J Shoulder Elbow Surg (2021) 30, 2660–2670

[Link]/locate/ymse

Risk factors affecting rotator cuff retear after

arthroscopic repair: a meta-analysis and
systematic review
Jinlong Zhao, MDa,b,1, Minghui Luo, MDb,c,1, Jianke Pan, MD, PhDb,c,1,
Guihong Liang, MDb,c, Wenxuan Feng, MDc, Lingfeng Zeng, MD, PhDb,c,
Weiyi Yang, MD, PhDb,c,*, Jun Liu, MD, PhDb,c,*

a
The Second School of Clinical Medical Sciences, Guangzhou University of Chinese Medicine, Guangzhou, China
b
Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine,
Guangzhou, China
c
The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional
Chinese Medicine), Guangzhou, China

Background: Retear after arthroscopic rotator cuff repair (ARCR) consistently challenges medical staff and patients, and the incidence
of retear after surgery is 10%-94%. The purpose of this study was to identify the risk factors that cause retear after ARCR and provide
theoretical guidance for clinical intervention to reduce the occurrence of postoperative rotator cuff retear.
Methods: The protocol for this meta-analysis was registered with PROSPERO (CRD42021225088). PubMed, Web of Science, and
Embase were searched for observational studies on risk factors for rotator cuff retear after arthroscopic repair. Meta-analytical methods
were used to determine the odds ratio or weighted mean difference of potential risk factors related to postoperative rotator cuff retear.
Stata 15.1 was used to quantitatively evaluate the publication bias of the statistical results.
Results: Fourteen studies from 6 countries with a total of 5693 patients were included. The meta-analysis revealed that the risk factors
for retear after rotator cuff repair were age, body mass index, diabetes, subscapularis and infraspinatus fatty infiltration, symptom dura-
tion, bone mineral density, tear length, tear width, tear size area, amount of retraction, critical shoulder angle, acromiohumeral interval,
distance from the musculotendinous junction to the glenoid, operative duration, biceps procedure, and postoperative University of Cal-
ifornia Los Angeles shoulder score.
Conclusion: These findings can help clinical medical staff identify patients who are prone to retear early after arthroscopic repair and
develop targeted prevention and treatment strategies for modifiable risk factors, which are of great significance for reducing the occur-
rence of rotator cuff retear after ARCR.
Level of evidence: Level IV; Meta-Analysis
Ó 2021 The Author(s). This is an open access article under the CC BY-NC-ND license ([Link]
4.0/).
Keywords: Arthroscopic repair; meta-analysis; risk factors; rotator cuff; retear

Institutional review board approval was not required for this study. (Guangdong Province Hospital of Traditional Chinese Medicine),
1
These authors contributed equally to this work. Guangzhou 510120, China.
*Reprint requests: Weiyi Yang, MD, PhD and Jun Liu, MD, PhD, The E-mail address: gzucmliujun@[Link] (J. Liu).
Second Affiliated Hospital, Guangzhou University of Chinese Medicine

1058-2746/Ó 2021 The Author(s). This is an open access article under the CC BY-NC-ND license ([Link]
[Link]
Risk factors affecting rotator cuff retear 2661

