Paper 06: Rotator cuff repair rohi scoring: identifying characteristics to validate or modify the score system

Objectives: Rotator cuff tears are common and affect up to 30% of the general population. Despite advances in arthroscopic technologies and techniques, the incidence of retears following primary repair has been reported to range from 4.5% to 94% across the literature, depending on the methods used. Retear after repair is associated with persistent pain, reduced function, and the potential need for revision surgery. The Rotator Cuff Healing Index (RoHI) was developed as a 15-point weighted scoring system that integrates six variables to estimate the probability of tendon healing after repair: age, bone mineral density, tear size, tendon retraction, infraspinatus fatty infiltration, and activity level. In this study, a modified RoHI was applied, excluding bone mineral density. Despite its widespread adoption and use, the RoHI score has yet to be retrospectively applied and compared to patient-reported outcomes (PROs). The objective of this study was to retrospectively apply the RoHI score to patients undergoing rotator cuff repair (RCR) and analyze PROs relative to preoperative RoHI score.
Methods: A retrospective review was conducted of 782 patients who underwent primary rotator cuff repair (RCR) between 2018 and 2025 within a large metropolitan healthcare system. Exclusion criteria included the absence of rotator cuff tears, presence of only a subscapularis tear, revision surgeries, lack of magnetic resonance imaging (MRI), and absence of PROs at baseline or 1-year postoperatively. Demographic and clinical variables were collected, including age at surgery, sex, body mass index (BMI), bone mineral density, and comorbid medical conditions (e.g., diabetes mellitus, hypothyroidism, immunomodulator use, systemic hormone replacement therapy use, and GLP-1 receptor agonist use). Perioperative laboratory and imaging data, including MRI assessments of anteroposterior (AP) tear size, tendon retraction, and fatty infiltration of the infraspinatus, as well as activity level and information regarding the use of biologic augmentation during repair, were also recorded. A modified RoHI score was then calculated for each patient. PROs, including the American Shoulder and Elbow Surgeons (ASES) scores and Single Assessment Numeric Evaluation (SANE) scores, were collected at baseline preoperatively and at 1- and 2-year postoperatively. Statistical analysis was conducted via Intellectus software (Clearwater, FL) and included descriptive tests, analysis of variance (ANOVA), regressions, and correlations.
Results: A total of 782 patients were included, with an average age of 60.9 +- 8.8 years and BMI of 30.0 +- 5.4; 58.8% were male, and most were ASA class II (66.8%). Diabetes was present in 13.0% of patients, with mean hemoglobin A1c 6.2 +- 0.9. Preoperative GLP-1 agonist use, systemic hormone replacement therapy, thyroid disorders, and immunomodulators were observed in 4.9%, 3.7%, 10.9%, and 7.9% of patients, respectively. Repairs were largely performed without augmentation (99.4%). Work activity was classified as low in 77.8%, medium in 20.5%, and high in 1.8%. The mean RoHI score was 2.9 +- 3.0, with average tear size 1.6 +- 0.9 cm, retraction 1.8 +- 2.2 cm, and procedure duration 94.7 +- 33.8 minutes.PROs demonstrated substantial improvement. Baseline ASES was 47.5 +- 17.9, increasing to 85.3 +- 17.4 at 1 year (n=782) and 88.9 +- 16.7 at 2 years (n=650). Baseline SANE averaged 41.9 +- 20.8, improving to 83.7 +- 20.2 at 1 year (n=782) and 87.0 +- 18.9 at 2 years (n=660). The majority of patients (74%) had RoHI scores in the 0-4 category (high chance of healing). RoHI category was not associated with 1-year ASES (ANOVA F=0.85, p=0.47) or SANE (F=0.66, p=0.58). Treating RoHI as continuous yielded no association with 1-year ASES (β=0.12, p=0.55, R²=0.00) or SANE (β=0.04, p=0.86, R²=0.00). Correlations between RoHI and ASES/SANE (and change scores) were near zero (|r|<=0.04, p>0.2).Among the five augmented cases (n=5), three had RoHI scores >=9, one had a score of 4, and one had a score of 0. Their baseline ASES scores ranged from 20.0-61.6 (mean 41.2 +- 18.4), improving to 86.7-100.0 at 1 year (mean 95.2 +- 5.0). Baseline SANE ranged from 20-50 (mean 38.0 +- 13.0), improving to 80-99 at 1 year (mean 90.8 +- 7.9). These outcomes were comparable to the overall cohort, though the small sample size precludes meaningful statistical comparison.
Conclusions: Substantial functional improvements were observed across the cohort, regardless of RoHI category. Preoperative RoHI score showed no association with 1-year ASES or SANE outcomes. These findings suggest that while RoHI may not predict short-term functional recovery following rotator cuff repair, further study-including postoperative imaging and retear analysis-may clarify its potential role in long-term prognostication. Importantly, patients with high RoHI scores, including those undergoing augmentation, still demonstrated meaningful improvement, suggesting that rotator cuff repair can yield favorable outcomes despite the perceived non-healing risk associated with higher scores.