Comparison of Functional Gains After Arthroscopic Rotator Cuff Repair in Patients Over 70 Years of Age Versus Patients Under 50 Years of Age: A Prospective Multicenter Study Constantina Moraiti, M.D., Ph.D., Pablo Valle, M.D., Ali Maqdes, M.D., Omar Boughebri, M.D., Chourky Dib, M.D., Giannis Giakas, B.Sc., Ph.D., Jean Kany, M.D., Kamil Elkholti, M.D., Jérôme Garret, M.D., Denis Katz, M.D., Franck Marie Leclère, M.D., Ph.D., and Philippe Valenti, M.D.
Purpose: To assess rotator cuff rupture characteristics and evaluate healing and the functional outcome after arthroscopic repair in patients older than 70 years versus patients younger than 50 years. Methods: We conducted a multicenter, prospective, comparative study of 40 patients younger than 50 years (group A) and 40 patients older than 70 years (group B) treated with arthroscopic rotator cuff repair. Patients older than 70 years were operated on only if symptoms persisted after 6 months of conservative treatment, whereas patients younger than 50 years were operated on regardless of any persistent symptoms. Imaging consisted of preoperative magnetic resonance imaging and postoperative ultrasound. Preoperative and postoperative function was evaluated with Constant and modified Constant scores. Patient satisfaction was also assessed. The evaluations were performed at least 1 year postoperatively. Results: No patient was lost to follow-up. The incidence of both supraspinatus and infraspinatus tears was greater in group B. Greater retraction in the frontal plane and greater fatty infiltration were observed in group B. The Constant score was significantly improved in both groups (51 12.32 preoperatively v 77.18 11.02 postoperatively in group A and 48.8 10.97 preoperatively v 74.6 12.02 postoperatively in group B, P < .05). The improvement was similar in both groups. The modified Constant score was also significantly improved in both groups (57.48 18.23 preoperatively v 81.35 19.75 postoperatively in group A and 63.09 14.96 preoperatively v 95.62 17.61 postoperatively in group B, P < .05). The improvement was greater for group B (P < .05). Partial rerupture of the rotator cuff occurred in 2 cases in group A and 5 cases in group B. Complete rerupture was observed in 2 patients in group B. In group A, 29 patients (72.5%) were very satisfied, 8 (20%) were satisfied, and 3 (7.5%) were less satisfied. In group B, 33 patients (82.5%) were very satisfied, 6 (15%) were satisfied, and only 1 (2.5%) was less satisfied. Conclusions: Rotator cuff tears are characterized by greater retraction in the frontal plane and greater fatty infiltration in patients older than 70 years compared with patients younger than 50 years. After arthroscopic repair, healing is greater for patients younger than 50 years. Functional gain is at least equal between the 2 groups. Level of Evidence: Level IV, therapeutic case series.
From Institut de la Main (C.M., P.Valle, A.M., P.Valenti), Paris; Hôpital Privé Armand Brillard (O.B.), Nogent-sur-Marne; Clinique La Montagne (C.D.), Courbevoie; Clinique de l’Union (J.K.), Toulouse; Clinique du Tonkin (K.E.), Lyon; Clinique du Parc (J.G.), Lyon; Clinique De Ploemeur (D.K.), Lorient; and Department of Plastic and Reconstructive Surgery, Institut Gustave Roussy (F.M.L.), Villejuif, France; and the University of Thessaly (G.G.), Trikala, Greece. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received July 7, 2013; accepted August 26, 2014. Address correspondence to Philippe Valenti, M.D., Institut de la Main, 6 Square Jouvenet, 75016 Paris, France. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/13467/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.08.020
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he incidence of rotator cuff tears increases with age. It has been reported that in asymptomatic shoulders, the prevalence of full-thickness tears is approximately 13% in persons aged between 50 and 59 years, 20% in those aged between 60 and 69 years, 37% in those aged between 70 and 79 years, and 51% in those older than 80 years.1 When these tears become symptomatic, shoulder pain and dysfunction are elicited,2 considerably affecting patients’ quality of life. Patients want to remain physically active, and in those who do not respond to nonoperative management, rotator cuff repair is indicated. Many studies have evaluated healing and shoulder function after rotator cuff repair trying to identify prognostic factors for a favorable outcome. Large cuff
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 2 (February), 2015: pp 184-190
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lesions, rotator muscle atrophy, osteoarthritis, muscle weakness, and limited motion seem to be related to poor functional results.3-6 Many of these factors have been related to advanced age, and several authors have reported poor results after rotator cuff repair in older patients.3,4,7 Intact rotator cuff repairs have been identified as an important parameter correlated with good functional results.4,7-11 Again, decreased healing rates have been reported in older patients, with the retear rate reaching 32% in patients older than 70 years.7,12 Humeral osteoporosis, tendon frailty, and large rotator cuff tears have been recognized as causative factors.9 Nonetheless, despite decreased healing rates, encouraging results concerning older patients have been reported, showing that this group of patients with persisting functional deficits can benefit from rotator cuff repair.12-17 On the other hand, excellent healing and functional results after anatomic reinsertion have been reported for patients younger than 50 years.18-20 The results are quite promising and early surgical treatment has been suggested in young patients with full-thickness tears who have a significant risk of developing irreparable rotator cuff changes.21 Thus the purpose of our study is to assess rotator cuff rupture characteristics and evaluate healing and the functional outcome after arthroscopic rotator cuff repair in the 2 extreme age groups: patients older than 70 years versus patients younger than 50 years. We hypothesized that both groups would benefit from this procedure and that patients younger than 50 years would exhibit greater healing rates and would have a greater functional gain than patients older than 70 years.
