The American Journal of Sports
The online version of this article can be found at:
2012 40: 2771 originally published online October 25, 2012Am J Sports Med
Xiao L. Wu, Lisa Briggs and George A.C. Murrell
Intraoperative Determinants of Rotator Cuff Repair Integrity : An Analysis of 500 Consecutive Repairs
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American Orthopaedic Society for Sports Medicine
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of Rotator Cuff Repair Integrity
An Analysis of 500 Consecutive Repairs
Xiao L. Wu,* MBBS, Lisa Briggs,* AMS, and George A.C. Murrell,*yMD, DPhil
Investigation performed at St George Hospital Campus, Sydney, Australia
Background: Rotator cuff repair has a relatively high (20%-90%) chance of retears. Patients with an intact rotator cuff 6 months
after surgery have better subjective and objective outcomes at 6 months and 2 years after rotator cuff repair than those who do
not have an intact repair.
Purpose: The aim of this study was to determine if, and if so which, intraoperative factors predict an intact repair 6 months after
rotator cuff repair.
Study Design: Cohort study; Level of evidence, 3.
Methods: The study consisted of a cohort of 500 consecutive patients who had an arthroscopic rotator cuff repair performed by
a single surgeon and an ultrasound evaluation using standard protocols of the repair 6 months after surgery. Exclusion criteria
included previous fracture or shoulder surgery, incomplete or partial rotator cuff repair, and concomitant arthroplasty. Rotator
cuff tear size was measured intraoperatively and mapped. The quality of the tendon, tendon mobility, and repair quality were as-
sessed and ranked based on predetermined scales (1-4) and recorded on a specifically designed form. Logistic regression anal-
ysis was performed, with cuff integrity at 6-month follow-up as the dependent variable and tear/repair factors as the independent
Results: The overall postoperative retear rate was 19% at 6 months. The best predictor of rotator cuff integrity was preoperative
tear size (correlation coefficient, r = 0.33; P\.001). Patients with small (?2 cm2) rotator cuff tears were least likely to have retears
(retear rate, 10%). As the tear size increased, the retear rate increased in a linear fashion: ?2 cm2(10%), 2 to 4 cm2(16%), 4 to 6
cm2(31%), 6 to 8 cm2(50%), and .8 cm2(57%). Other surgeon-ranked intraoperative assessments did correlate with retears, but
the correlations were relatively weak: repair quality (r = –0.17; P\.001), tendon mobility (r = –0.15; P\.001), and tendon quality
(r = –0.14; P \.01). Regression analysis showed that the retear rate at 6-month follow-up was best predicted from the preoper-
ative tear size and the surgeon-ranked repair quality: chance of retear = 0.38 1 (0.02 3 tear size in cm2) – (0.08 3 repair quality).
Tendon quality and tendon mobility did not contribute significantly to this prediction.
Conclusion: Tear size was the best intraoperative predictor of repair integrity after rotator cuff repair, with tears less than 2 cm2
twice as likely to heal than tears greater than 6 cm2.
Keywords: shoulder; rotator cuff tear; preoperative cuff tear size; rotator cuff tissue quality; age; arthroscopic rotator cuff repair;
rotator cuff integrity
Rotator cuff retears after repair are associated with infe-
rior shoulder function.1,13,14,19,25There have, however,
been very few studies that have identified and quantified
possible factors that predict rotator cuff integrity after
repair. Several studies have suggested that preoperative
tear size and age are important predictors of rotator cuff
integrity after repair.zHowever, the cohort numbers of
these studies were often small (less than 100, with the
largest being 210), and the rotator cuff integrity at
follow-up was either not the primary outcome measure or
there was not a systematic analysis of the relationship
between cuff integrity and potential predictive factors.
Oh et al21demonstrated the predictive role of fatty degen-
eration in the rotator cuff muscles; however, the study was
limited by a relatively small cohort size. Gladstone et al11
yAddress correspondence to George A.C. Murrell, MD, DPhil, Depart-
ment of Orthopedic Surgery, St George Hospital, Kogarah, Sydney, NSW,
Australia 2217 (e-mail: firstname.lastname@example.org).
*Sports Medicine and Shoulder Service, St George Hospital Campus,
University of New South Wales, Sydney, Australia.
Presented at the interim meeting of the AOSSM, San Francisco, Cal-
ifornia, February 2012.
One or more of the authors has declared the following potential con-
flict of interest or source of funding: A grant for this research study was
received from ArthroCare Australia Pty Ltd.
