ORTHOPAEDICS

The Royal College of Surgeons of England

Ann R Coll Surg Engl 2008; 90: 326–331
doi 10.1308/003588408X285964

The use of a patient-based questionnaire (the

Oxford Shoulder Score) to assess outcome after
rotator cuff repair
LM OLLEY, AJ CARR

Nuffield Department of Orthopaedic Surgery, University of Oxford, Headington, Oxford, UK

ABSTRACT
INTRODUCTION It is increasingly important for surgeons to monitor the outcome of their practice for the purpose of audit. The
main difficulty has been the lack of appropriate methods of assessing outcome. Outcome has traditionally been assessed by
clinical means which can be inaccurate, irreproducible and subject to surgeon bias. In addition, the perspective of the patient
and surgeon may differ with respect to outcome and interest has grown in patient-based scoring systems. The Oxford Shoulder
Score (OSS) is one such patient-based scoring system. The main aim of this study was to assess whether a patient-based
questionnaire, in this case the OSS, could be effectively used to audit outcome from shoulder surgery. A secondary aim was to
assess the value of gathering outcome information by post.

PATIENTS AND METHODS A total of 24 patients (14 male; median age 59 years; age range, 43–73 years) who had completed a
pre-operative OSS questionnaire and had undergone rotator cuff repair were included in the study. Participants were assessed
postoperatively at regular intervals using the OSS at hospital visits and by postal questionnaire.

RESULTS The completion level for the OSS was 97% and the response rate to the postal questionnaire was 96%. At 3 months’
post-surgery, 21 of 24 patients had improved; at final review (16–37 months), 23 patients had improved following surgery. The OSS
was observed to be a robust tool for the quantitative assessment and tracking of patient outcomes after surgery.

CONCLUSIONS This study shows the value of using a postal questionnaire to follow-up patients after surgery and demonstrates
the successful use of a patient-based questionnaire to audit the outcome from shoulder surgery.

KEYWORDS
Oxford Shoulder Score – Outcome assessment (healthcare) – Shoulder – Surgery

CORRESPONDENCE TO
LM Olley, 166 Leesons Hill, Chislehurst, Kent BR7 6QL, UK
E: lmolley@hotmail.com

Shoulder pain is a significant problem. Its prevalence is agement of shoulder conditions but these derive from clin-
reported to be around 7% of the population, rising to ical and radiological data and are dependent on the sur-
approximately 20% in individuals over 70 years of age.1–5 It geons’ judgement.13
usually arises from disorders of peri-articular soft tissue, It is increasingly apparent that clinical assessments of
especially the rotator cuff.5,6 key aspects of outcome are often inaccurate and not repro-
Shoulder pain is responsible for a significant proportion ducible.14,15 In addition, the concerns and priorities of the
of visits to general practitioners7,8 and hospital specialists.9,10 patient and surgeon may differ.16 Methods are required
Some patients will require surgery and, as a result, there which elicit the patient’s perception of the outcome.17 This
are important socio-economic implications because of mor- has led to increased interest in patient-based assessments.
bidity and time lost from work.11 Research has shown that reports from patients can be
It is increasingly important for surgeons to record the reliable, valid and sensitive to clinical change.18 The evi-
outcome from their practice for the purposes of audit; how- dence also suggests that patient-based questionnaires are a
ever, the main problem has been the lack of appropriate useful adjunct to clinical assessment in shoulder disor-
assessment methods.12 Several scoring methods have been ders.12 Where a questionnaire is used, it should be short,
developed to evaluate the outcome of the orthopaedic man- practical, reliable, valid and sensitive to clinical change.