Methods This is a prospective study of 312 arthroscopic rotator cuff repair procedures that were performed between January 2008 and January 2009 in 5 centers specializing in shoulder surgery. There were 40 patients younger than 50 years and 41 patients older than 70 years. The inclusion criteria were age (70 years) and the absence of prior shoulder trauma or surgery. In addition, patients with shoulder osteoarthritis greater than grade 2 or 3 according to the Samilson classification were excluded from the study.22 In patients older than 70 years, arthroscopic rotator cuff repair was indicated only if pain and functional deficit persisted after 6 months of conservative treatment (nonsteroidal anti-inflammatory drugs, corticosteroid injections, and physiotherapy). All patients younger than 50 years underwent arthroscopic rotator cuff repair regardless of any persistent symptoms. Institutional review board approval was obtained. The surgical procedures were performed by 5 surgeons (P.V., J.K., K.E., J.K., D.K.; 1 surgeon per center participating in the study).
Preoperative magnetic resonance imaging (MRI) was obtained for all patients. Retraction of the cuff in the frontal plane was described according to the Patte classification.23 The Lafosse classification was used for subscapularis tears.24 Fatty infiltration was evaluated in each tendon according to the Goutallier classification.25 In all cases MRI was obtained just before surgery. The reading of all MRI studies was blinded and was performed by 1 observer (P.V.). All patients underwent arthroscopic tendon-to-bone rotator cuff repair. In all cases all ruptured tendons were repaired. In all cases single-loaded anchors were used. Double-row repair was performed in 25 cases in group A (62.5%) and 18 cases in group B (45%). Single-row repair was performed in 15 cases in group A (37.5%) and 22 cases in group B (55%). The mean number of anchors used was 3 1.28 in group A and 2 1.15 in group B. No statistical difference was noted. All techniques (single or double row, speed bridge, U-sutures) were equally performed by all surgeons. No augmentation was used. Where indicated, acromioplasty, resection of the coracoacromial ligament, resection of the acromioclavicular joint, and tenotomy or tenodesis of the long head of the biceps tendon were performed (Table 1). All patients were immobilized postoperatively in a sling in 30 of abduction for 4 to 6 weeks. Physiotherapy was started immediately postoperatively with daily pendular and passive range-of-motion (ROM) exercises. Activeassisted ROM was commenced at 4 weeks postoperatively, and active ROM with terminal stretching and rotator cuff strengthening exercises was started at 6 weeks postoperatively. Patient evaluation included preoperative and postoperative Constant scores,26 as well as age- and sexmatched Constant scores.27 Patient satisfaction was also noted. Preoperative evaluation was performed just before surgery. Ultrasound assessment of the shoulder was performed in all patients at the latest follow-up. The examination was blinded and was performed by 5 radiologists specializing in ultrasound shoulder examination. The mean follow-up period was 12.9 months in group A (range, 12 to 18 months) and 13.8 months in group B (range, 12 to 32 months).
Table 1. Additional Surgical Procedures Performed in Each Group Acromioplasty Resection of coracoacromial ligament Resection of acromioclavicular joint Tenotomy of long head of biceps tendon Tenodesis of long head of biceps tendon
Group A 36 (90) 34 (85) 5 (12.5) 11 (27.5) 16 (40)
Group B 33 (82.5) 28 (70) 6 (15) 30 (75) 4 (10)
NOTE. Data are presented as number of patients (percent).
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Statistical Analysis The values obtained for the Constant and modified Constant scores were submitted to multiple 2-way repeated-measures (preoperative v postoperative) and between-group analyses of variance. Post hoc analysis was performed using the least significant difference test. The level of significance was set at P .005. The SPSS software package was used (version 19; SPSS, Chicago, IL). Post hoc analysis of power was calculated using G*Power (Heinrich Heine Universitat Düsseldorf, Düsseldorf, Germany; Available at http://www.psycho. uniduesseldorf.de/abteilungen/aap/gpower3).