Rotator cuff tears (RCTs) are one of the main causes of divided into case groups and control groups to compare exposure
shoulder joint pain and mobility disorders, accounting for factors. (4) The studies included at least 1 evaluation index. (5)
approximately 50% of shoulder joint diseases.43 The inci- The included evaluation indicators were reported in at least 2
dence of rotator cuff injury gradually increases with age. literature studies. (6) The publication language was not limited.
The exclusion criteria were as follows: (1) The research was
Approximately 25.6% of people aged
60 years experience
repetitively published literature. (2) The data reported in the
rotator cuff injury, and this prevalence is as high as 45.8%
article or the original data obtained could not be converted and
for people aged
70 years.7 With the development of merged. (3) The publication was a review or a case report. (4) The
arthroscopic technology, arthroscopic rotator cuff repair quality of the literature was too low (New Castle-Ottawa Scale
(ARCR) has become the main method for treating [NOS] score <4 points or Agency for Healthcare Research and
RCTs.14,45 Each year, 4.5 million patients in the United Quality score <4 points).
States visit a doctor because of rotator cuff injury; nearly
250,000 of these cases are treated through surgical repair,
of which arthroscopic surgery accounts for more than 95%, Search strategy
and the related treatment and rehabilitation costs are as
high as 7 billion US dollars.18 The retear rate after ARCR is A computer search of 3 databases, namely, PubMed, Web of
10%-48.4%,12,16,29,32,49 and the retear rate after arthro- Science, and Embase, was performed. The search adopted a
scopic repair of massive rotator cuff injuries is as high as combination of subject terms and free words, and the search time
94%.17,18 Compared with primary rotator cuff repair, ro- extended from the establishment of each database to October
tator cuff revision is more difficult, time-consuming, and 2020. In addition, the references of the included literature were
less effective.32,44 The curative effect of secondary repair traced to supplement the further acquisition of relevant literature.
after retear is far lower than expected, and patient satis- The main search terms included risk factor, factor risk, population
faction is significantly decreased.44 Therefore, it is very at risk, rotator cuff, subscapularis, infraspinatus, arthroscopic
important to identify high-risk populations and pay atten- repair, rotator cuff repair, and arthroscopy. See Supplementary
Material S2 for the search strategy used in each database.
tion to the risk assessment of patients with rotator cuff
retear.
Before the operation, a risk assessment of the influ-
encing factors of patients with postoperative retear should Literature screening and data extraction
be performed to develop the best treatment measures,
which is particularly critical for the diagnosis and treatment Two researchers independently screened the literature and
of patients with RCTs. Some studies have revealed that the extracted and cross-checked the data. Disagreements were
resolved through discussion or negotiation with a third party.
cause of rotator cuff retear after ARCR may be related to
When selecting documents, the researchers read the title first, and
factors such as age, diabetes, gout, hyperlipidemia, physical
after excluding obviously irrelevant documents, they read the
labor, and low education level,5,28,32,44 but some risk fac- abstract and full text to determine whether to include the publi-
tors are contradictory across different studies. Therefore, cation. If necessary, the original research authors were contacted
this study used a quantitative, systematic evaluation method via e-mail or telephone to obtain information that had not yet been
to analyze the risk factors for rotator cuff retear after determined but was important to this research. The extracted in-
arthroscopic repair and to clarify the risk factors that affect formation included the following: (1) basic information of the
rotator cuff retear. included research, including first author, publication time, and
research type; (2) baseline characteristics of the research object,
including sample, and age; (3) key elements of the bias risk
Methods evaluation; and (4) the outcome indicators and measurement data
of concern.
This meta-analysis was performed in strict accordance with the
relevant requirements of the Meta-analysis of Observational
Studies in Epidemiology (MOOSE) statement (Supplementary Evaluation of literature quality
Material S1)51 and was registered with the PROSPERO Interna-
tional Prospective Register of Systematic Reviews (registration
The types of documents included in this article were cohort
number CRD42021225088).
studies, case-control studies, and cross-sectional studies. The NOS
was adopted to evaluate the risk of bias for the case-control studies
Literature inclusion and exclusion criteria and cohort studies.58 The evaluation includes 3 parts: study object
selection, intergroup comparability, and outcome measurement.
The following inclusion criteria were applied: (1) All included The total score is 9 points. The higher the score, the better the
patients needed to undergo arthroscopic repair. (2) The case quality of the literature. Cross-sectional studies were evaluated
groups were defined as patients with rotator cuff retear after sur- using the risk of bias evaluation criteria recommended by the
gery, and the control groups comprised patients with rotator cuff Agency for Healthcare Research and Quality.7 There are 11 items
healing. (3) The investigations were designed as cohort studies, in total, and each item is answered with ‘‘yes,’’ ‘‘no,’’ or ‘‘not
case-control studies, or cross-sectional studies that were clearly clear.’’8
2662 J. Zhao et al.

Figure 1 Flowchart of the number of studies identified and included in this meta-analysis.