326 Ann R Coll Surg Engl 2008; 90: 326–331

OLLEY CARR THE USE OF A PATIENT-BASED QUESTIONNAIRE TO ASSESS
OUTCOME AFTER ROTATOR CUFF REPAIR

The Oxford Shoulder Score (OSS) is a patient-based Where a claim for legal compensation existed this was
questionnaire used to assess shoulder pain. It is a condition- also recorded, as this group tend to report worse results
specific questionnaire, completed unaided by the patient. It after surgery.20
contains a mixture of pain and function questions, derived We recorded the size of the cuff tear found at the time of
from over 200 initial question models based on in-depth surgery, another factor potentially associated with outcome.
patient and clinician interviews. It has been validated Although a matter of debate, a poorer prognosis may be
against clinician-based and general health status meas- expected with a larger rotator cuff tear even where surgery
ures.5,12 The OSS is sensitive to clinical change, is simple to was performed.21,22
complete and has proved to be consistently reliable in This pilot study included all 24 patients who had com-
determining the outcome from shoulder surgery.5,12 pleted a questionnaire and had undergone surgery to repair
The aim of this study was to assess whether a patient- a rotator cuff tear between May 2002 and October 2003.
based questionnaire can be effectively used to audit shoul- Patients attended clinics at various time points during their
der surgery. In particular we wished to evaluate whether care and, therefore, the sample included patients who had
the surgeon can use a patient-based questionnaire to track been followed prospectively.
the outcome over time of an individual, or a group, under- Of the 24 patients who underwent rotator cuff surgery all
going a particular surgical procedure. had an arthroscopy initially, followed by open surgery in 23
In addition to selecting an appropriate measure to audit patients and arthroscopic cuff repair in one patient. Of those
outcome, the surgeon needs also consider how the informa- 23 who had open surgery, one patient had an irreparable
tion is to be gathered. It may be costly to provide extra clin- cuff tear and two patients had tears that were only
ic appointments for audit purposes, and patients are often amenable to partial repair. A good repair was achieved in
unable or unwilling to attend for assessment on multiple the remainder.
occasions after treatment. In addition to rotator cuff surgery, 23 had a sub-acromi-
One solution is the use of a postal questionnaire. al decompression. Sixteen were performed arthroscopical-
Administration of questionnaires is usually simpler to ly, six open and one both arthroscopic and open. In one
organise than additional clinics and the response rate high- patient, no abnormality of the acromion was found at
er than attendance at supplementary clinics.19 A good arthroscopy and so acromioplasty was not performed.
response avoids additional clinic costs and minimises To evaluate the postal aspect of the study and to gather fur-
inconvenience to both surgeon and patient. A further aim, ther follow-up data on individual patients, a copy of the OSS
therefore, was to assess the response rate and quality of was posted to all 24 patients. Prospective follow-up data were,
completion of a patient-based postal questionnaire. therefore, gathered up to a maximum of 3.1 years postopera-
tively (minimum follow-up 16 months). Patients were asked to
return a blank copy if they did not wish to participate. If not
Patients and Methods
returned, patients were contacted once by telephone.
Patients attending shoulder clinics, pre-admission clinics
and for day-case surgery within our unit were invited to
Results
complete an OSS, as part of routine clinical practice.
The OSS consists of 12 questions each with five response Participant information is shown in Table 1. Table 2
options (Appendix 1). Each option carries a score from 1 contains shoulder specific details for the cohort. A total of
(best) to 5 (worst). The scores from each question combine 119 questionnaires were completed and 97% (116) of these
to give a total score with a range from 12 (best, no pain or were completed in full. Questionnaires with missing data (n
functional impairment) to 60 (worst). = 3) were excluded from subsequent analysis. Where more
In addition, the patients completed a basic information than one pre-operative questionnaire was completed, the
form which elicited details about their age, gender, employ- score closest to surgery was analysed.
ment and carer status. Younger patients and those who are in The response rate to the subsequent postal question-
employment or a full time carer may have higher expectations naires was 96% (23 of 24 patients). All returned question-
and require a greater level of function following surgery. They naires were fully completed. Of note, the single non-respon-
may be expected to be less satisfied following surgery. der had completed a questionnaire at a clinic near to the
Whether the rotator cuff tear affected the dominant date of the postal questionnaire.
shoulder was also recorded. Where the dominant shoulder Figure 1 shows the overall scores for the group following
is affected a patient’s function may be more limited, partic- surgery, normalised for their pre-operative score to allow
ularly with respect to activities of daily living. comparison.
Information as to whether their condition was of sudden Overall scores improved following surgery, although not
onset and related to an injury was also gathered. all individuals followed the same recovery and, for some,

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OLLEY CARR THE USE OF A PATIENT-BASED QUESTIONNAIRE TO ASSESS
OUTCOME AFTER ROTATOR CUFF REPAIR

Table 1 Participant information Table 2 Shoulder-specific details for participants

Gender Condition affecting dominant shoulder

Male 14 (58.3%) Yes 20 (83.3%)
Female 10 (41.7%) No 4 (16.7%)