Results Two groups were formed: Group A comprised patients younger than 50 years, and group B comprised patients older than 70 years. Forty patients met the inclusion criteria for group A. There were 19 women (47.5%) and 21 men (52.5%) with a mean age of 45 years (range, 25 to 49 years). The dominant extremity was involved in 28 of 40 cases (70%). Forty patients fulfilled the inclusion criteria for group B. Initially, there were 41 patients older than 70 years. One patient was excluded because he had undergone latissimus dorsi tendon transfer. There were 27 women (67.5%) and 13 men (32.5%) with a mean age of 73 years (range, 70 to 83 years). The dominant extremity was involved in 24 of 40 cases (60%). The mean duration of symptoms was 25 months (range, 1 to 120 months) in group A and 19 months (range, 2 to 120 months) in group B. According to MRI, the supraspinatus was the most affected tendon in both groups. Actually, 36 shoulders in group A had a supraspinatus lesion (retraction type I in 23 cases, type II in 10, and type III in 3), whereas all patients in group B had a supraspinatus lesion (type I in 14 cases, type II in 16, and type III in 10) (Fig 1). The
Fig 1. MRI findings regarding retraction type for supraspinatus and infraspinatus in each group according to Patte classification. Rotator cuff tears were larger in patients older than 70 years (group B). Specifically, retraction of the supraspinatus in the frontal plane was greater in this age group and the infraspinatus was proportionally more affected.
Fig 2. Rupture type for subscapularis in each group according to Lafosse classification. The subscapularis tendon was the least affected in both groups.
infraspinatus was affected in only 9 patients in group A (type I in 5 cases, type II in 3, and type III in 1) and in 18 patients in group B (type I in 9 cases, type II in 7, and type III in 2) (Fig 1). The subscapularis tendon was the least affected in both groups. The subscapularis was affected in 8 shoulders in group A (type 1 in 4 cases, type 2 in 3, and type 3 in 1) and in 9 patients in group B (type 1 in 7 cases and type 2 in 2) (Fig 2). In all cases, MRI findings were confirmed intraoperatively. In all 3 muscles, fatty infiltration was more advanced in group B than in group A (Fig 3). The Constant score was significantly improved in both groups (51 [range, 26 to 70] preoperatively v 77.2 [range, 51 to 97] postoperatively in group A and 48.8 [range, 22 to 71] preoperatively v 74.6 [range, 47 to 96] postoperatively in group B, P < .05). Both groups had similar benefit after arthroscopic rotator cuff repair. Statistically significant improvement (preoperative v postoperative) was found for all parameters forming the Constant score in both groups. In all cases the improvement was similar for both groups. The results are summarized in Table 2.
Fig 3. Fatty infiltration of each muscle according to Goutallier classification. Patients older than 70 years (group B) exhibited greater fatty infiltration in all muscles than patients younger than 50 years (group A).
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AGE-RELATED CUFF REPAIR OUTCOMES Table 2. Detailed Results of Parameters Forming Constant Scores Group A Parameter Pain Activity level Flexion, Abduction, External rotation, Internal rotation, Forcez
Preoperative 4 3.9 8 2.9 151 29 135 32.8 7.5 2.5 8 2.2 5 4.8
Postoperative 13.7 2.7 16 3 172 15.4 156 25.4 9 1.2 9 1.3 11 5.9
Group B Preoperative 3 2.9 7 2.5 145 34.6 134 34.3 6.4 2.6 8 2.3 5 8.5
Postoperative 12 3.1 15 5 164 25.5 150 31.3 9 1.6 9 1.7 10 7.1
P Value PreoperativePostoperative* < .001 < .001 < .001 < .001 < .001 < .001 < .001
Preoperative-Postoperative Groupy .300 .896 .759 .589 .366 .307 .120
NOTE. Data presented as mean standard deviation unless otherwise indicated. *We assessed whether there were differences between the preoperative and postoperative values for all patients. There were significant differences for all parameters examined. y The interaction indicates whether group A had different results (or showed different behavior) than group B. Both groups had similar results (i.e., the benefit was similar for both groups) for all parameters. z 1 point per 500-g maintained for 5 seconds.
The modified Constant score was also significantly improved in both groups (57.5 [range, 28 to 86] preoperatively v 81.35 [range, 54 to 101] postoperatively in group A and 63.1 [range, 31 to 91] preoperatively v 95.6 [range, 60 to 120] postoperatively in group B, P < .05). The improvement was greater for group B (P < .05). In group A, 29 patients (72.5%) were very satisfied, 8 (20%) were satisfied, and 3 (7.5%) were less satisfied. In group B, 33 patients (82.5%) were very satisfied, 6 (15%) were satisfied, and only 1 (2.5%) was less satisfied. According to the ultrasound imaging results, in group A, complete healing was noted in 38 of 40 shoulders (95%); a partial-thickness retear was observed in the other 2 shoulders. In group B, the cuff was healed in 33 cases (82.5%) whereas a partial-thickness retear was observed in 5 (12.5%) and a full-thickness retear in 2 (5%). Table 3 presents the characteristics of the cases of complete or partial retear. One case of postoperative infection was noted in group A. In group B there was also 1 case of superficial infection, whereas algodystrophy developed in 3 patients and biceps tendinitis developed in 1 patient. In the latter patient, no biceps tendon pathology had been detected intraoperatively and thus no action had been taken.