Statistical analysis articles from Web of Science, and 17 articles from other
sources. After excluding duplicate articles, 307 articles
RevMan 5.3 software was used for the meta-analysis. The remained. After reading the title and abstract, 237 studies
weighted mean difference (WMD) was employed as the effect size that clearly did not meet the requirements were excluded,
for measurement data, and the odds ratio (OR) was used for binary and 70 documents were initially screened. After further
variables. Each effect size is provided with its 95% confidence reading the full text, according to the inclusion and
interval (CI). The heterogeneity of the included studies was exclusion criteria established in this study, 14 documents
evaluated by the heterogeneity test. If there was no heterogeneity were finally included.10,15,18,28,30,33,35-37,39,40,44,46,53 The
(I2  50%), the fixed effects model was used to merge the effect
specific retrieval process and results are shown in Fig. 1.
sizes. If there was heterogeneity (I2 > 50%), the random effects
model was used to merge the effect sizes. According to the
This study included 10 retrospective cohort studies and 4
characteristics of the research object, sample size, research design case-control studies. A total of 5693 patients from 6
type, etc, a subgroup analysis or sensitivity analysis was con- countries were enrolled, including 4779 in the rotator cuff
ducted to find the source of heterogeneity. For outcome indicators healing group and 914 in the retear group. The specific
with more than 7 articles included, Stata 15.1 software was used to conditions of the included literature are shown in Table I.
perform Egger linear regression test to evaluate publication bias.
Literature quality evaluation
Results The publications included in this study comprised retro-
spective cohort studies and case-control studies, and the
Literature screening process and results NOS was used to evaluate the quality of the literature. The
quality evaluation results of the included literature are
A total of 1299 articles were initially retrieved, including shown in Table I. The NOS score of the included literature
405 articles from PubMed, 162 articles from Embase, 715 was between 6 and 9 points. Only 1 article18 had an NOS
 Risk factors affecting rotator cuff retear
Table I Characteristics of the included studies
Included studies Country Study No. of patients AP tear size*, Age, yr Symptom Imaging Time to Incidence of Level of NOS
(first author/year) design cm duration,* mo modality imaging, mo retear, % evidence
Retear Healed Retear Healed Retear Healed Retear Healed
Le (2014) 37
Australia RC 174 826 2.8 1.6 65.7  10.4 57.6  11.7 NR NR US 6 17.4 III 7
Diebold (2017)15 Australia RC 212 1388 2.8 1.7 65  11.65 58  11.8 NR NR US 6 13 Ⅳ 8
Garcia (2016)18 USA RC 11 57 NR NR NR NR NR NR US 7 16.1 III 6
Jeong (2018)30 Korea CS 51 51 3.3 3.2 66.4  6.6 64.9  6.6 32.2 17.8 MRI 9 46 III 7
Kim (2016)33 Korea RC 37 245 NR NR NR NR NR NR MRI 6 13.1 Ⅳ 8
Park (2015)46 Korea CS 45 294 NR NR 63.2  7.1 59.2  7.8 43.6 31.1 MRI 12 13.3 III 8
Kwon (2018)36 Korea CS 145 458 2.8 1.7 64.1  7.5 59.4  8.2 39.4 26.3 CT or MRI 12 24 III 7
Lobo-Escolar (2020)40 Spain RC 15 143 NR NR 52.5  7.2 52.3  6.8 10.7 8.7 MRI 8 9.5 III 8
Harada (2020)26 Japan RC 32 254 3.4 2.6 66.8  5.4 64.7  7.3 12.6 9.3 MRI 6 11.19 III 9
Tashjian (2010)53 USA CS 24 25 NR NR 63.3  10 55.1  10 NR NR US 6 NR Ⅳ 8
Chung (2011)10 Korea RC 62 210 2.7 1.7 65.0  7.6 58.2  7.5 49 33.2 CT or US 12 22.8 III 8
Namdari (2014)44 USA RC 28 33 2.5 2.2 60.3  8.3 62.2  8.5 NR NR MRI or US 12 33 III 7
Lee (2017)39 Korea RC 50 643 NR NR 64.6  7.75 59.1  12.7 NR NR MRI 12 7.22 III 9
Kim (2017)35 Korea RC 28 152 4.1 3.1 61.8  1.4 60.1  0.6 20.4 15.7 MRI 24 15.6 III 8
RC, retrospective cohort study; CS, case-control study; AP, anteroposterior; NR, not reported; US, ultrasonography; MRI, magnetic resonance imaging; CT, computed tomography; NOS, New Castle-Ottawa
scale.
* Values are expressed as mean.

2663
2664 J. Zhao et al.