The American Journal of Sports Medicine, Vol. 40, No. 12
? 2012 The Author(s)
zReferences 2, 7, 10, 13, 17, 18, 22, 24.
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demonstrated that although fatty atrophy of the cuff
muscles was related to poor shoulder function, it did not
predict cuff integrity. The aim of this study was to deter-
mine if, and if so which, intraoperative factors predict an
intact repair 6 months after rotator cuff repair.
MATERIALS AND METHODS
Study Design and Patient Selection
The study was a retrospective cohort study; the primary
outcome measure was rotator cuff integrity at 6-month
follow-up. Ethics approval was obtained from the South
Eastern Sydney Illawarra Area Health Service, Human
Research and Ethics Committee–Central Network.
The inclusion criteria for the study were (1) arthroscopic
rotator cuff repair by the senior author (G.A.C.M.) and (2)
repairs performed using Opus Magnum metallic knotless
suture anchors (ArthroCare Corp, Sydney, Australia)
between January 2006 and February 2009. Exclusion crite-
ria were (1) partial or incomplete cuff repairs, (2) inability
to have an ultrasound evaluation of the shoulder at the 6-
month visit, (3) previous surgery to the shoulder or redo of
the rotator cuff repairs, (4) ipsilateral grade 3 (moderate)
or 4 (severe) glenohumeral osteoarthritis, (5) a concomitant
shoulder fracture, and (6) isolated subscapularis repair.
Surgical Technique and Rehabilitation
The surgical methods for repairing rotator cuff tears
described previously.19,26In brief, repairs were performed
with the patient in a beach-chair position under intersca-
lene block. The arthroscope was inserted into the gleno-
a lateral portal was created, and the torn tendon was visu-
alized and repaired from its undersurface (undersurface
repairs). Alternatively, after the evaluation of the gleno-
humeral joint, the arthroscope was directed into the sub-
acromial space, and the torn supraspinatus tendon was
visualized and repaired from its bursal side (bursal side
repair). The torn tendon was grasped with an Opus Smart-
Stitch Suture Device (ArthroCare Corp), which would
deliver 1 inverted mattress suture to the tendon per grasp.
Both strands of the suture exited above the tendon, creat-
ing a tension band effect. An anchor hole was then
punched on the greater tuberosity of the humerus with
a T-handle through the lateral port. Both limbs of the mat-
tress suture were then passed into the anchor (Opus Mag-
num Knotless Implant, ArthroCare Corp), and the anchor
was inserted into the prepunched hole and deployed.
Finally, the TensionLock winding mechanism (ArthroCare
Corp) was used to wind the suture through the anchor,
reduce the tendon onto the bone, and lock the suture in
the anchor in a knotless manner. The whole procedure
was repeated if more anchors were required as a result of
a larger tear. In these cases, all mattress sutures were usu-
ally placed in a single row in the tendon in an anterior-
posterior orientation. Sutures were usually placed prior
to anchor placement and deployment.
Patients were discharged on the same day, and the
operated arm was placed in a sling with a small abduction
pillow, for example, the UltraSling (DJO, Vista, Califor-
nia). The patients were initially started on pendulum exer-
cises. At the 2-week postoperative follow-up, the patients
were introduced to passive external rotation range of
motion exercises. At the 6-week postoperative visit, active
range of motion and simple isometric strengthening exer-
cises were initiated. Finally, at the 3-month follow-up,
the patients were allowed to proceed to free overhead-
throwing activities and lifting 5 kg or more.26
Preoperative rotator cuff tear size was measured intra-
operatively under direct arthroscopic visualization and
mapped based on the size of the head of the shaver used,
which was either 4.0 mm or 5.5 mm. The area of the torn
cuff was calculated by multiplying the medial-lateral and
anterior-posterior dimensions of the tear and expressed
in cm2. The quality of the tendon (1 = fair, 2 = good, 3 =
very good, 4 = excellent), tissue mobility (1 = fair, 2 =
good, 3 = very good, 4 = excellent), and quality of repair
(1 = fair, 2 = good, 3 = very good, 4 = excellent) were
assessed intraoperatively and scored as outlined in Table
1 and recorded on a standardized form.
The repair was considered to be weak when sutures
used to pull the torn tendon to the greater tuberosity
were insecure and be easily pulled out and the tendon
was difficult to mobilize to the landing site. Repair was
considered strong when the repair was robust, when the
tendon was easily attached to the landing site, and the
sutures were unlikely to be pulled out when the shoulder
was placed through a range of motion intraoperatively.