Discussion This study assessed rotator cuff rupture characteristics and compared healing and the functional outcome after arthroscopic rotator cuff repair in 2 age groups: patients older than 70 years versus patients younger than 50 years. According to our results, rotator cuff tears in patients older than 70 years are characterized by greater size, greater retraction, and greater fatty infiltration than in patients younger than 50 years. Shoulder function is improved in all patients after arthroscopic rotator cuff repair. Healing is shown to be poorer in elderly patients. In addition, in patients older than
70 years, the benefit in terms of functional gain is equal or even superior to that in younger patients. Our results, which are consistent with the literature,3 show that retraction of the supraspinatus in the frontal plane according to the Patte classification is greater in patients older than 70 years. In addition, the infraspinatus is proportionally more affected in this age group. Despite the fact that rotator cuff ruptures were larger in group B, the number of anchors used was greater in group A. This finding could be explained by the fact that a greater number of double-row repairs were performed in patients younger than 50 years. We found that fatty infiltration according to the Goutallier classification in all rotator cuff muscles is greater in patients older than 70 years. This could be correlated to the increased retraction of the tendon and the chronicity of the lesion found in these patients. This finding is supported by Meyer et al.,28 who showed that Table 3. Tendon Involved, Grade of Retraction According to Patte Classification (Lafosse Classification for Subscapularis Tears), and Fatty Infiltration According to Goutallier Classification for Complete or Partial Retear Cases Retraction
Fatty Infiltration
Supraspinatus Supraspinatus/ infraspinatus
1 1/1
1 1/1
Supraspinatus/ subscapularis Supraspinatus/ infraspinatus Supraspinatus Supraspinatus/ infraspinatus Supraspinatus/ infraspinatus Supraspinatus Supraspinatus/ infraspinatus
2/1
2/1
1/1
1/1
2 2/1
3 2/1
3/2
3/2
1 2/2
1 2/2
Tendon Ruptured Patients aged 70 yr Partial retear Partial retear Partial retear Partial retear Partial retear Complete retear Complete retear
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tear size and muscle retraction increased proportionally with the Goutallier stage. They showed that musculotendinous retraction in chronic rotator cuff tears results mainly from shortening of the muscle fibers but, in advanced stages, results also from shortening of the tendon tissue itself. Both of these factors (tear size and fatty infiltration), as well as age, have been associated with poor tendon healing.7,10,29-31 Furthermore, even for small supraspinatus tears, it has been shown that the existence of intratendinous cleavage is correlated with higher rerupture rates.32 Boileau et al.7 showed the importance of tear extension in the sagittal plane. They concluded that the extension of the tear in the sagittal plane with associated delamination (or cleavage) of the infraspinatus posteriorly or of the subscapularis anteriorly should be considered a poor prognostic factor for tendon healing. Meyer et al.33 proposed that both Goutallier grading and preoperative tendon length should be taken into consideration when predicting rotator cuff repair reparability and healing rates. The poorer healing encountered in older patients has been attributed to the limited capacity to store local reserves of various growth factors involved in the healing process or to the failure of the repair due to the osteoporotic bone found in elderly persons.7 Our findings support these results. Specifically, we found that complete healing was noted in 95% of patients younger than 50 years (a partial-thickness retear was observed in only 2 shoulders). In contrast, in patients older than 70 years, who exhibited greater retraction, fatty infiltration, and supraspinatus involvement, complete healing was achieved in only 82.5% (a partial-thickness retear was observed in 5 patients and a full-thickness retear in 2). Our results concerning decreased healing rates in older patients are consistent with the literature. This finding supports our hypothesis. Boileau et al.7 showed that an isolated supraspinatus tear exhibits a healing rate of up to 95% after rotator cuff repair in patients younger than 55 years and that this percentage drops to 43% for patients older than 65 years. In a 5-year follow-up with ultrasound assessment, Djahangiri et al.11 showed that healing occurs in 70% of cases in patients older than 65 years. Charousset et al.16 showed that 54 of 88 patients older than 65 years (61.36%) had complete or partial rerupture 6 months after arthroscopic rotator cuff repair. Robinson et al.12 assessed healing with ultrasound 1 year postoperatively in patients older than 70 years and showed a retear rate of 32%. Age at operation reversely correlated with rotator cuff healing. Dezaly et al.34 found a rerupture rate of 47.6% in patients older than 70 years. Our results are closer to those presented by Flurin et al.17 They showed that 1 year after arthroscopic rotator cuff repair, there is a healing rate of 89% in patients older than 70 years.