score of 6, and the average NOS score was 7.7 points, 0.48, 1.18; P < .001), tear width (WMD 0.62, 95% CI 0.26,
which indicates that the quality of the included literature 0.98; P < .001), tear size area (WMD 3.58, 95% CI 2.31,
was very high. The literature quality evaluation details of 5.40; P < .001), amount of retraction (WMD 1.13, 95%
the 14 included studies10,15,18,28,30,33,35-37,39,40,44,46,53 are CI 1.07, 1.19; P < .001), critical shoulder angle (CSA;
shown in Supplementary Material S3. WMD 1.66, 95% CI 0.76, 2.57; P < .001), acromiohumeral
interval (AI; WMD 1.45, 95% CI 1.59, 1.31; P <
Meta-analysis results .001) and distance from the musculotendinous junction to
the glenoid (WMD 4.67, 95% CI 5.05, 4.29; P <
Sociodemographic risk factors .001) were risk factors for rotator cuff retear after ARCR.
This study conducted a statistical analysis of 15 socio- Among the anatomic factors in this study, only glenoid
demographic factors (Table II) and then evaluated their inclination (WMD 2.39, 95% CI 0.13, 4.92; P ¼ .06) was
impact on rotator cuff healing after ARCR. Eight studies not a risk factor.
reported on the correlation of age with rotator cuff healing
after arthroscopic repair. The results of the studies had high Intraoperative risk factors
heterogeneity (I2 ¼ 93%), and the random effects model This study analyzed the effects of 6 surgery-related factors
was used for analysis. The results showed that the corre- on rotator cuff healing (Table IV). Based on the combined
lation between age and rotator cuff retear was statistically ORs or WMDs, the following risk factors were identified:
significant (WMD 4.38, 95% CI 2.16, 6.61; P < .001). operative duration (WMD 4.32, 95% CI 0.40, 8.24; P ¼
Meta-analysis showed that rotator cuff retear was more .003), biceps procedure (OR 1.71, 95% CI 1.31, 2.23; P <
likely with increasing body mass index (BMI) (WMD 0.52, .001), and postoperative UCLA score (WMD 1.85, 95%
95% CI 0.23, 0.82; P < .001). A total of 7 CI 3.27, 0.43; P ¼ .01). In addition, the results of the
studies10,26,35,36,40,44,46,53 reported the impact of diabetes on meta-analysis showed that the repair technique (single row
rotator cuff healing. Meta-analysis showed that diabetes or double row) and distal clavicle resection were not risk
was a risk factor for retear after ARCR (OR 1.42, 95% CI factors for rotator cuff retear.
1.02, 1.97; P ¼ .04). The results showed that male sex,
female sex, the dominant hand, the affected shoulder, a
high exercise level, hypertension, cardiovascular disease, Publication bias
hyperlipidemia, smoking, and a history of trauma did not
cause rotator cuff retear after ARCR. Stata 15.1 software was used to perform Egger test on the
risk factors for
7 included articles and then to evaluate
Preoperative clinical evaluation whether there was publication bias. Egger test showed no
Sixteen preoperative clinical objective and subjective publication bias for age (P ¼ .81), tear length (P ¼ .11),
evaluation indicators were statistically analyzed (Table III). symptom duration (P ¼ .37), dominant hand (P ¼ .07),
Bone mineral density was measured by dual-energy X-ray diabetes (P ¼ .89), smoking (P ¼ .56), single-row repair (P
absorptiometry before the operation, and the lowest T score ¼ .82), or double-row repair (P ¼ .49). Male sex (P ¼ .03)
of the proximal femur or lumbar spine was used for the data and female sex (P ¼ .03) showed publication bias, and the
analysis. Steroid injection refers to treatment with steroid interpretation of the results of these 2 indicators requires
injections before the operation. Meta-analysis showed that caution. The statistical process and results for publication
if the subscapularis and infraspinatus exhibited fat infil- bias of the above 10 outcome indicators are shown in
tration, whether the Goutallier grade was
2 or <2, Supplementary Material S5.
these indicators were all risk factors for rotator cuff retear
(P < .001). In addition, the research results showed
that symptom duration (WMD 4.09, 95% CI 2.34, 5.85; Discussion
P < .001) and bone mineral density (WMD 0.56, 95% CI
1.04, 0.08; P ¼ .02) were both risk factors for rotator This study analyzed a total of 45 risk factors in 4 aspects
cuff retear. Fatty infiltration of the supraspinatus, forward (sociodemographic, preoperative clinical evaluation, and
flexion, external rotation, internal rotation, preoperative anatomic and intraoperative factors), thereby presenting the
frozen shoulder, symptom aggravation, preoperative visual most comprehensive data for the analysis of factors related
analog scale pain score, preoperative University of Cali- to rotator cuff retear after ARCR. This study used a
fornia Los Angeles (UCLA) shoulder score, and steroid quantitative, systematic evaluation method for the first time
injection were not risk factors for rotator cuff retear. to analyze risk factors of rotator cuff retear after ARCR,
which is beneficial for the early identification of patients
Anatomic risk factors prone to postoperative retear and to reduce the occurrence
Eight anatomic factors were analyzed (Table IV). Meta- of retear after rotator cuff repair by intervening in modifi-
analysis showed that tear length (WMD 0.83, 95% CI able factors.
Risk factors affecting rotator cuff retear 2665

