Introduction
Ever since the first description over 200 years ago, rotator cuff tears have fascinated orthopedic surgeons. As surgeons moved away from simply identifying rotator cuff tears, focus moved toward treatment of these often debilitating injuries. The first English-language description of an open rotator cuff repair technique, now over 100 years ago, has been followed by a rapid evolution of changing management strategies, operative techniques, and postoperative protocols. The development of diagnostic imaging modalities, including arthrography and magnetic resonance imaging (MRI), has helped fuel this rapid evolution, as have advances in shoulder arthroscopy, which was first described nearly 85 years ago. These developments led to debates about the optimal treatment of rotator cuff tears, which initially compared open and arthroscopically driven miniopen repair techniques and eventually all-arthroscopic repair techniques. With continued technologic advances, debates have moved toward comparison of specific suture repair techniques, including single- and double-row techniques, with the most recent studies investigating the role of biologic agents or augmentations in rotator cuff repair.
Today, it is estimated that over 250,000 rotator cuff repairs are performed annually in the United States, with a dramatic increase in the number of rotator cuff repair procedures over the last decade. Similarly, the number of peer-reviewed publications on the rotator cuff has increased, with a nearly exponential increase in publications over the last 30 years, with rotator cuff–specific publications dominating recent clinical shoulder literature. Although the volume and breadth of literature are impressive, at times it seems as though more questions are raised than answers provided. This, at least in part, may be attributable to the difficulty in defining a successful rotator cuff repair. Defining success is complicated by the fact that there is great inconsistency throughout the literature when reporting surgical indications, particularly important given the high number of asymptomatic rotator cuff tears, and outcomes. Multiple outcomes are available for assessment of the shoulder. This includes patient-reported outcome measures as well as various imaging parameters to assess repair integrity. However, there has been a lack of consistency for assessment of strength and function. Although quality of life may improve after rotator cuff repair, other parameters, including maintenance of the structural integrity of the rotator cuff repair following surgery, have yielded less satisfying results. Despite the high volume of procedures and publications, evaluating the success of rotator cuff repair is hindered by inconsistent reporting of important variables throughout the literature. Although these shortcomings have been acknowledged and suggestions made to improve reporting, questions undoubtedly remain. This chapter evaluates the current best evidence available to better answer the question at the crux of rotator cuff repair surgery: Are we doing better?