They found no correlation between healing and retraction or the fatty infiltration stage. The inconsistency of these results could be because of the differences in surgical techniques and rehabilitation protocols or the existence of other factors (dominance, smoking, use of cortisone injections, osteoarthritis) that may have an influence on healing after rotator cuff repair.11,35 Despite the differences in healing rate in our study, both groups were satisfied and had improved Constant and modified Constant scores. Many studies have shown that there is a correlation between healing and the functional outcome after rotator cuff repair.7,8,17,34 However, Lafosse et al.4 found only a trend without statistical significance between these parameters. Boughebri et al.32 examined patients with arthroscopically repaired small infraspinatus tears and showed that no correlation exists between tendon healing and patient satisfaction or shoulder function according to the Constant score, which is consistent with our results. What is quite interesting and refutes our hypothesis is that the elderly patients exhibited greater functional gain after rotator cuff repair than the younger patients based on the results of the modified Constant score. However, no difference was found for the improvement in Constant scores. This is certainly due to the age and sex modifications of the normalized Constant score. Thus, according to the results of our study, patients older than 70 years benefit from rotator cuff repair. However, our knowledge base is still evolving. There have been other studies that have proposed, because of muscle atrophy, tear size, and poor healing rates, that rotator cuff tears in elderly patients be treated with acromioplasty and biceps tenotomy alone. However, in a randomized study, Dezaly et al.34 showed that there is a benefit of repair in intermediate-size rotator cuff tears over acromioplasty and biceps tenotomy in patients older than 60 years, which supports our study’s findings. Limitations This is a multicenter study, signifying that there was not only 1 surgeon. However, all of the surgeons were experienced shoulder surgeons, and arthroscopic tendon-to-bone repair was performed in all cases. In addition, the same rehabilitation program was applied in all patients. Second, the evaluation of healing was performed by ultrasound, an operator-dependent examination, and not by the same radiologist. All ultrasound examinations took place in imaging centers specializing in musculoskeletal ultrasound and shoulder pathology. Third, the mean follow-up period was 12.9 months in group A and 13.8 months in group B. However, in all cases the latest evaluation took place at least 12 months postoperatively. It has been shown that a minimum of 6 months is appropriate to assess secure tendon healing.24,36 Moreover, Heikenfeld et al.37
AGE-RELATED CUFF REPAIR OUTCOMES
showed that after arthroscopic repair of subscapularis tears, there is no difference in the Constant score between 12 and 24 months postoperatively.
Conclusions Rotator cuff tears are characterized by greater retraction in the frontal plane and greater fatty infiltration in patients older than 70 years compared with patients younger than 50 years. After arthroscopic repair, healing is greater for patients younger than 50 years. Functional gain is at least equal between the 2 groups.
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32. Boughebri O, Roussignol X, Delattre O, Kany J, Valenti P. Small supraspinatus tears repaired by arthroscopy: Are clinical results influenced by the integrity of the cuff after two years? Functional and anatomic results of forty-six consecutive cases. J Shoulder Elbow Surg 2012;21: 699-706. 33. Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med 2012;40: 2242-2247. 34. Dezaly C, Sirveaux F, Philippe R, et al. Arthroscopic treatment of rotator cuff tear in the over-60s: Repair is preferable to isolated acromioplasty-tenotomy in the
short term. Orthop Traumatol Surg Res 2011;97: S125-S130. 35. Kukkonen J, Joukainen A, Lehtinen J, Aärimaa V. The effect of glenohumeral osteoarthritis on the outcome of isolated operatively treated supraspinatus tears. J Orthop Sci 2013;18:405-409. 36. Iannotti JP, 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. 37. Heikenfeld R, Gigis I, Chytas A, Listringhaus R, Godolias G. Arthroscopic reconstruction of isolated subscapularis tears: Clinical results and structural integrity after 24 months. Arthroscopy 2012;28:1805-1811.
Purpose: To assess rotator cuff rupture characteristics and evaluate healing and the functional outcome after arthroscopic repair in patients older than 70 years versus patients younger than 50 years. Methods: We conducted a multicenter, prospective, comparative study of 40 patients younger than 50 years (group A) and 40 patients older than 70 years (group B) treated with arthroscopic rotator cuff repair. Patients older than 70 years were operated on only if symptoms persisted after 6 months of conservative treatment, whereas patients younger than 50 years were operated on regardless of any persistent symptoms. Imaging consisted of preoperative magnetic resonance imaging and postoperative ultrasound. Preoperative and postoperative function was evaluated with Constant and modified Constant scores. Patient satisfaction was also assessed. The evaluations were performed at least 1 year postoperatively. Results: No patient was lost to follow-up. The incidence of both supraspinatus and infraspinatus tears was greater in group B. Greater retraction in the frontal plane and greater fatty infiltration were observed in group B. The Constant score was significantly improved in both groups (51 12.32 preoperatively v 77.18 11.02 postoperatively in group A and 48.8 10.97 preoperatively v 74.6 12.02 postoperatively in group B, P < .05). The improvement was similar in both groups. The modified Constant score was also significantly improved in both groups (57.48 18.23 preoperatively v 81.35 19.75 postoperatively in group A and 63.09 14.96 preoperatively v 95.62 17.61 postoperatively in group B, P < .05). The improvement was greater for group B (P < .05). Partial rerupture of the rotator cuff occurred in 2 cases in group A and 5 cases in group B. Complete rerupture was observed in 2 patients in group B. In group A, 29 patients (72.5%) were very satisfied, 8 (20%) were satisfied, and 3 (7.5%) were less satisfied. In group B, 33 patients (82.5%) were very satisfied, 6 (15%) were satisfied, and only 1 (2.5%) was less satisfied. Conclusions: Rotator cuff tears are characterized by greater retraction in the frontal plane and greater fatty infiltration in patients older than 70 years compared with patients younger than 50 years. After arthroscopic repair, healing is greater for patients younger than 50 years. Functional gain is at least equal between the 2 groups. Level of Evidence: Level IV, therapeutic case series.
