Journal of Shoulder and Elbow Surgery

Clinical outcome and repair integrity after arthroscopic rotator cuff repair significantly improved during the surgeon’s learning curve

Published:November 30, 2020DOI:

      Hypothesis and Background

      Whether learning curve could affect the surgical outcome after arthroscopic rotator cuff repair is still unknown. The purpose of this study was to evaluate surgical learning curve for clinical outcome and retear rate after arthroscopic rotator cuff repairs that were performed by the beginner shoulder surgeon. We hypothesized that clinical outcome and retear rate would improve over time with the accumulation of a surgeon’s experience.


      This retrospective study consisted of 200 consecutive patients who had arthroscopic rotator cuff repairs, performed by a single surgeon between 2011 and 2018. We included symptomatic rotator cuff tears involving the supraspinatus/infraspinatus and/or subscapularis tendon and follow-up magnetic resonance imaging evaluations of repair integrity 6 months after surgery. Surgeon’s learning was evaluated with calculation of cumulative retear rate and cumulative summation (CUSUM) analysis. Clinical outcomes and the retear rates were compared between group A (the first-half 100 patients) and group B (the latter-half of 100 patients).


      The mean follow-up period was 21 months (range, 12-55). The overall retear rate was 13% (26 patients). The CUSUM analysis showed that after patient number 97, the curve was maintained below the level of acceptable failure rate, suggesting the competency was obtained consistently. Comparing between groups, retear rate showed significant decrease from 18% in group A to 8% in group B (P = .036). Notably, retear rate in small to medium-sized tears (<3 cm) significantly decreased from 26% (12 of 46 patients) in group A to 2% (1 of 49 patients) in group B (P = .001). However, analysis in large to massive tears (≥3 cm) failed to show difference between groups (30%, 6 of 20, in group A and 25%, 6 of 24, in group B; P = .711). In multivariate analysis, higher fatty infiltration of the supraspinatus muscle (P = .008), more severe muscle atrophy of the teres minor (P = .010), and belonging to group A (P = .011) were associated with retear.


      Clinical outcomes and retear rate after arthroscopic rotator cuff repairs significantly improved during the learning curve period of a beginner shoulder surgeon.