Table II The main outcomes of meta-analysis and subgroup analysis (sociodemographic risk factors)
Risk factors No. of studies OR or WMD LL 95% CI UL 95% CI P value I2, % Analysis model
y
Age, yr 8 4.38 2.16 6.61 <.001 93 IV, random
Subgroup analysis
Age (Australia) 2 7.53y 6.32 8.74 <.001 0 IV, fixed
Age (Korea) 5 3.98y 1.80 6.17 .004 90 IV, random
Age (Korea, EHS) 3 5.38y 4.31 6.44 <.001 22 IV, fixed
Sex: male 11 0.83* 0.58 1.20 .330 70 M-H, random
Sex: female 11 1.05* 0.79 1.41 .730 55 M-H, random
Sex: female (EHS) 10 0.85* 0.71 1.02 .080 23 M-H, fixed
Dominant arm 7 0.89* 0.68 1.16 .380 0 M-H, fixed
Right shoulders 2 1.03* 0.81 1.31 .820 0 M-H, fixed
Left shoulders 2 0.97* 0.77 1.23 .820 0 M-H, fixed
Level of sports activity: high 2 0.85* 0.42 1.69 .640 56 M-H, random
Body mass index 4 0.52y 0.23 0.82 .006 62 IV, random
Body mass index (EHS) 3 0.69y 0.53 0.84 <.001 22 IV, fixed
Hypertension 2 1.34* 0.49 3.69 .570 74 M-H, random
Hyperlipidemia 4 1.50* 0.99 2.26 .050 0 M-H, fixed
Cardiovascular disease 2 1.33* 0.77 2.31 .300 0 M-H, fixed
Diabetes 7 1.42* 1.02 1.97 .040 0 M-H, fixed
Smoking 8 1.02* 0.75 1.39 .910 35 M-H, fixed
Demanding work 5 1.50* 0.64 3.51 .350 79 M-H, random
Trauma history 5 1.04* 0.78 1.39 .780 42 M-H, fixed
EHS, eliminate heterogeneous sources; OR, odds ratio; WMD, weighted mean differences; LL, lower limit; CI, confidence interval; UL, upper limit; IV,
inverse variance; M-H, Mantel Haenszel test.
Bold values are statistically significant.
The Forest map of all risk factors is shown in Supplementary Material S5.
* OR.
y
WMD.

Sociodemographic risk factors ARCR. Meta-analysis revealed that the higher the BMI
(WMD 0.52, 95% CI 0.23, 0.82; P < .001), the more likely
This study shows that advanced age (WMD 4.38, 95% CI the rotator cuff retear is after ARCR. Animal studies have
2.16, 6.61; P <.001) is a risk factor for rotator cuff retear. shown that the quality of tendons in obese mouse models is
Because of the high heterogeneity of combining age data, poor and that obesity is related to proinflammatory cyto-
we conducted a subgroup analysis according to different kines and reactive oxygen species.13,41 Therefore, an in-
countries (Australia and South Korea). The results showed crease in BMI promotes inflammation and affects tendon
that in both the South Korean group and the Australian healing. Previous studies have also shown that obesity leads
group, age was a risk factor for retear, which shows that the to a higher tear rate.2,24,56 The possible reason is that as a
statistical results are reliable. Animal biomechanics ex- result of the accumulation of fatty tissue, obese patients
periments have proven that the maximum load of the need more strength to lift their shoulders. An increase in
tendon in elderly rats at 8 weeks after rotator cuff repair is BMI may increase the mechanical load on the joints and
significantly lower than that in young rats, and pathologic cause greater pressure on the healing tendons.31 Obesity
sections have shown that the arrangement of tendon-bone may also promote or involve hypercholesterolemia.4 Some
fibroblasts in elderly rats is disordered, the formation of studies have shown that hypercholesterolemia is not
collagen fibrous tissue at the tendon-bone interface is conducive to rotator cuff tendon healing in rats.3,34
reduced, and the structure of the original tendon is very Therefore, the control of BMI and hypercholesterolemia
different, which reduces the stability of tendon healing.48 is particularly important for patients with rotator cuff
Because the above study is based on the induced tear injury. Diabetes (OR 1.42, 95% CI 1.02, 1.97; P ¼ .04) is
model, it does not necessarily represent the research results also a risk factor for postoperative rotator cuff retear. An-
after the natural progression of degenerative RCT repair. imal experiments4 have shown that compared with nondi-
However, it also provides a way for us to understand the abetic rats, diabetic rats have less fibrocartilage and tissue
effect of age on retear after rotator cuff repair. The results collagen formation at the tendon-bone interface after rota-
of this study are consistent with those reported by Diebold tor cuff repair, and the maximum failure load is lower,
and Cho,7,15 and, therefore, advanced age can be identified which indicates that continuous hyperglycemia can inhibit
as an independent risk factor for rotator cuff retear after rotator cuff healing after repair. Moreover, clinical
2666 J. Zhao et al.

