Increased HbA1c Levels in Diabetics During the Postoperative 3-6 Months After Rotator Cuff Repair Correlated With Increased Retear Rates

  • Myung Seo Kim
    Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea

    College of Medicine, Kyung Hee University, Seoul, Republic of Korea
    Search for articles by this author
  • Sung Min Rhee
    Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea

    College of Medicine, Kyung Hee University, Seoul, Republic of Korea
    Search for articles by this author
  • Nam Su Cho
    Address correspondence to Nam Su Cho, M.D., Department of Orthopedic Surgery, Cheil Orthopedic Hospital, 726, Yeongdong-daero, Gangnam-gu, Seoul 06075, Republic of Korea.
    Department of Orthopedic Surgery, Cheil Orthopedic Hospital, Seoul, Republic of Korea
    Search for articles by this author


      To evaluate whether glycemic control affects the integrity of the repaired rotator cuff during the postoperative healing period after arthroscopic double-row suture bridge rotator cuff repair (RCR)


      We retrospectively reviewed patients with diabetes mellitus (DM) who underwent arthroscopic double-row suture bridge RCR at our institution between March 2016 and November 2019. We included the patients who evaluated for serum glycosylated hemoglobin (HbA1c) levels within 1 month before and 3–6 months after surgery. Magnetic resonance imaging was conducted 6 months after surgery to evaluate the integrity of the repaired cuff tendon. Patients were categorized into two groups based on comparison between preoperative and postoperative HbA1c values: Group I (increased postoperative HbA1c) and Group D (same or decreased postoperative HbA1c). The correlation between preoperative/postoperative HbA1c, HbA1c increase/same or decrease (during the healing period), and post-RCR integrity was evaluated, including various demographic and radiologic factors.


      A total of 103 patients were analyzed, group I was 47, and group D was 56, respectively. The retear rate of 51.1% (24/47) in Group I was significantly higher than 14.3% (8/56) in Group D (P < .001). HbA1c levels measured 3-6 months after surgery (mean: 6.9; 95% CI: 6.6–7.3 vs mean: 6.5; 95% CI: 6.3–6.7, P = .034), and the proportion of group I and group D were significantly different (75%/25% vs 32.4%/67.6%, P < .001) between the retear and healing groups. Multivariable logistic regression analysis identified increased HbA1c as an independent risk factor for retear (odds ratio: 5.402; 95% CI: 2.072–14.086; P < .001).


      The glycemic control within 3-6 months after surgery when the healing process of the tendon was in progress had a significant effect on retear rate. In particular, the retear rate was higher when the HbA1c level increased at postoperative 3-6 months compared to before surgery.

