# Patient-specific risk factors for repair failure and poor functional outcome after rotator cuff repair - an umbrella review

## TL;DR

This review identifies patient-specific factors like age, BMI, and genetic markers that affect rotator cuff repair outcomes, helping surgeons tailor treatments.

## Contribution

The study provides a comprehensive umbrella review of preoperative risk factors influencing rotator cuff repair outcomes, including genetic and psychological factors.

## Key findings

- Advanced age, diabetes, and larger tear size are linked to higher retear rates after rotator cuff repair.
- Genetic mutations in MMP3, TNC, and ESRRβ are associated with healing failure, while BMP5 and COL3 improve tendon healing.
- High preoperative expectations correlate with better functional outcomes, while fear avoidance correlates with poorer outcomes.

## Abstract

Understanding patient-specific factors that influence postoperative outcomes and failure rates following rotator cuff repair is crucial for surgeons to tailor individualized treatments. The purpose of this umbrella review was to identify preoperatively measurable factors that influence the risk of retear and functional outcomes following rotator cuff repair (RCR). Additionally, the study aimed to evaluate the quality of evidence from systematic reviews and meta-analyses to provide a comprehensive understanding of these predictive factors.

A systematic search of the MEDLINE database via PubMed was conducted to identify systematic reviews and meta-analyses reporting preoperatively measurable factors affecting functional outcomes and failure rates following arthroscopic rotator cuff repair. The methodological quality of included reviews was assessed using the AMSTAR checklist. Data synthesis summarized key risk factors, quantified study overlap via Corrected Covered Area (CCA), and examined heterogeneity and publication bias when reported in the reviews.

Twenty-three systematic reviews, including 11 meta-analyses, met the inclusion criteria, yielding a CCA of 0.403, which reflects moderate overlap. The average AMSTAR score was 7.57, indicating moderate methodological quality. However, only a few reviews included analyses of heterogeneity or publication bias, and the evidence presented was often contradictory. Meta-analyses revealed statistically significant associations between higher retear rates and factors such as advanced age, reduced bone mineral density, elevated body mass index, diabetes, shorter acromiohumeral interval, increased critical shoulder angle, involvement of multiple tendons, greater tendon retraction, longer symptom duration, larger tear size, poor tissue quality, and greater distance from the musculotendinous junction to the glenoid. Genetic analyses provided moderate to strong evidence linking healing failure to mutations in the matrix metallopeptidase 3 (MMP3) and Tenascin C (TNC) genes, as well as a single nucleotide polymorphism (SNP) in the Estrogen Related Receptor β (ESRRβ) gene. Improved tendon healing was associated with the upregulation of the growth factor Bone Morphogenetic Protein 5 (BMP5) and increased expression of collagen type III (COL3). High preoperative expectations consistently correlated with better functional outcomes, whereas other psychological factors, such as concerns and fear avoidance, were associated with poorer outcomes.

Evidence synthesized in this review underscores the importance of patient age, expectations, and the extent of the rotator cuff tear in influencing outcomes following rotator cuff repair. These factors should be carefully considered in treatment planning for patients undergoing rotator cuff repair.

The online version contains supplementary material available at 10.1186/s12891-025-08608-w.