Table III The main outcomes of meta-analysis and subgroup analysis (preoperative clinical evaluation)
Risk factors No. of studies OR or WMD LL 95% CI UL 95% CI P value I2, % Analysis model
Subscapularis fatty infiltration, grade <2 3 0.23* 0.16 0.33 <.001 0 M-H, fixed
Subscapularis fatty infiltration, grade
2 3 3.37* 1.43 7.93 .005 78 M-H, random
Subscapularis fatty infiltration, grade
2 (EHS) 2 5.25* 3.48 7.93 <.001 0 M-H, fixed
Supraspinatus fatty infiltration, grade <2 2 0.50* 0.15 1.70 .270 87 M-H, random
Supraspinatus fatty infiltration, grade
2 2 1.88* 0.51 6.96 .350 90 M-H, random
Infraspinatus fatty infiltration, grade <2 3 0.08* 0.02 0.29 <.001 89 M-H, random
Infraspinatus fatty infiltration, grade
2 3 11.02* 4.30 28.24 <.001 80 M-H, random
Forward flexion, degrees 2 3.53y 9.12 2.07 .220 0 IV, fixed
External rotation, degrees 2 0.26y 7.08 7.60 .940 82 IV, random
Internal rotation, degrees 2 0.32y 0.91 0.26 .280 45 IV, fixed
Preoperative Frozen shoulder 3 0.99* 0.60 1.62 .960 0 M-H, fixed
Symptom duration, months 7 4.09y 2.34 5.85 <.001 28 IV, fixed
Symptom aggravation, months 2 1.65y 0.96 4.27 .220 0 IV, fixed
Preoperative VAS pain score 2 0.30y 0.03 0.63 .070 0 IV, fixed
Preoperative UCLA score 2 0.35y 2.27 2.96 .800 84 IV, random
Steroid injection 3 1.60* 0.34 7.41 .550 86 M-H, random
Steroid injection (EHS) 2 0.76* 0.41 1.44 .400 0 M-H, fixed
Bone mineral density, T score 3 0.56y 1.04 0.08 .020 84 IV, random
Bone mineral density (EHS) 2 0.31y 0.52 0.10 .003 0 IV, fixed
EHS, eliminate heterogeneous sources; VAS, visual analog scale; UCLA, University of California Los Angeles shoulder score; OR, odds ratio; WMD, weighted
mean differences; LL, lower limit; CI, confidence interval; UL, upper limit; M-H, Mantel Haenszel test; IV, inverse variance.
Fat infiltration evaluation adopts Goutallier classification.
Bold values are statistically significant.
* OR.
y
WMD.

Table IV The main outcomes of meta-analysis and subgroup analysis (anatomic and intraoperative factors)
Risk factors No. of OR or WMD LL 95% CI UL 95% CI P value I2, % Analysis model
studies
Anatomic factors
Tear length, cm 7 0.83y 0.48 1.18 <.001 92 IV, random
Tear length, cm (EHS) 6 1.03y 0.86 1.19 <.001 49 IV, fixed
Tear width, cm 5 0.62y 0.26 0.98 .007 91 IV, random
Tear width, cm (EHS) 4 0.77y 0.51 1.03 <.001 66 IV, random
Tear size area, cm2 3 3.58y 2.31 5.40 <.001 82 IV, random
Tear size area, cm2 (EHS) 2 4.78y 4.43 5.14 <.001 0 IV, fixed
Amount of retraction, cm 3 1.13y 1.07 1.19 <.001 0 IV, fixed
Critical shoulder angle, degree 3 1.66y 0.76 2.57 .003 0 IV, fixed
Glenoid inclination, degree 2 2.39y 0.13 4.92 .060 0 IV, fixed
Acromiohumeral interval, mm 4 1.45y 1.59 1.31 <.001 40 IV, fixed
Distance of musculotendinous 2 4.67y 5.05 4.29 <.001 0 IV, fixed
junction to glenoid, mm
Intraoperative factors
Operative time, min 4 4.32y 0.40 8.24 .030 79 IV, random
Operative time (EHS) 3 6.57y 5.08 8.07 <.001 0 IV, fixed
Repair technique, single row 7 1.07* 0.84 1.37 .560 42 M-H, fixed
Repair technique, double row 7 0.91* 0.72 1.16 .450 42 M-H, fixed
Distal clavicle resection 2 1.23* 0.68 2.25 .490 0 M-H, fixed
Biceps lesion/Biceps procedure 5 1.71* 1.31 2.23 <.001 44 M-H, fixed
Postoperative UCLA score 2 1.85y 3.27 0.43 .010 68 IV, random
EHS, eliminate heterogeneous sources; UCLA, University of California Los Angeles shoulder score; OR, odds ratio; WMD, weighted mean differences; LL,
lower limit; CI, confidence interval; UL, upper limit; IV, inverse variance; M-H, Mantel Haenszel test.
Bold values are statistically significant.
* OR.
y
WMD.
Risk factors affecting rotator cuff retear 2667

