtained for all included patients in this study, so this study cannot comment on the overall healing rate for ARCR in this population.
Conclusion
ARCR for full-thickness tears in patients aged 30 and under is extremely uncommon, comprising 0.11% of all ARCRs performed at this single-academic center, and showed low reported rotator cuff repair failure rates of 9.4% and a high return to sport rate of 78.6% at an average 9-year follow-up. Surgeons can expect that their young patients with full-thickness ARCR can have similar surgical and return to sport outcomes as their older counterparts, but further studies with more significant patient numbers and patient-reported outcomes are needed to understand the functional and subjective results of ARCR for full-thickness tears in patients aged 30 and under.
Acknowledgements
None.
Footnotes
Contributorship: All authors contributed to the study's conception and design. Anna Maria Ifarraguerri wrote the first draft of the manuscript, and all authors commented on previous versions. All authors read and approved the final manuscript. All authors agree to be accountable for all aspects of the work.
Conflicting interests: Author Bryan Michael Saltzman, MD receives research support from Arthrex, Inc, publishing royalties, financial, or material support from Nova Science Publishers, consulting fees from Bioventus, and education payments from Peerless Surgical, Medwest Associates, Arthrex, and Smith + Nephew. Author Shadley Schiffern, MD has received consulting fees from Medacta USA, INC, Wright Medical Technology, Inc., and Limacorporate S.p.A. Author Nady Hamid, MD has received consulting fees from Stryker Corporation and education payments from Arthrex, Inc. Author Anthony Martin, MD has received education payments from Peerless Surgical and Arthrex.
Ethical approval: Ethical approval for this study was obtained from Wake Forest University Institutional Review Board (IRB00091855)
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
Guarantor: BMS
Informed consent: Informed consent was not sought for the present study due to its design as a retrospective analysis.
Trial registration: Not applicable.
ORCID iDs: Alexander N. Berk https://orcid.org/0000-0003-4161-7747
Bryan M. Saltzman https://orcid.org/0000-0003-3984-4246
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