From Institut de la Main (C.M., P.Valle, A.M., P.Valenti), Paris; Hôpital Privé Armand Brillard (O.B.), Nogent-sur-Marne; Clinique La Montagne (C.D.), Courbevoie; Clinique de l’Union (J.K.), Toulouse; Clinique du Tonkin (K.E.), Lyon; Clinique du Parc (J.G.), Lyon; Clinique De Ploemeur (D.K.), Lorient; and Department of Plastic and Reconstructive Surgery, Institut Gustave Roussy (F.M.L.), Villejuif, France; and the University of Thessaly (G.G.), Trikala, Greece. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received July 7, 2013; accepted August 26, 2014. Address correspondence to Philippe Valenti, M.D., Institut de la Main, 6 Square Jouvenet, 75016 Paris, France. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/13467/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.08.020
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he incidence of rotator cuff tears increases with age. It has been reported that in asymptomatic shoulders, the prevalence of full-thickness tears is approximately 13% in persons aged between 50 and 59 years, 20% in those aged between 60 and 69 years, 37% in those aged between 70 and 79 years, and 51% in those older than 80 years.1 When these tears become symptomatic, shoulder pain and dysfunction are elicited,2 considerably affecting patients’ quality of life. Patients want to remain physically active, and in those who do not respond to nonoperative management, rotator cuff repair is indicated. Many studies have evaluated healing and shoulder function after rotator cuff repair trying to identify prognostic factors for a favorable outcome. Large cuff
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 2 (February), 2015: pp 184-190
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lesions, rotator muscle atrophy, osteoarthritis, muscle weakness, and limited motion seem to be related to poor functional results.3-6 Many of these factors have been related to advanced age, and several authors have reported poor results after rotator cuff repair in older patients.3,4,7 Intact rotator cuff repairs have been identified as an important parameter correlated with good functional results.4,7-11 Again, decreased healing rates have been reported in older patients, with the retear rate reaching 32% in patients older than 70 years.7,12 Humeral osteoporosis, tendon frailty, and large rotator cuff tears have been recognized as causative factors.9 Nonetheless, despite decreased healing rates, encouraging results concerning older patients have been reported, showing that this group of patients with persisting functional deficits can benefit from rotator cuff repair.12-17 On the other hand, excellent healing and functional results after anatomic reinsertion have been reported for patients younger than 50 years.18-20 The results are quite promising and early surgical treatment has been suggested in young patients with full-thickness tears who have a significant risk of developing irreparable rotator cuff changes.21 Thus the purpose of our study is to assess rotator cuff rupture characteristics and evaluate healing and the functional outcome after arthroscopic rotator cuff repair in the 2 extreme age groups: patients older than 70 years versus patients younger than 50 years. We hypothesized that both groups would benefit from this procedure and that patients younger than 50 years would exhibit greater healing rates and would have a greater functional gain than patients older than 70 years.
Methods This is a prospective study of 312 arthroscopic rotator cuff repair procedures that were performed between January 2008 and January 2009 in 5 centers specializing in shoulder surgery. There were 40 patients younger than 50 years and 41 patients older than 70 years. The inclusion criteria were age (70 years) and the absence of prior shoulder trauma or surgery. In addition, patients with shoulder osteoarthritis greater than grade 2 or 3 according to the Samilson classification were excluded from the study.22 In patients older than 70 years, arthroscopic rotator cuff repair was indicated only if pain and functional deficit persisted after 6 months of conservative treatment (nonsteroidal anti-inflammatory drugs, corticosteroid injections, and physiotherapy). All patients younger than 50 years underwent arthroscopic rotator cuff repair regardless of any persistent symptoms. Institutional review board approval was obtained. The surgical procedures were performed by 5 surgeons (P.V., J.K., K.E., J.K., D.K.; 1 surgeon per center participating in the study).
Preoperative magnetic resonance imaging (MRI) was obtained for all patients. Retraction of the cuff in the frontal plane was described according to the Patte classification.23 The Lafosse classification was used for subscapularis tears.24 Fatty infiltration was evaluated in each tendon according to the Goutallier classification.25 In all cases MRI was obtained just before surgery. The reading of all MRI studies was blinded and was performed by 1 observer (P.V.). All patients underwent arthroscopic tendon-to-bone rotator cuff repair. In all cases all ruptured tendons were repaired. In all cases single-loaded anchors were used. Double-row repair was performed in 25 cases in group A (62.5%) and 18 cases in group B (45%). Single-row repair was performed in 15 cases in group A (37.5%) and 22 cases in group B (55%). The mean number of anchors used was 3 1.28 in group A and 2 1.15 in group B. No statistical difference was noted. All techniques (single or double row, speed bridge, U-sutures) were equally performed by all surgeons. No augmentation was used. Where indicated, acromioplasty, resection of the coracoacromial ligament, resection of the acromioclavicular joint, and tenotomy or tenodesis of the long head of the biceps tendon were performed (Table 1). All patients were immobilized postoperatively in a sling in 30 of abduction for 4 to 6 weeks. Physiotherapy was started immediately postoperatively with daily pendular and passive range-of-motion (ROM) exercises. Activeassisted ROM was commenced at 4 weeks postoperatively, and active ROM with terminal stretching and rotator cuff strengthening exercises was started at 6 weeks postoperatively. Patient evaluation included preoperative and postoperative Constant scores,26 as well as age- and sexmatched Constant scores.27 Patient satisfaction was also noted. Preoperative evaluation was performed just before surgery. Ultrasound assessment of the shoulder was performed in all patients at the latest follow-up. The examination was blinded and was performed by 5 radiologists specializing in ultrasound shoulder examination. The mean follow-up period was 12.9 months in group A (range, 12 to 18 months) and 13.8 months in group B (range, 12 to 32 months).
