European Journal of Cardiovascular Medicine

The rotator cuff tear is the leading cause of shoulder-related disability and the primary reason for shoulder surgery in middle-aged and older adults, placing a notable economic and social burden on patients.1,3 The corresponding biomechanical changes contribute to the activity-related pain in the deltoid region and might cause the loss of active range of motion in the shoulder.4 5 Numerous surgical options have been discussed for rotator cuff tear, including tendon repair (open or arthroscopic), latissimus dorsi transfer, superior capsular reconstruction and arthroscopic fixation.6 7 Although tendon repair is considered to be a first-choice treatment, the optimal approach is still under discussion.2 8 9 Compared with open or mini-open repair, the arthroscopic approach demonstrated non-inferior results in improving postoperative pain, range of motion and strength.10 11 The most recent meta-analysis12 noted a higher healing rate for arthroscopic cuff repair, specifically with knotless double-row fixation. In addition, decreased operating room time and reduced overall costs might be a decisive factor for knotless arthroscopic repair to become the new gold standard for rotator cuff treatment.13 However, there are numerous factors that should be deeply considered in clinical decision-making, both by doctors and patients.

The knowledge, attitude and practice (KAP) model might provide access to the patients’ opinions regarding the treatment choice and define the barriers for treatment adherence.14 15 Previous studies were mostly undertaken among healthcare professionals, such as the study by Johnson et al16 that draws attention to surgeons' cost awareness in the setting of rotator cuff repairs. Some patient-driven factors were also identified that may act as barriers to potentially beneficial surgical interventions for shoulder surgery, including lower income and perceived surgery complications.17 18 Further analysis of the patient’s point of view might help to better understand the landscape of clinical care in rotator cuff tear. In addition, arthroscopic rotator cuff repair has only recently become an alternative treatment choice1; how this method is perceived by patients is still mostly unknown.

Therefore, this study aimed to explore KAP towards arthroscopic shoulder surgery (ASS) in patients with rotator cuff tears. We hypothesized that the knowledge of the procedure among patients already diagnosed with rotator cuff tear would be good or at least moderate, which in turn might influence their practice and attitude.

This study was a cross-sectional observational study done in a tertiary medical college in central India from 1^stOctober 2022 to September 2024 on 588 patients with rotator cuff tear.

Inclusion criteria:

All patients with rotator cuff syndrome confirmed by MRI and giving consent for the procedure will be included in our study.

Exclusion criteria:

(1) patients with other diseases in the shoulder joint area who need open surgery; (2) patients with malignant tumours, severe hepatic or renal insufficiency; and (3) patients with cognitive impairment or unwillingness to cooperate. No interventions were done. Written informed consent was obtained from all the participants before the survey by including the informed consent form on the first page of the online questionnaire.

A pretest was conducted among 43 voluntary participants who were not included in the primary analysis, with Cronbach’s α being 0.914, indicating good reliability. Patients were also encouraged to spread the information about the rotator cuff tear during and beyond the study.

The questionnaire was designed after reviewing the literature and clinical guidelines.19 20 After the first draft of the questionnaire was designed, it was revised with comments from two experts with senior titles. The research fields of the two experts were joint diseases and sports medicine.

The final questionnaire was in English and included four sections with 43 items which was later translated to local language Marathi and Hindi. Among them, the demographic information included 11 items; the knowledge of ASS included 12 items; the attitude towards ASS included 12 items; and the practice included eight items. The knowledge items were scored one point for each correct answer and 0 points for the wrong or unclear answer, with a theoretical score range of 0–12 points. For the attitude, 11 questions were scored ranging from highly positive (four points) to extremely negative (0 points), with a theoretical score range of 0–44 points. Item A12 was to investigate the preferred surgery of patients with rotator cuff tears, which could not be scored and were presented by descriptive statistics. The seven items in the practice ranged from 4 to 0 points based on the positivity degree of behaviour, with a theoretical score range of 0–28 points; item P8 was to investigate the access to knowledge, which could not be scored and was also presented by descriptive statistics. For the final assessment, modified Bloom’s criteria were adopted21 to set the cut-off points for good KAP to be a score ≥80% of maximal.

Residents, interns and trained clerks with no medical background were available to assist those who had difficulty filling out the questionnaire without leading to bias. The questionnaires with missing answers or questionable answers (such as choosing only the first option) were considered invalid.

The sample size was calculated based on item-respondent theory, in which a ratio of 1:5 up to 1:20 is considered suitable.22 Thus, a ratio of 1:15 was selected and with 32 KAP items in the questionnaire (excluding demographics), the required sample size was 480. Considering a 15-20% invalid rate, the minimal sample size was taken as 588.