      Level of evidence


      To read this article in full you will need to make a payment


      Subscribe to Journal of Shoulder and Elbow Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Castricini R.
        • De Benedetto M.
        • Orlando N.
        • Rocchi M.
        • Zini R.
        • Pirani P.
        Arthroscopic Latarjet procedure: analysis of the learning curve.
        Musculoskelet Surg. 2013; 97: 93-98
        • Chan G.
        • Pautler S.E.
        Use of cumulative summation (CUSUM) as a tool for early feedback and monitoring in robot-assisted radical prostatectomy outcomes and performance.
        Can Urol Assoc J. 2019; 13: 53-58
        • Cho C.H.
        • Song K.S.
        • Koo T.W.
        Clinical outcomes and complications during the learning curve for reverse total shoulder arthroplasty: an analysis of the first 40 cases.
        Clin Orthop Surg. 2017; 9: 213-217
        • Cundy T.P.
        • Rowland S.P.
        • Gattas N.E.
        • White A.D.
        • Najmaldin A.S.
        The learning curve of robot-assisted laparoscopic fundoplication in children: a prospective evaluation and CUSUM analysis.
        Int J Med Robot. 2015; 11: 141-149
        • Fuchs B.
        • Weishaupt D.
        • Zanetti M.
        • Hodler J.
        • Gerber C.
        Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging.
        J Shoulder Elbow Surg. 1999; 8: 599-605
        • Groh G.I.
        • Groh G.M.
        Complications rates, reoperation rates, and the learning curve in reverse shoulder arthroplasty.
        J Shoulder Elbow Surg. 2014; 23: 388-394
        • Guttmann D.
        • Graham R.D.
        • MacLennan M.J.
        • Lubowitz J.H.
        Arthroscopic rotator cuff repair: the learning curve.
        Arthroscopy. 2005; 21: 394-400
        • Hein J.
        • Reilly J.M.
        • Chae J.
        • Maerz T.
        • Anderson K.
        Retear rates after arthroscopic single-row, double-row, and suture bridge rotator cuff repair at a minimum of 1 year of imaging follow-up: a systematic review.
        Arthroscopy. 2015; 31: 2274-2281
        • Howells N.R.
        • Auplish S.
        • Hand G.C.
        • Gill H.S.
        • Carr A.J.
        • Rees J.L.
        Retention of arthroscopic shoulder skills learned with use of a simulator: demonstration of a learning curve and loss of performance level after a time delay.
        J Bone Joint Surg Am. 2009; 91: 1207-1213
        • Issat T.
        • Beta J.
        • Januszewski M.
        • Jakimiuk A.J.
        Cumulative summation test for learning curve (LC-CUSUM) in outpatient hysteroscopy.
        Ginekol Pol. 2017; 88: 9-12
        • Jeong J.Y.
        • Yoon Y.C.
        • Lee S.M.
        • Yoo J.C.
        Arthroscopic incomplete repair using a "hybrid technique" for large to massive rotator cuff tears: clinical results and structural integrity.
        Arthroscopy. 2018; 34: 2063-2073
        • Leong P.
        • Deshpande S.
        • Irving L.B.
        • Bardin P.G.
        • Farmer M.W.
        • Jennings B.R.
        • et al.
        Endoscopic ultrasound fine-needle aspiration by experienced pulmonologists: a cusum analysis.
        Eur Respir J. 2017; 50
        • Lo I.K.
        • Burkhart S.S.
        The interval slide in continuity: a method of mobilizing the anterosuperior rotator cuff without disrupting the tear margins.
        Arthroscopy. 2004; 20: 435-441
        • McColl A.H.
        • Lam P.H.
        • Murrell G.A.C.
        Are we getting any better? A study on repair integrity in 1600 consecutive arthroscopic rotator cuff repairs.
        JSES Open Access. 2019; 3: 12-20
        • Moga I.
        • Konstantinidis G.
        • Coady C.
        • Ghosh S.
        • Wong I.H.
        Arthroscopic anatomic glenoid reconstruction: analysis of the learning curve.
        Orthop J Sports Med. 2018; 6 (2325967118807906)
        • O'Neill P.J.
        • Cosgarea A.J.
        • Freedman J.A.
        • Queale W.S.
        • McFarland E.G.
        Arthroscopic proficiency: a survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs.
        Arthroscopy. 2002; 18: 795-800
        • Russell R.D.
        • Knight J.R.
        • Mulligan E.
        • Khazzam M.S.
        Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis.
        J Bone Joint Surg Am. 2014; 96: 265-271
        • Sugaya H.
        • Maeda K.
        • Matsuki K.
        • Moriishi J.
        Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: single-row versus dual-row fixation.
        Arthroscopy. 2005; 21: 1307-1316
        • Sultana A.
        • Nightingale P.
        • Marudanayagam R.
        • Sutcliffe R.P.
        Evaluating the learning curve for laparoscopic liver resection: a comparative study between standard and learning curve CUSUM.
        HPB (Oxford). 2019; 21: 1505-1512
        • Vickers A.J.
        • Bianco F.J.
        • Serio A.M.
        • Eastham J.A.
        • Schrag D.
        • Klein E.A.
        • et al.
        The surgical learning curve for prostate cancer control after radical prostatectomy.
        J Natl Cancer Inst. 2007; 99: 1171-1177
        • Visona E.
        • Vio S.
        • Franceschi G.
        • Maron A.
        • Corona K.
        • Cerciello S.
        • et al.
        Orthopedic resident's learning curve for arthroscopic subscapularis tendon repair: short-term clinical and radiographic outcomes.
        Musculoskelet Surg. 2017; 101: 145-151
        • Warner J.J.
        • Higgins L.
        • Parsons IMt
        • Dowdy P.
        Diagnosis and treatment of anterosuperior rotator cuff tears.
        J Shoulder Elbow Surg. 2001; 10: 37-46
        • Wen Z.
        • Liang H.
        • Liang J.
        • Liang Q.
        • Xia H.
        Evaluation of the learning curve of laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy in children: CUSUM analysis of a single surgeon's experience.
        Surg Endosc. 2017; 31: 778-787
        • Wilson F.
        • Hinov V.
        • Adams G.
        Arthroscopic repair of full-thickness tears of the rotator cuff: 2- to 14-year follow-up.
        Arthroscopy. 2002; 18: 136-144
        • Yamakado K.
        Clinical and radiographic outcomes with assessment of the learning curve in arthroscopically assisted latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears.
        Arthroscopy. 2017; 33: 2144-2151