Table 1. Additional Surgical Procedures Performed in Each Group Acromioplasty Resection of coracoacromial ligament Resection of acromioclavicular joint Tenotomy of long head of biceps tendon Tenodesis of long head of biceps tendon
Group A 36 (90) 34 (85) 5 (12.5) 11 (27.5) 16 (40)
Group B 33 (82.5) 28 (70) 6 (15) 30 (75) 4 (10)
NOTE. Data are presented as number of patients (percent).
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Statistical Analysis The values obtained for the Constant and modified Constant scores were submitted to multiple 2-way repeated-measures (preoperative v postoperative) and between-group analyses of variance. Post hoc analysis was performed using the least significant difference test. The level of significance was set at P .005. The SPSS software package was used (version 19; SPSS, Chicago, IL). Post hoc analysis of power was calculated using G*Power (Heinrich Heine Universitat Düsseldorf, Düsseldorf, Germany; Available at http://www.psycho. uniduesseldorf.de/abteilungen/aap/gpower3).
Results Two groups were formed: Group A comprised patients younger than 50 years, and group B comprised patients older than 70 years. Forty patients met the inclusion criteria for group A. There were 19 women (47.5%) and 21 men (52.5%) with a mean age of 45 years (range, 25 to 49 years). The dominant extremity was involved in 28 of 40 cases (70%). Forty patients fulfilled the inclusion criteria for group B. Initially, there were 41 patients older than 70 years. One patient was excluded because he had undergone latissimus dorsi tendon transfer. There were 27 women (67.5%) and 13 men (32.5%) with a mean age of 73 years (range, 70 to 83 years). The dominant extremity was involved in 24 of 40 cases (60%). The mean duration of symptoms was 25 months (range, 1 to 120 months) in group A and 19 months (range, 2 to 120 months) in group B. According to MRI, the supraspinatus was the most affected tendon in both groups. Actually, 36 shoulders in group A had a supraspinatus lesion (retraction type I in 23 cases, type II in 10, and type III in 3), whereas all patients in group B had a supraspinatus lesion (type I in 14 cases, type II in 16, and type III in 10) (Fig 1). The
Fig 1. MRI findings regarding retraction type for supraspinatus and infraspinatus in each group according to Patte classification. Rotator cuff tears were larger in patients older than 70 years (group B). Specifically, retraction of the supraspinatus in the frontal plane was greater in this age group and the infraspinatus was proportionally more affected.
Fig 2. Rupture type for subscapularis in each group according to Lafosse classification. The subscapularis tendon was the least affected in both groups.
infraspinatus was affected in only 9 patients in group A (type I in 5 cases, type II in 3, and type III in 1) and in 18 patients in group B (type I in 9 cases, type II in 7, and type III in 2) (Fig 1). The subscapularis tendon was the least affected in both groups. The subscapularis was affected in 8 shoulders in group A (type 1 in 4 cases, type 2 in 3, and type 3 in 1) and in 9 patients in group B (type 1 in 7 cases and type 2 in 2) (Fig 2). In all cases, MRI findings were confirmed intraoperatively. In all 3 muscles, fatty infiltration was more advanced in group B than in group A (Fig 3). The Constant score was significantly improved in both groups (51 [range, 26 to 70] preoperatively v 77.2 [range, 51 to 97] postoperatively in group A and 48.8 [range, 22 to 71] preoperatively v 74.6 [range, 47 to 96] postoperatively in group B, P < .05). Both groups had similar benefit after arthroscopic rotator cuff repair. Statistically significant improvement (preoperative v postoperative) was found for all parameters forming the Constant score in both groups. In all cases the improvement was similar for both groups. The results are summarized in Table 2.
Fig 3. Fatty infiltration of each muscle according to Goutallier classification. Patients older than 70 years (group B) exhibited greater fatty infiltration in all muscles than patients younger than 50 years (group A).
