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Functional and pain outcomes after arthroscopic surgery to repair rotator cuff tears were worse among tobacco users compared with nonusers, according to a new study.¹

Factors that may be predictive for functional outcomes after rotator cuff repair surgery include age, sex, tear size, symptom duration, preoperative functional status, preoperative pain, fatty degeneration of the supraspinatus muscle, rheumatologic disease, and Workers鈥� Compensation claims.^2,3 A few studies have also found that preoperative modifiable risk factors, such as smoking, obesity, or narcotic use, were associated with postoperative pain and some functional outcomes.⁴

鈥淭he outcomes from rotator cuff repair surgery continue to confuse shoulder surgeons,鈥� said study author Thomas W. Throckmorton, MD, a professor in the Department of Orthopaedic Surgery and Biomedical Engineering at the University of Tennessee 鈥� Campbell Clinic in Memphis, TN, in an interview with 乌鸦传媒視頻. 鈥淢uch of the literature has focused on technical factors that can influence rotator cuff healing and outcomes. However, we felt that there were likely some patient-specific risk factors for inferior outcomes that may help us better understand why some patients do better than others.鈥�

To this end, the investigators analyzed factors influencing the 2-year functional and pain outcomes of patients who underwent arthroscopic rotator cuff repair.

This retrospective cohort study included patients with primary arthroscopic rotator cuff repair surgery at the University of Tennessee 鈥� Campbell Clinic who were followed up for 2 or more years. Patients who had revisions or open-approach surgeries were excluded. All patients had the same surgeon and underwent a standardized postsurgical rehabilitation protocol that included physical therapy.

Patients completed health screening questionnaires at intake. Variables assessed included obesity (BMI >30), mood disorders, current tobacco use, alcohol use, opioid use within 3 months of surgery, disability claims, and Workers鈥� Compensation claims. 

Outcomes at follow-up included American Shoulder and Elbow Surgeons (ASES) scores, Single Assessment Numeric Evaluation (SANE) scores, strength on manual motor testing, patient-reported range of motion (ROM) scores, and visual analog scale (VAS) pain scores.

Patient characteristics

In total, 75 patients participated in the study with a mean follow-up time of 3.7 years (range, 2.2 to 6.5 years). There were 35 male and 40 female patients, with a mean age of 57.6 years (range, 38 to 89 years). Thirty-seven rotator cuff tears were classified as small, 22 as medium, 8 as large, and 8 as massive. No significant differences were seen in preoperative or 2-year VAS scores between patients with small and medium tears and between those with large and massive tears.

Of the 75 participants, 39 (52.0%) were obese, 36 (48.0%) reported alcohol use, 27 (36.0%) reported opioid use within 3 months of surgery, 19 (25.3%) had a mood disorder diagnosis, 11 (14.7%) reported tobacco use, 8 (10.7%) claimed Workers鈥� Compensation, and 6 (8.0%) claimed disability.

Between the preoperative visit and the last follow-up visit, the mean VAS scores for the study group improved significantly from 5.8 (range, 0-10) to 1.8 (range, 0-10; 伪 = .05; effect size = 1.63; power = 0.99; P < .001). VAS scores improved significantly between the 2- and 6-week follow-ups and the 6- and 12-week follow-ups, but beyond 12 weeks the differences were not significant. At the 2-year follow-up, the mean ASES score for the study group was 81.1 (range, 8.3-100).

Tobacco users suffer worse outcomes

No significant differences were found for range of motion at 2-year follow-up between patients with or without any of the potential prognostic factors. In addition, no significant differences in ASES scores, SANE scores, or VAS pain scores were found between groups with or without obesity, mood disorders, opioid use, Workers鈥� Compensation claims, or disability claims.

In contrast, the investigators found worse outcomes in patients who reported tobacco use. ASES scores at the 2-year follow-up visit were significantly worse in patients who used tobacco compared with those who did not (62.4 vs 84.0; 伪 = .05; effect size = 0.91; power = 0.77; P = .004). SANE scores were also significantly worse in patients with tobacco use at follow-up compared with non-users (63 vs 83.4; 伪 = .05; effect size = 0.78; power = 0.71; P = .011). 

Compared with tobacco nonusers, VAS pain scores were significantly worse in patients who reported tobacco use both at the preoperative visit (7.4 vs 5.6; 伪 = .05; effect size = 0.98; power = 0.81; P = .001) and at the 2-year follow-up (4.5 vs 1.3; 伪 = .05; effect size = 1.2; power = 0.90; P = .009).

Unlike tobacco users, the alcohol use group had significantly better ASES scores at the most recent follow-up appointment compared with alcohol nonusers (86.5 vs 76.2; 伪 = .05; effect size = 0.47; power = 0.63; P = .046). There were no significant differences in SANE scores at follow-up or VAS scores at the preoperative visit or follow-up between alcohol users and nonusers. 

What does this mean for clinicians?

鈥淏eware the smoker with a rotator cuff tear,鈥� said Dr. Throckmorton. 鈥淭heir outcomes after rotator cuff repair are remarkably worse than non-smokers.鈥�

The authors wrote in their paper that 鈥減otentially modifiable risk factors can be corrected prior to operative intervention to optimize outcomes and maximize value.鈥� 

If smokers with rotator cuff tears quit smoking before arthroscopic surgery, would their outcomes improve? The study design could not address this question directly. However, Dr. Throckmorton told 乌鸦传媒視頻, 鈥淲e now routinely send current smokers for a smoking cessation program prior to rotator cuff repair.鈥� 

In addition to the retrospective design, study limitations were the use of patients who had the same surgeon at one institution and the lack of analysis of radiographic or imaging assessments at follow-up. 

Another limitation was the small sample size for individual groups. 鈥淟arger, registry-level studies are needed to follow up on these findings,鈥� said Dr. Throckmorton. 鈥淥ur study was likely underpowered to show a significant difference in some variables, particularly preoperative opioid use.鈥�

Published: August 22, 2024