All patients were followed up at 1 week, 6 weeks, 3
months, and 6 months. Six-month follow-up was chosen
as studies have shown that the clinical outcomes do not
demonstrate significant changes thereafter.15,19Ultra-
sound evaluations of rotator cuff integrity were made for
all patients at the 6-month visit. Ultrasonography was car-
ried out with a General Electric Logiq 9 (GE Healthcare,
Sydney, Australia) using a 12-MHz linear transducer by
an experienced sonographer (L.B.) following standardized
defined as a full-thickness defect in the supraspinatus ten-
don that could be smaller or larger than the original tear.
The medial-lateral and anterior-posterior dimensions of
the tear size were measured and recorded on a standard-
All data were analyzed using SigmaStat version 3.5 and
SigmaPlot version 10.0 (Systat Software Inc, Richmond,
California). Correlations were tested using the Spearman
rank-order correlation for each of the independent varia-
bles (preoperative tear size, age, tendon quality, and mobil-
ity, as well as repair quality) against the rotator cuff
2772 Wu et alThe American Journal of Sports Medicine
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integrity at 6 months. Stepwise forward and backward
regression analyses were used to determine the relative
significance of each of the independent variables in con-
tributing to the cuff integrity at 6 months. Regression anal-
ysis was also used to establish a mathematical equation for
predicting the likelihood of the rotator cuff retear rate at 6
During the study period (between January 2006 and Feb-
ruary 2009), 722 rotator cuff repairs were performed. Of
these, 667 repairs were performed using the Opus Mag-
num knotless anchor. A total of 167 patients were excluded
on the basis of the exclusion criteria: 14 patients were
excluded because of previous shoulder surgery or redo of
rotator cuff repair, 22 were excluded for incomplete or par-
tial cuff repairs, 38 were excluded for moderate to severe
osteoarthritis of the shoulder, 10 were excluded for isolated
subscapularis repair, 1 patient was excluded because of
a greater tuberosity fracture, and 82 patients were
excluded because they were lost to follow-up or no ultra-
sound was performed at 6 months. The remaining 500
patients form the study cohort.
Of 500 rotator cuff repairs that form the study cohort,
308 repairs were for the right shoulder (62%). The mean
6 standard deviation age of patients enrolled in the study
was 60 6 11 years (range, 28-89). The number of patients
who were found to have a retear in their rotator cuff as
demonstrated by the 6-month ultrasound was 94, corre-
sponding to an overall retear rate of 19%.
The preoperative tear size had the largest positive correla-
tion with retears of the repaired cuff at 6 months, with the
correlation coefficient being .33 (P\.001). Age also demon-
strated a moderate positive correlation, with the correla-
tion coefficient being .23 (P \ .001).
There was a weak negative correlation for the tendon
quality (correlation coefficient, r = –0.14; P \ .01), tendon
mobility (r = –0.15; P \ .001), and repair quality (r = –0.17;
P \ .001) with rotator cuff integrity at 6 months. Lower
(poorer) intraoperative scores were associated with a higher
rate of rotator cuff retears. This information is summarized
in Table 2.
Multivariate Regression Analysis
Forward stepwise regression was then performed using the
6-month rotator cuff integrity (tear vs no tear) as the inde-
pendent variable and tendon quality, tendon mobility,
repair quality, preoperative tear size, and age as the
dependent variables. Preoperative tear size was the most
significant factor in predicting cuff integrity at 6 months
(F-to-enter value = 45; P \ .001). Age of the patient was
the next most significant predictor (F-to-enter = 14; P \
.001) followed by repair quality (F-to-enter = 5.1; P =
.02). Tendon quality (F-to-enter = 0.9; P = .33) and tendon
mobility (F-to-enter = 2.1; P = .15) did not contribute signif-
icantly to the prediction of the cuff integrity at 6 months.
Similar findings were also obtained when backward
stepwise regression was performed using the same inde-
pendent and dependent variables. Preoperative tear size
(F-to-remove value = 23.5; P \ .001), age (F-to-remove =
12.6; P \ .001), and repair quality (F-to-remove = 5.1;
P = .02) were the 3 significant variables that remained in
the regression analysis.