studies6,11 have revealed that diabetic patients exhibit greater the preoperative RCT and the longer the post-
poorer efficacy after rotator cuff repair than nondiabetic operative recovery period, the higher the possibility of
patients and present higher failure and infection rates. retear.1,42,53 Gasbarro et al19 found through a retrospective
study that the average supraspinatus tendon tear size in
patients with RCT repair failure was significantly larger
Preoperative clinical evaluation
than that in patients without repair failure. A study
involving 1000 cases showed that the size of the preoper-
The results of the meta-analysis suggest that if the sub-
ative RCT (tear size, tear area, tear layer number) was
scapularis and infraspinatus exhibit fat infiltration, regard-
closely related to the postoperative retear rate.37 Studies
less of whether the Goutallier stage is
2 or <2, these
have shown that there is a certain correlation between
indicators are all risk factors for rotator cuff retear after
preoperative muscle and tendon retraction and the occur-
ARCR (P < .001). Adipose tissue will replace internal
rence of rotator cuff retear, which is the most important
muscle fibers, and with the increase in connective tissue
pathophysiological result of chronic tendon tearing.50
content and fibrosis, fatty infiltration will reduce the elas-
Muscle retraction is assessed by the position of the mus-
ticity and vitality of the rotator cuff tendon tissue and affect
culotendinous junction relative to the scapula, and the gap
the healing of the rotator cuff.20 Gladstone et al22 believe
between the large nodule and the edge of the tendon may be
that in most cases, the greater the degree of muscle fat
due to tendon shortening or muscle retraction. Rotator cuff
infiltration, the worse the treatment effect. Muscle atrophy
retraction can increase the tension of the repair, resulting in
and fat infiltration are independent influencing factors, fat
poor footprint coverage, and the more severe the rotator
infiltration progresses significantly after rotator cuff repair,
cuff retraction is, the longer the patient’s disease course and
and the progression in retear patients is more obvious than
the worse the tendon quality.35,50,53 Studies have shown that
that in patients who show healing. Rotator cuff muscle at-
the compression force and shear force of the shoulder joint
rophy and fat infiltration, especially that of the infra-
depend on the CSA,23,57 and the shear force of the joint
spinatus muscle, play a key role in determining the
increases as the CSA increases, which will cause the
functional efficacy of the repair operation. The meta-
shoulder joint to become unstable. Thus, the supraspinatus
analysis showed that the longer the duration of symptoms
muscle needs additional force to maintain the stability of
(WMD 4.09, 95% CI 2.34, 5.85; P < .001) and the lower
the joint. Too high of a CSA will induce the supraspinatus
the bone density (WMD 0.56, 95% CI 1.04, 0.08;
muscle to overload, and this also proves that too high of a
P ¼ .02 < .05), the more likely rotator cuff retear was after
CSA will cause the biomechanical properties of the rotator
ARCR. Tan et al52 found that patients whose symptoms
cuff to induce tearing after ARCR.21 The AI refers to the
lasted for a period of 12 months had no increase in the rate
shortest distance between the dense cortical bone under the
of retear 6 months after ARCR. However, patients whose
acromion and the subchondral cortex on the upper part of
symptoms lasted longer than 24 months had a significantly
the humeral head, which is an important factor affecting the
higher rate of retear at 6 months after ARCR than those
function of the rotator cuff. Lee et al’s38 observation of 32
whose symptoms lasted less than 24 months (20% vs. 13%,
patients after shoulder arthroscopy revealed that the dif-
P ¼ .04).52 Tingart et al used computed tomography (CT)
ference between the immediate postoperative AI and the
scans to observe the bone density of the greater tuberosity
preoperative AI in the retear group was significantly
of humerus specimens and found that the higher the bone
smaller than that in the nonretear group (P ¼ .02). Studies
density of the proximal humerus, the greater the force
have shown that a shorter AI affects normal glenohumeral
required to pull out the anchor.54 Pietschmann et al47
mechanics, causing the rotator cuff to tear again after
evaluated the pull-out strength of metal and absorbable
surgery.9
anchors on healthy and osteoporotic cadaveric specimens
and concluded that the higher the bone density, the greater
the pull-out strength required. Combined with the results of
Intraoperative factors
this meta-analysis, there is sufficient evidence to confirm
that the lower the bone density is, the easier it is to tear the
In the analysis of the factors related to surgery, we found
rotator cuff again after ARCR.
that operative duration (WMD 4.32, 95% CI 0.40, 8.24),
biceps procedure (OR 1.71, 95% CI 1.31, 2.23), and post-
Anatomic factors operative UCLA score (WMD 1.85, 95% CI 3.27,
0.43) were risk factors for retear after rotator cuff surgery.
The statistical results show that tear length (P < .001), tear Studies15,39 have shown that the longer the operation is, the
width (P < .001), tear size area (P < .001), amount of easier it is to tear the rotator cuff after ARCR, but further
retraction (P < .001), distance of the musculotendinous research is still needed to determine the related mechanism.
junction to the glenoid (P < .001), CSA (P < .001), and AI Le et al37 believe that a longer operation is related to the
(P < .001) are all risk factors of postoperative rotator cuff length and number of RCTs, especially the size of the tear.
retear after ARCR. Previous studies have shown that the Therefore, the long operation may be an indirect cause, and
2668 J. Zhao et al.