      Level of Evidence

      Retrospective case-control comparative study, Level III.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Oh J.H.
        • Park M.S.
        • Rhee S.M.
        Treatment strategy for irreparable rotator cuff tears.
        Clinics Orthop Surg. 2018; 10: 119-134
        • Rhee S.M.
        • Youn S.M.
        • Park J.H.
        • Rhee Y.G.
        Biceps rerouting for semirigid large-to-massive rotator cuff tears.
        Arthroscopy. 2021; 37: 2769-2779
        • Oh J.H.
        • Kim D.H.
        • Jeong H.J.
        • Park J.H.
        • Rhee S.M.
        Effect of recombinant human parathyroid hormone on rotator cuff healing after arthroscopic repair.
        Arthroscopy. 2019; 35: 1064-1071
        • Amit P.
        • Kuiper J.H.
        • James S.
        • Snow M.
        Does statin-treated hyperlipidemia affect rotator cuff healing or muscle fatty infiltration after rotator cuff repair?.
        J Shoulder Elbow Surg. 2021; 30: 2465-2474
        • Yang L.
        • Zhang J.
        • Ruan D.
        • Zhao K.
        • Chen X.
        • Shen W.
        Clinical and structural outcomes after rotator cuff repair in patients with diabetes: A meta-analysis.
        Orthop J Sports Med. 2020; 82325967120948499
        • Cho N.S.
        • Moon S.C.
        • Jeon J.W.
        • Rhee Y.G.
        The influence of diabetes mellitus on clinical and structural outcomes after arthroscopic rotator cuff repair.
        Am J Sports Med. 2015; 43: 991-997
        • Song F.C.
        • Yuan J.Q.
        • Zhu M.D.
        • et al.
        High glucose represses the proliferation of tendon fibroblasts by inhibiting autophagy activation in tendon injury.
        Biosci Rep. 2022; 42 (BSR20210640.2021)
        • Bedi A.
        • Fox A.J.
        • Harris P.E.
        • et al.
        Diabetes mellitus impairs tendon-bone healing after rotator cuff repair.
        J Shoulder Elbow Surg. 2010; 19: 978-988
        • Huang S.W.
        • Wang W.T.
        • Chou L.C.
        • Liou T.H.
        • Chen Y.W.
        • Lin H.W.
        Diabetes mellitus increases the risk of rotator cuff tear repair surgery: A population-based cohort study.
        J Diabetes Complications. 2016; 30: 1473-1477
        • Miyatake K.
        • Takeda Y.
        • Fujii K.
        • et al.
        Comparable clinical and structural outcomes after arthroscopic rotator cuff repair in diabetic and non-diabetic patients.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 3810-3817
        • Nikolaidou O.
        • Migkou S.
        • Karampalis C.
        Rehabilitation after rotator cuff repair.
        Open Orthop J. 2017; 11: 154-162
        • Gulotta L.V.
        • Rodeo S.A.
        Growth factors for rotator cuff repair.
        Clin Sports Med. 2009; 28: 13-23
        • Iannotti J.P.
        • Deutsch A.
        • Green A.
        • et al.
        Time to failure after rotator cuff repair: A prospective imaging study.
        J Bone Joint Surg Am. 2013; 95: 965-971
        • Miller B.S.
        • Downie B.K.
        • Kohen R.B.
        • et al.
        When do rotator cuff repairs fail? Serial ultrasound examination after arthroscopic repair of large and massive rotator cuff tears.
        Am J Sports Med. 2011; 39: 2064-2070
        • Cancienne J.M.
        • Deasey M.J.
        • Kew M.E.
        • Werner B.C.
        The association of perioperative glycemic control with adverse outcomes within 6 months after arthroscopic rotator cuff repair.
        Arthroscopy. 2019; 35: 1771-1778
        • American Diabetes Association
        2. Classification and diagnosis of diabetes.
        Diabetes Care. 2015; 38: S8-S16
        • Kim S.J.
        • Lee S.K.
        • Kim S.H.
        • Kim S.H.
        • Ryu S.W.
        • Jung M.
        Effect of cigarette smoking on the clinical outcomes of ACL reconstruction.
        J Bone Joint Surg Am. 2014; 96: 1007-1013
        • Jang H.D.
        • Hong J.Y.
        • Han K.
        • et al.
        Relationship between bone mineral density and alcohol intake: A nationwide health survey analysis of postmenopausal women.
        PLoS One. 2017; 12e0180132
        • Kim S.H.
        • Kim Y.H.
        • Lee H.R.
        • Choi Y.E.
        Short-term effects of high-intensity laser therapy on frozen shoulder: A prospective randomized control study.
        Man Ther. 2015; 20: 751-757
        • Chung S.W.
        • Park J.S.
        • Kim S.H.
        • Shin S.H.
        • Oh J.H.
        Quality of life after arthroscopic rotator cuff repair: Evaluation using SF-36 and an analysis of affecting clinical factors.
        Am J Sports Med. 2012; 40: 631-639
        • Moor B.K.
        • Bouaicha S.
        • Rothenfluh D.A.
        • Sukthankar A.
        • Gerber C.
        Is there an association between the individual anatomy of the scapula and the development of rotator cuff tears or osteoarthritis of the glenohumeral joint?: A radiological study of the critical shoulder angle.
        Bone Joint J. 2013; 95-B: 935-941
        • Nove-Josserand L.
        • Edwards T.B.
        • O'Connor D.P.
        • Walch G.
        The acromiohumeral and coracohumeral intervals are abnormal in rotator cuff tears with muscular fatty degeneration.
        Clin Orthop Relat Res. 2005; 433: 90-96
        • Lafosse L.
        • Reiland Y.
        • Baier G.P.
        • Toussaint B.
        • Jost B.
        Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: A new classification based on arthroscopic observations.
        Arthroscopy. 2007; 23: 73-80
        • 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
        • Sugaya H.
        • Maeda K.
        • Matsuki K.
        • Moriishi J.
        Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study.
        J Bone Joint Surg Am. 2007; 89: 953-960
        • DeOrio J.K.
        • Cofield R.H.
        Results of a second attempt at surgical repair of a failed initial rotator-cuff repair.
        J Bone Joint Surg Am. 1984; 66: 563-567
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Gowd A.K.
        • Charles M.D.
        • Liu J.N.
        • et al.
        Single assessment numeric evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.
        J Shoulder Elbow Surg. 2019; 28: 2238-2246
        • Akturk M.
        • Karaahmetoglu S.
        • Kacar M.
        • Muftuoglu O.
        Thickness of the supraspinatus and biceps tendons in diabetic patients.
        Diabetes Care. 2002; 25: 408
        • Chbinou N.
        • Frenette J.
        Insulin-dependent diabetes impairs the inflammatory response and delays angiogenesis following Achilles tendon injury.
        Am J Physiol Regul Integr Comp Physiol. 2004; 286: R952-R957
        • Lin T.T.
        • Lin C.H.
        • Chang C.L.
        • Chi C.H.
        • Chang S.T.
        • Sheu W.H.
        The effect of diabetes, hyperlipidemia, and statins on the development of rotator cuff disease: a nationwide, 11-year, longitudinal, population-based follow-up study.
        Am J Sports Med. 2015; 43: 2126-2132
        • Smith K.M.
        • Presson A.P.
        • Zhang C.
        • et al.
        Does diabetes mellitus predispose to both rotator cuff surgery and subsequent failure?.
        JSES Int. 2021; 5: 636-641
        • Fox A.J.
        • Bedi A.
        • Deng X.H.
        • et al.
        Diabetes mellitus alters the mechanical properties of the native tendon in an experimental rat model.
        J Orthop Res. 2011; 29: 880-885
        • Thomas S.J.
        • Sarver J.J.
        • Yannascoli S.M.
        • et al.
        Effect of isolated hyperglycemia on native mechanical and biologic shoulder joint properties in a rat model.
        J Orthop Res. 2014; 32: 1464-1470
        • Chung S.W.
        • Choi B.M.
        • Kim J.Y.
        • et al.
        Altered gene and protein expressions in torn rotator cuff tendon tissues in diabetic patients.
        Arthroscopy. 2017; 33 (e511): 518-526
        • Kim I.B.
        • Kim M.W.
        Risk factors for retear after arthroscopic repair of full-thickness rotator cuff tears using the suture bridge technique: Classification system.
        Arthroscopy. 2016; 32: 2191-2200