Formulating an Equation to Predict Retear
Rate at 6 Months
Based on the forward and backward stepwise regression
findings, a mathematical equation was formulated to pre-
dict the chance of cuff retears at 6 months. Using the pre-
operative size and repair quality as independent variables,
the following equation was obtained:
Intraoperative Scoring System
Fair (1 Point)Good (2 Points) Very Good (3 Points)Excellent (4 Points)
Quality of the tendonThin, friable, does
not hold suture
Immobile and retracted
Poor mobility, can be
to the landing site
Repair not optimal
Normal thickness, holds
suture incidentally well
Mobile, can be pulled easily
to the landing site
Thick and robust, holds
suture very well
Mobile, can be easily pulled
to the landing site
Repair qualityVery weak repairRelatively strong repairVery strong repair
Summary of the Correlation of All Independent Variables
Against the Cuff Integrity at 6 Months
Independent VariableCorrelation Coefficient (r)
Preoperative tear size
Age of the patient
Vol. 40, No. 12, 2012Intraoperative Determinants of Rotator Cuff Retears2773
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Chanceof cuff retearat6months50:381 0:023preoperativetearsize
ðÞ;R25:096; F 526:2; P\:001:
When age was included in the analysis, the equation
was modified so that it contained 3 independent variables:
Chanceof cuff retearat6months50:041 0:023preoperativecuff tearsize
ð Þ ? 0:073repairquality
The predictions made by the latter equation were not
statistically significantly different (P = .08) from those
made by the equation containing just 2 independent varia-
bles (preoperative tear size and repair quality). Different
values could be used as end points to indicate the possibil-
ity of cuff retears, although a value of .2 had the most diag-
nostic accuracy. When .2 is used, the likelihood ratio of the
first equation = 4 (sensitivity = 68%, specificity = 83%), and
the likelihood ratio of the second equation = 3.7 (sensitivity
= 74%, specificity = 80%).
Relationship Between Preoperative
Tear Size and Retear Rate
The data were then reorganized according to the preoperative
tear size in increments of 2 cm2and the chance of cuff retears
calculated (Table 3 and Figure 1). It was evident from the
graph (Figure 1) that the percentage of cuff retears increased
proportionally as the preoperative tear size increased.
Patients with a preoperative rotator cuff tear size of less
than 2 cm2were least likely to have retears, estimated to
be 10%. For preoperative tear size of 2 to 4 cm2, the retear
rate was 16%, 31% for preoperative tear size of 4 to 6 cm2,
50% for tear size of 6 to 8 cm2, and for preoperative tear
size greater than 8 cm2, the retear rate increased to 57%.
This study demonstrated that preoperative tear size was
the most significant factor in predicting rotator cuff integ-
rity after repair. Patient age and surgeon-ranked repair
quality were the next important predicting factors. Sur-
geon-determined rotator cuff tendon quality and tissue
mobility were not significant predictors of cuff integrity
after repair. The retear rate increased linearly as the
preoperative tear size increased. A preoperative tear size
less than 2 cm2had a less than 10% chance of retears at
6 months, increasing to 57% when the preoperative tear
size was greater than 8 cm2.
In the study, the overall rotator cuff retear rate at 6-
month follow-up was 19%. This result is comparable
with, although lies at the lower end of, the current pub-
lished results.§Chung et al8reported a similar retear
rate of 23% in a recent publication. Miller et al,20however,
reported a higher retear rate of 41% for repairing larger
rotator cuff defects (.3 cm).
There are several studies that have found similar effects
of tear size on rotator cuff repair integrity. Huijsmans
et al13found that for a preoperative tear size of less than
1 cm in the medial-lateral axis, the retear rate at the final
follow-up was found to be 12%. For a tear size between 1 to
3 cm, the retear rate was 7%. This increased to 22% for
a preoperative tear size between 3 and 5 cm. This then
increased significantly to 53% for massive tears greater
than 5 cm.13Sugaya et al24demonstrated similar findings.
Small preoperative cuff tears had a retear rate of 13% in
single-row arthroscopic rotator cuff repair, and this
increased to 44% for large tears. Galatz et al9demon-
strated an even higher retear rate of 94% in patients
with large to massive rotator cuff tears.
In our study, we were able to demonstrate a mathemat-
ical relationship between preoperative tear size and cuff
integrity at 6 months. We postulate that some of the var-
iances in rates of retears reported by various studies may
be directly related to the average tear sizes that were oper-
ated on. For instance, Bishop et al2demonstrated a higher
rate of retears compared with Huijsmans et al13(47% vs
17%), and this may merely reflect that 52% of the Bishop2
cohort had a preoperative cuff tear size .3 cm while only
27% of patients in the Huijsmans13cohort had a preopera-
tive cuff tear size .3 cm.