The SPSS V.26.0 software (IBM, Armonk, New York, USA) was used for statistical analysis. Continuous variables were presented by mean±SD and analysed by an independent sample t-test or analysis of variance. Categorical variables were presented as n (%). The KAP total score was an aggregate of the KAP scores. For logistic regression analysis, participants who had a KAP total score ≥45 (in the upper 25th percentile) were considered to have a ‘high KAP score’ towards ASS, while those who had a KAP total score <45 (in the lower 75th percentile) were considered to have a ‘low KAP score’.23 Variables with p<0.05 in univariate logistic regression analysis were included in multivariate logistic regression analysis of KAP score. Structural equation modelling was used to test the hypotheses that (H1) knowledge regarding ASS in patients with rotator cuff tears has an effect on attitudes; (H2) knowledge has an effect on practice, and (H3) attitude has an effect on practice. A two-sided p<0.05 was considered a statistical difference.

In our study, a total of 650 questionnaires were collected, while 50 were excluded for missing or questionable answers, and finally, 588 valid questionnaires (92%) were included in this study. Among all participants, 276 (47%) were male and 312 (53%) were females; 222 (37%) were under 30 years old and 216 (36%) were over 40 years old, with the maximum age being 71 years. The majority of participants lived in urban areas (60%) and had been diagnosed with rotator cuff tear for more than 3 months (73%). Half of the participants (50%) had already undergone the ASS and 22% had undergone open shoulder surgery.

The mean score of KAP was 4.51±2.09 (37.58%, maximum theoretical score: 12), 20.55±6.45 (46.70%, maximum theoretical score: 44) and 18.31±6.16 (65.39%, maximum theoretical score: 28), respectively. The score of KAP all varied among patients with different incomes, exercise time and disease durations (all p<0.05), but no significant differences were observed between patients with a history of ASS and those without (p>0.05) (online supplemental table 1). The knowledge item with the highest correct rate was that ‘ASS can be used not only for treatment but also for diagnostic examination’, with a correct rate of 55.44%; the item with the lowest correct rate was that ‘ASS is usually performed under local anaesthesia’, with a correct rate of only 16.16% (online supplemental table 2).

More than half of the participants (51.36%) agreed that after ASS, they would be able to recover to the level and intensity of exercise before the injury; almost one-fifth of participants (18.88%) noted that they would be very scared if the doctor suggested ASS (online supplemental table 3). Regarding the practice, the majority of participants agreed that after ASS movements of the shoulder joint should be restricted and were willing to take the initiative to learn about rotator cuff injuries and ASS. However, almost one-third of participants (32.82%) noted that they would not actively seek medical treatment after the diagnosis of a rotator cuff tear (online supplemental table 4). While most patients (251, 42.69%) typically would follow their doctor’s recommendation when it came to preferred surgical approach, those residing in rural areas showed a preference for open surgery over arthroscopic surgery (online supplemental figure 1). Regarding the source of knowledge, the primary sources for all were magazines, newspapers and the internet, and participants from urban areas relied on the internet less compared with others (figure 1). No significant differences were found in KAP scores among patients who underwent ASS, open surgery or both (online supplemental table 5).

The KAP total score was 43.36±8.14 (21.80%, maximum theoretical score: 84). The multivariate logistic regression analysis showed that education (ref. middle school and below; high school/technical secondary school education, OR 2.73, 95% CI 1.15 to 6.46, p=0.022; college/bachelor degree, OR 2.33, 95% CI 1.084 to 5.00, p=0.030), income (ref. <2000; 5000–10000: OR 2.33, 95% CI 1.06 to 5.15, p=0.036; >10 000: OR 7.38, 95% CI 3.05 to 17.87, p<0.001), average exercise time per week (ref. ≥7 hours; 2–4 hours, OR 0.28, 95% CI 0.13 to 0.60, p=0.001; 0.5–2 hours, OR 0.30, 95% CI 0.14 to 0.66, p=0.003) and duration of diagnosed rotator cuff tear (ref. <3 weeks; ≥1 year, OR 3.56, 95% CI 1.62 to 7.80, p=0.002) were independent risk factors of KAP score (table 1)

The method of structural equation modelling was used to explore the factors that might have an influence on KAP scores (figure 2). It was found that while knowledge had a direct positive effect on attitude (β=2.102, p<0.001), neither knowledge nor attitude influenced practice scores (both p>0.05). To further test the distribution of scores, the impact of all questions was analysed individually (online supplemental tables 6 and 7): in the knowledge dimension, question K9 (lifting heavy objects from the first day to the sixth weeks postoperatively) demonstrated the most notable impact on the scores (β=1.237, p<0.001), in the attitude dimension, all questions demonstrated significant impact, with A2 (continue to exercise as long as pain is tolerable) being the most notable influence (β=1.126, p<0.001), while in the practice dimension, neither question impacted scores significantly (all p>0.05).