the direct risk factor may be related to the severity of the

RCT. Intraoperative surgical manipulation of the biceps glenoid), and intraoperative factors (operative duration,
brachii will directly affect retearing of the rotator cuff after biceps procedure, postoperative UCLA score) are risk
ARCR. As there are still few studies on this aspect, further factors for rotator cuff retear after ARCR. Clinical
study is needed to determine the mechanism of action. medical staff can refer to the results of this study to
Studies have shown that there is a negative correlation enhance the surgical evaluation of high-risk individuals
between the RCT severity and the UCLA score, which who are prone to develop retears and to intervene and
indicates that the smaller the RCT is, the better the treat- manage modifiable factors, such as BMI, diabetes mel-
ment effect.1 Therefore, the postoperative UCLA score and litus, bone mineral density, and operative duration, that
even the preoperative UCLA score can reflect the severity may reduce the rate of postoperative retear after ARCR.
of the RCT, which is conducive to the evaluation of post-
operative rotator cuff healing. Many previous studies have
shown that the double-row repair technique can achieve
stronger fixation and a lower rotator cuff retear rate.25,27,55 Disclaimer
The results of this study suggest that the repair technique
(single row or double row) is not a risk factor for rotator This work was supported by the National Natural Sci-
cuff retear after ARCR. Based on the results of this study ence Foundation of China (No. 81974574, No.
and considering the clinical practicability and the economic 81873314, No. 82004386, No.82004383), the Project of
ability of patients, a single-row suture technique with Administration of Traditional Chinese Medicine of
relatively low cost and technical difficulty can be selected. Guangdong Province (No.20201129), the Project of
Guangdong Provincial Department of Finance (No.
[2014]157, No.[2018]8), the Medical Science Research
Limitations
Foundation of Guangdong Province (No.A2020105,
No.B2019091), the Science and Technology Planning
This study has the following limitations. (1) The studies
Project of Guangdong Province (No.
included in this meta-analysis did not consider the size of
2020A1414050050), the Science and Technology Plan-
the RCT, which may have an impact on the results of this
ning Project of Guangzhou (No. 202102010273) and the
report. (2) The cases of retear included in this review were
Science and Technology Research Project of Guangdong
not clearly defined as a natural biological tear or as a retear
Provincial Hospital of Chinese Medicine
because of human factors, which are areas that need to be
(No.YN2019ML08, YN2015MS15).
explored in depth in future studies. (3) The included liter-
The authors, their immediate families, and any
ature is limited, and some risk factors, such as the lateral
research foundations with which they are affiliated have
acromion angle, physical labor, and surgical materials,
not received any financial payments or other benefits
cannot be combined for analysis. (4) Because the original
from any commercial entity related to the subject of this
sample data of the included literature could not be obtained,
article.
it was impossible to calculate the accurate average data or
interval of some risk factors, such as age, symptom dura-
tion, CSA, and AI. Further multicenter and large-sample
data need to be explored in the future. (5) The included Supplementary Data
cases in this study did not clearly distinguish between
chronic RCTs or traumatic RCTs, which may affect the Supplementary data to this article can be found online at
credibility of this study. [Link]

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