Age (years): median, [range] 59 [43–73] Injury related

41–50 6 (25%) Yes 16 (sports 1, work 5,
51–60 9 (38%) other 10) (66.7%)
61–70 7 (29%) No 8 (33.3%)
71–80 2 (8%)
Sudden onset of symptoms
Employment status Yes 13 (54.2%)
Paid employment 15 (full time 10) (63%) No 11 (45.8%)
Retired 7 (29%)
Involves legal claim for compensation
Unemployed 2 (8%)
Yes 0 (0%)
Regularly care for children or dependent adult No 21 (87.5%)
Yes 8 (33.3%) Maybe 1 (4.2%)
No 16 (66.6%) Unknown (item not completed) 2 (8.3%)

Size of rotator cuff tear

Small (< 1 cm) 1 (4.2%)
Moderate (1–3 cm) 8 (33.3%)
there were interesting patterns. These were reviewed in Large (3–5 cm) 12 (50%)
conjunction with medical notes to seek an explanation. Massive (> 5 cm) 3 (12.5%)
The score for patient ‘PG’ appears to rise following sur-
gery. ‘PG’ had a large cuff tear and impingement, treated by
open sub-acromial decompression and rotator cuff repair.
Clinically, she made a slow initial recovery with on-going
signs of impingement. The cuff repair was felt to be intact were contacted for a brief telephone interview to seek an
until 18 months (529 days) postoperatively. At this time, she explanation.
had signs of weakness as well as impingement. A re-rupture Patient ‘DM’ had a large cuff tear and had an arthroscop-
was suspected and a massive tear was confirmed by ultra- ic sub-acromial decompression and open rotator cuff
sound scan. She underwent a revision open rotator cuff repair. No particular event was cited by the patient to
repair and open sub-acromial decompression 649 days after account for the change. She described a slight deterioration
initial surgery. The cuff tear was found to be massive and in terms of pain and function and felt she had reached a
irreparable. At clinical review following revision surgery, plateau in her recovery. Components of her OSS reflected
she had improved pain and function. This clinical pattern is this description.
well reflected in the outcome scores for this patient. The Patient ‘DC’ appeared to have shown little improvement
scores were slow to improve and there is a correlation despite surgery. However, his pre-operative score was only
between the rise in outcome score and diagnosis of re-rup- 19 and, although this declined to 16, with a low score initial-
ture. Following revision surgery, her score showed ly it would be difficult for surgery to produce a dramatic
improvement. improvement. Pain, particularly at night, had been his main
The score for patient ‘MP’, who had a moderate cuff tear symptom pre-operatively and had improved with surgery.
and underwent open rotator cuff repair and sub-acromial This was reflected in his scores for Q1 and Q12, which fell
decompression, was slow to improve after surgery. A review from 3/5 pre-operatively to 1/5 postoperatively. From his
of the medical notes found that there had been a delay in perspective, surgery was worthwhile, despite a low pre-
the patient receiving physiotherapy due to concurrent ill- operative score, having improved his main complaint of
ness but, once commenced, she went on to make a steady night pain.
recovery. At over 2 years, her score had improved by 62%. Figure 2 presents an example of changes in one individ-
Some patients already discharged from clinic and who ual’s overall score and its components following surgery.
appeared to have a good outcome from surgery later showed a The overall score improved by 1 month although interest-
rise in their scores which may reflect a deterioration. They ingly, at this stage, the score for some questions actually

328 Ann R Coll Surg Engl 2008; 90: 326–331

OLLEY CARR THE USE OF A PATIENT-BASED QUESTIONNAIRE TO ASSESS
OUTCOME AFTER ROTATOR CUFF REPAIR

Figure 1 Normalised outcome scores for cohort.

rose (Q2, 6, 7 and 10) or were unchanged (Q9). All were Discussion
function questions and the rise very likely reflects the initial
deterioration in function reasonably expected after surgery. This study demonstrates that the OSS can be used to audit
By 5 months, all components had markedly improved rep- the outcome of a group undergoing a particular procedure,
resenting a good global recovery. in this case rotator cuff repair. Results indicate an overall

Figure 2 Outcome score for an individual.

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OLLEY CARR THE USE OF A PATIENT-BASED QUESTIONNAIRE TO ASSESS
OUTCOME AFTER ROTATOR CUFF REPAIR

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330 Ann R Coll Surg Engl 2008; 90: 326–331

OLLEY CARR THE USE OF A PATIENT-BASED QUESTIONNAIRE TO ASSESS
OUTCOME AFTER ROTATOR CUFF REPAIR

Appendix 1

The Oxford Shoulder Score questionnaire

Ann R Coll Surg Engl 2008; 90: 326–331 331