TABLE 1 showing multivariate logistic regression analysis of total knowledge, attitude and practice score.

The results indicated the relatively poor knowledge, neutral attitude and acceptable practice towards ASS among patients, which might contribute to future patient education and clinical studies.

Although this study included only patients who were diagnosed with rotator cuff syndrome, the overall knowledge scores were notably low. In addition, there was no significant difference in the knowledge scores between patients who already underwent arthroscopic surgery and those yet to decide upon surgical treatment, which is a cause of concern. Data were collected in outpatient clinics, and all participants have already received formal consultations and relevant examinations. Moreover, health advocacy and education have also been provided in the outpatient clinic, which was reflected by the fact that patients diagnosed less than 3 weeks ago demonstrated higher levels of knowledge. Patients that were diagnosed a long time ago most likely turned to other sources and were subjected to the outdated or controversial information.1 24 In addition, a number of previous studies have compared the benefits of rotator cuff repair with non-operative treatment, discussing existing risks to nonsurgical treatment.25 26 In the present study, a considerable part of participants doubted that they would be able to fully recover and almost 20% of them noted that they would be very scared if the doctor suggested the ASS. Contrary to our expectations, no significant differences in KAP were found between patients who underwent ASS, open repair or both, but higher KAP scores were demonstrated by diagnosed ≥1 year ago participants with a higher education level and above average income, suggesting that it is important to consider patients’ backgrounds when accessing their opinion on open rotator cuff repair, arthroscopic surgery and non-surgical treatment.

The informed participation of the patient is mandatory for the decision-making in rotator cuff tear repair. However, Randelli et al27 suggested that the majority of orthopaedic surgeons did not rely on patients’ choice, preferring arthroscopic rotator cuff repair or arthroscopic acromioplasty for large tendon tears and non-surgical treatment for smaller injuries. Some barriers to proactive participation on the patient’s side were previously discussed, such as unfounded preference for the non-surgery or less-invasive treatment28 or misjudging the seriousness of the injury.18 Another study implemented a patient decision aid for subacromial pain syndrome surgery, but it still had no effect on treatment intention, attitudes, informed choice or decisional conflict.29 In line with the above, in this study, the majority of participants relied on their doctor to make a decision, with knowledge influencing only attitude but not practice scores. Although the practice scale score was acceptable, some statements, such as unwillingness to actively seek medical treatment or follow postoperative rehabilitation, were expressed by some participants. In addition, SEM analysis uncovered that questions related to exercising with rotator cuff tear and after ASS had a notable impact on the final KAP scores, drawing attention to the lack of knowledge in the area of rehabilitation. It should be taken into account during the decision-making phase, especially because the arthroscopic approach was often chosen by patients on the basis of mini-invasiveness only, without consulting other sources.28

This study has some limitations. First, this was a single-centre cross-sectional study and the obtained results have regional peculiarities that should be taken into account during interpretation. Second, while the self-reported questionnaire offers valuable insights from the patient’s perspective, which can benefit patient education, it also carries the possibility of bias. Some participants may have reported desired outcomes rather than actual experiences. A follow-up study is needed to minimise recall bias and Neyman bias. Additionally, self-reported data prevented us from collecting more complex or professional characteristics, such as the cause of the cuff tear, from the patients. Third, almost 40% of the patients were under 30 years old, which may at least partly reflect the disease becoming younger; however, most likely it is explained by selection bias, as younger patients in China seek help more actively. Finally, both newly onset and re-examined patients were included, and the cause of the rotator cuff tear could not be determined. Moreover, the study included both patients who already underwent ASS and had yet to choose the surgery treatment, with naturally different histories; although there was no significant difference in KAP scores between the two groups, patients who had undergone ASS had a higher level of acceptance and a better attitude towards the procedure.

Thus, the present study showed relatively poor knowledge, a neutral attitude and acceptable practice towards ASS in patients with rotator cuff tears, with no significant differences between patients who already underwent ASS and those who did not. In the future, a standardised education programme must be planned and implemented to assure that the knowledge level of patients is sufficient at the time of decision and successfully covers postoperational rehabilitation; it is of some interest to compare KAP outcomes and the ratio of chosen arthroscopic versus open shoulder surgery in patients after finishing the education programme.

This study included participants diagnosed with the rotator cuff tear, and 50.51% of them already underwent ASS. We hypothesised that knowledge of the procedure would be good or at least moderate, which in turn might influence practice and attitude. However, study results showed relatively poor knowledge, a neutral attitude and acceptable practice, with the majority of participants relying on their doctor to make a decision; it is possible that starting 1 month after the initial consultation, patients turn to other sources and are subjected to the outdated or controversial information. This must be taken into account and additional educational interventions should be planned to avoid less-informed choices or negative impacts on decision-making.

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