Massive Rotator Cuff Tears in Patients Older Than Sixty-five: Indications for Cuff Repair versus Reverse Total Shoulder Arthroplasty
TAKE-HOME POINTS
- Rotator cuff repair and reverse total shoulder arthroplasty are both viable options for patients >65 years with massive rotator cuff tears without arthritis.
- Treatment must be individualized for each patient, with careful consideration of a number of preoperative variables and patient characteristics.
- At our institution, patients with previous rotator cuff repair, decreased range of motion, poor function, and strong radiographic evidence of subluxation were more likely to undergo reverse total shoulder arthroplasty.
- Patients selected for rotator cuff repair had greater preoperative flexion, abduction, and external rotation, as well as higher functional scores, and were less likely to have had previous cuff surgery.
- When chosen appropriately, both rotator cuff repair and reverse total shoulder arthroplasty can result in improved range of motion, function, and high patient satisfaction in this patient population.
MASSIVE CUFF TEAR DETERMINATION
We defined MCT on the basis of previously described criteria of tears involving ≥2 tendons or tears measuring ≥5 cm in greatest dimension.12,13 Patient charts were screened, and those whose clinical notes or radiology reports indicated an absence of MCT were excluded. Preoperative imaging of the remaining patients was then evaluated by 3 fellowship-trained shoulder surgeons to confirm MCT in all patients with a clinically documented MCT, as well as to assess those who had insufficient documentation of tear size in the notes.
Advanced imaging was evaluated for fatty atrophy of the rotator cuff musculature, and Goutallier classification was assigned.14,15 Length of retraction was measured from the tendon end to the medial aspect of the footprint on coronal imaging, and the subscapularis and teres minor were assessed and documented as torn or intact.16,17
DATA COLLECTION
We reviewed clinical charts and patient questionnaire forms from both the preoperative and follow-up visits. Clinical data collected included gender, age at surgery, active range of motion (forward elevation, abduction, external rotation, and internal rotation), comorbidities, smoking status, BMI, history of shoulder surgery, and any postoperative complications or need for secondary surgery. All patients completed patient-centered questionnaires regarding shoulder pain and dysfunction at each visit or via telephone communication with clinic staff. Outcome measurements used for analysis included American Shoulder and Elbow Surgeons (ASES) Score, simple shoulder test (SST), visual analog score (VAS) pain scale, and patient-reported satisfaction (Graded 1-10; 1 = poor outcome; 4 = satisfactory outcome; 7 = good outcome; 10 = excellent outcome).
DATA ANALYSIS AND STATISTICAL METHODS
Statistical tests were selected based on the result of Shapiro–Wilk test for normality. Continuous variables were evaluated with either independent t test or Mann–Whitney U test. Dependent t test was used to evaluate outcome variables. For categorical variables, either Pearson’s χ2or Fisher’s exact test was performed depending on the sample size. Alpha was set at P =.05.
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