Editor’s note: The following content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting, but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage at aaos.org/VirtualAAOS2020.
Risk of degenerative rotator cuff tears increases with older age. Arthroscopic rotator cuff repair can improve function and decrease pain, but retear is a concern for older patients; for that reason, reverse shoulder arthroplasty (RSA) is often performed for large rotator cuff tears without arthritis in this patient population.
However, older patients (aged 75 years or older) with repairable, full-thickness rotator cuff tears can experience a significant clinical benefit from arthroscopic rotator cuff repair, according to midterm data from a study performed at the Rothman Orthopaedic Institute that was presented by Michael Stone, MD, of the Department of Orthopaedics at Cedars-Sinai Medical Center, as part of the Annual Meeting Virtual Experience.
“A repairable rotator cuff tear in an older patient without severe glenohumeral arthritis can be successfully repaired, and a good clinical outcome is expected,” Dr. Stone told AAOS Now. “RSA should be reserved for those with advanced cuff tear arthritis, an irreparable rotator cuff tear, or potentially a failed rotator cuff repair.”
The retrospective study assessed 83 patients aged 75 years or older who were undergoing arthroscopic rotator cuff repair at a minimum of 24 months after surgery. Patients were identified through a database of those who underwent rotator cuff repair performed by eight fellowship-trained shoulder surgeons at one institution between January 2009 and November 2016. Eligible patients had MRI evidence and physical examination findings of a symptomatic, full-thickness rotator cuff tear. Single- or double-row repairs were used at the surgeon’s discretion and were based on the characteristics of the tear. Most patients (51.8 percent) were female, mean age was 77 years (range, 75–85 years), and patients were followed for a mean 56.9 months (range, 24.0–127.0 months).
At final follow-up of about five years, 77 patients (93.5 percent) were free of revision. “There was excellent survivorship for arthroscopic rotator cuff repair in the older population,” said Dr. Stone. Among the six patients (6.5 percent) who underwent additional surgery, three underwent revision rotator cuff repair for retear at a mean 7.5 months (range, 6.0–9.0 months) after the index operation, two underwent RSA at 13.3 and 30.0 months after index rotator cuff repair, and one underwent arthroscopic capsular release and removal of a loose anchor at 3.7 months after the index rotator cuff repair.
Patients who did not undergo revision surgery had significant improvements in range of motion (Fig. 1) and functional outcome scores (Fig. 2).
There was no association between revision surgery and size of cuff tear (P = 0.15) or number of tendons torn (P = 0.24), and there was overall clinical improvement regardless of tear size. Small and medium tears had a statistically significantly higher postoperative American Shoulder and Elbow Society (ASES) score than large and massive tears (P = 0.006). Tear size did not statistically significantly impact Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS), or Short Form Health Survey 12 (SF-12) scores.
“The dramatic improvements in functional outcomes and pain were surprising findings, despite the lack of postoperative imaging to evaluate the integrity of the cuff,” said Dr. Stone. “There was also a very low rate of conversion to RSA within five-year follow-up (2.4 percent).”
There was also no statistical association between reoperation and age, sex, smoking status, tear chronicity, involved tendon (subscapularis, supraspinatus, infraspinatus, teres minor), or number of tendons torn.
Thirty patients (38.5 percent) had preoperative pseudoparesis (commonly defined as inability to actively forward elevate past 90 degrees), and after surgery, just seven patients (9.5 percent) had pseudoparesis (P = 0.005). Preoperative pseudoparesis trended toward a statistically lower postoperative ASES score (81.6 versus 90.2; P = 0.06) and was associated with a statistically significantly lower SANE score (78.8 versus 88.5; P = 0.048). There was no statistically significant association between preoperative pseudoparesis and postoperative VAS or SF-12 scores, nor revision surgery.
“Patients continue to stay active and are healthier at an older age,” said Dr. Stone. “We need to change our perception of older patients and not use age as the primary factor when treating orthopaedic problems. Although age does play a role, our study indicates that these patients can have a good outcome with a minimally invasive soft-tissue procedure versus an open joint replacement. Future studies should continue to focus on the role of minimally invasive options for older patients without arthritis.”
The study is limited by its retrospective design and shorter follow-up. “We also were not able to review preoperative MRI data, nor did we get postoperative imaging to assess the integrity of the repair in patients who were doing well,” said Dr. Stone.
Dr. Stone’s coauthors of “Mid-Term Outcomes of Arthroscopic Rotator Cuff Repair in Patients Age 75 and Older” are Jason Ho, Liam Thomas Kane, Mark D. Lazarus, and Surena Namdari.
Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at firstname.lastname@example.org.