Some studies have demonstrated that age is a signifi-
cant predictive factor for cuff integrity after repair, with
Rotator Cuff Retear Rate at 6 Months Versus Preoperative
Cuff Tear Size
Percentage of Retears
at 6-Month Follow-up
.2 and ?4
.4 and ?6
.6 and ?8
Preopera?ve Tear Size (cm2)
Figure 1. Effect of rotator cuff tear size on retear rate as
assessed 6 months postoperatively (n = 500).
§References 2, 7, 8, 10, 13, 17, 18, 20, 21, 24.
2774Wu et al The American Journal of Sports Medicine
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younger patients achieving superior functional and ana-
tomic outcomes after repair.3,6,12,16,23However, the find-
ings are not entirely conclusive, as Oh et al22in their
more recent work in 2010 demonstrated that although
age was a significant predictive factor of cuff integrity
using a univariate analysis, the significance was not found
when a multivariate analysis was performed. They sug-
gested a possible reason was that age was a significant con-
founder to most of the independent variables studied, such
as preoperative cuff tear size and fatty degeneration of the
cuff muscle. The present study demonstrated that age was
a significant predictive factor for rotator cuff integrity after
a multivariate analysis. The significance, however, was not
as great as preoperative cuff tear size. The correlation coef-
ficient for age and retears was also lower than for tear size
and retear rate.
Charousset et al7demonstrated that poor tendon qual-
ity and tendon mobility as assessed by the surgeon at the
time of surgery were related to higher repair failure. Huijs-
mans et al13showed that poor quality tendons as assessed
by the surgeon at the time of surgery were related to
a higher chance of cuff retears. No correlation or multivar-
iate analysis was performed in these studies. The present
study demonstrated that there were weak negative corre-
lations between the tendon quality, tendon mobility, repair
quality, and repair integrity at 6 months. Tendon quality
and mobility did not remain as significant predictive fac-
tors when logistic regression analysis was performed.
Therefore, our study suggests that tendon quality and
mobility by themselves are not adequate in making any
reliable clinical predictions of the rotator cuff repairs: frail
and immobile tendons do not necessarily produce poor
The stepwise regression analysis was helpful in formu-
lating an equation that would assist in predicting the
chance of rotator cuff retears after repair using only the
significant predictive factors. For instance, for a patient
who had a preoperative rotator cuff tear size of 3 cm2
and had a good rotator cuff repair, say, a repair quality
score of 3, the chance of cuff retears at 6-month follow-up
will equal 0.38 1 (0.02 3 3) – (0.08 3 3) = .2, or 20%.
This value is nearly identical to the prediction by the dif-
ferent analysis as plotted in Figure 1, which gives a 19%
retear rate for a preoperative tear size between 2 to 4 cm2.
The study has several strengths. To date, it has the
largest cohort number with 500 enrolled patients, with
strict inclusion and exclusion criteria. All repairs were per-
formed by a single surgeon at a single center. The data
were collected in a standardized format.
There are, however, some limitations to the study that
should be considered. First, the intraoperative scoring sys-
tem was subjective and has not been validated. These
scores were from a single surgeon; therefore, bias was inev-
itable. Furthermore, when establishing a mathematical
model to predict the chance of retears after repair, the
retear rate is assumed to be linearly related to the contrib-
uting variables, which may or may not be the case. Only 5
intraoperative factors were analyzed in this study, and
there are possibly more intraoperative contributing factors
that we are unaware of, or for which we have not collected
data, which can affect the retear rate after rotator cuff
repair. Fatty infiltration of the supraspinatus muscle
may be another potential risk factor for retears of the
repaired cuff; however, because the cuff integrity was
assessed using ultrasound, this potential risk factor could
not be evaluated. Finally, the surgery was performed by
a single senior surgeon at a single center using 1 tech-
nique, and the results may not translate to other surgeons
in other centers using their techniques.
Preoperative tear size, age, and surgeon-ranked repair
quality were significant factors in predicting rotator cuff
integrity after repair, whereas cuff quality and mobility
assessed by the surgeon at the time of the repair were
not. Preoperative tear size was linearly related to the
retear rate, and the chance of cuff retears at 6 months
could be predicted by the following equation:
Chanceof cuff retearat6months5
ð Þ ? 0:083repairquality
The authors are grateful to the patients for participating in
this study and to ArthoCare Australia for a research grant.
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