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AGE-RELATED CUFF REPAIR OUTCOMES Table 2. Detailed Results of Parameters Forming Constant Scores Group A Parameter Pain Activity level Flexion, Abduction, External rotation, Internal rotation, Forcez
Preoperative 4 3.9 8 2.9 151 29 135 32.8 7.5 2.5 8 2.2 5 4.8
Postoperative 13.7 2.7 16 3 172 15.4 156 25.4 9 1.2 9 1.3 11 5.9
Group B Preoperative 3 2.9 7 2.5 145 34.6 134 34.3 6.4 2.6 8 2.3 5 8.5
Postoperative 12 3.1 15 5 164 25.5 150 31.3 9 1.6 9 1.7 10 7.1
P Value PreoperativePostoperative* < .001 < .001 < .001 < .001 < .001 < .001 < .001
Preoperative-Postoperative Groupy .300 .896 .759 .589 .366 .307 .120
NOTE. Data presented as mean standard deviation unless otherwise indicated. *We assessed whether there were differences between the preoperative and postoperative values for all patients. There were significant differences for all parameters examined. y The interaction indicates whether group A had different results (or showed different behavior) than group B. Both groups had similar results (i.e., the benefit was similar for both groups) for all parameters. z 1 point per 500-g maintained for 5 seconds.
The modified Constant score was also significantly improved in both groups (57.5 [range, 28 to 86] preoperatively v 81.35 [range, 54 to 101] postoperatively in group A and 63.1 [range, 31 to 91] preoperatively v 95.6 [range, 60 to 120] postoperatively in group B, P < .05). The improvement was greater for group B (P < .05). In group A, 29 patients (72.5%) were very satisfied, 8 (20%) were satisfied, and 3 (7.5%) were less satisfied. In group B, 33 patients (82.5%) were very satisfied, 6 (15%) were satisfied, and only 1 (2.5%) was less satisfied. According to the ultrasound imaging results, in group A, complete healing was noted in 38 of 40 shoulders (95%); a partial-thickness retear was observed in the other 2 shoulders. In group B, the cuff was healed in 33 cases (82.5%) whereas a partial-thickness retear was observed in 5 (12.5%) and a full-thickness retear in 2 (5%). Table 3 presents the characteristics of the cases of complete or partial retear. One case of postoperative infection was noted in group A. In group B there was also 1 case of superficial infection, whereas algodystrophy developed in 3 patients and biceps tendinitis developed in 1 patient. In the latter patient, no biceps tendon pathology had been detected intraoperatively and thus no action had been taken.
Discussion This study assessed rotator cuff rupture characteristics and compared healing and the functional outcome after arthroscopic rotator cuff repair in 2 age groups: patients older than 70 years versus patients younger than 50 years. According to our results, rotator cuff tears in patients older than 70 years are characterized by greater size, greater retraction, and greater fatty infiltration than in patients younger than 50 years. Shoulder function is improved in all patients after arthroscopic rotator cuff repair. Healing is shown to be poorer in elderly patients. In addition, in patients older than
70 years, the benefit in terms of functional gain is equal or even superior to that in younger patients. Our results, which are consistent with the literature,3 show that retraction of the supraspinatus in the frontal plane according to the Patte classification is greater in patients older than 70 years. In addition, the infraspinatus is proportionally more affected in this age group. Despite the fact that rotator cuff ruptures were larger in group B, the number of anchors used was greater in group A. This finding could be explained by the fact that a greater number of double-row repairs were performed in patients younger than 50 years. We found that fatty infiltration according to the Goutallier classification in all rotator cuff muscles is greater in patients older than 70 years. This could be correlated to the increased retraction of the tendon and the chronicity of the lesion found in these patients. This finding is supported by Meyer et al.,28 who showed that Table 3. Tendon Involved, Grade of Retraction According to Patte Classification (Lafosse Classification for Subscapularis Tears), and Fatty Infiltration According to Goutallier Classification for Complete or Partial Retear Cases Retraction
Fatty Infiltration
Supraspinatus Supraspinatus/ infraspinatus
1 1/1
1 1/1
Supraspinatus/ subscapularis Supraspinatus/ infraspinatus Supraspinatus Supraspinatus/ infraspinatus Supraspinatus/ infraspinatus Supraspinatus Supraspinatus/ infraspinatus
2/1
2/1
1/1
1/1
2 2/1
3 2/1
3/2
3/2
1 2/2
1 2/2
Tendon Ruptured Patients aged 70 yr Partial retear Partial retear Partial retear Partial retear Partial retear Complete retear Complete retear
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tear size and muscle retraction increased proportionally with the Goutallier stage. They showed that musculotendinous retraction in chronic rotator cuff tears results mainly from shortening of the muscle fibers but, in advanced stages, results also from shortening of the tendon tissue itself. Both of these factors (tear size and fatty infiltration), as well as age, have been associated with poor tendon healing.7,10,29-31 Furthermore, even for small supraspinatus tears, it has been shown that the existence of intratendinous cleavage is correlated with higher rerupture rates.32 Boileau et al.7 showed the importance of tear extension in the sagittal plane. They concluded that the extension of the tear in the sagittal plane with associated delamination (or cleavage) of the infraspinatus posteriorly or of the subscapularis anteriorly should be considered a poor prognostic factor for tendon healing. Meyer et al.33 proposed that both Goutallier grading and preoperative tendon length should be taken into consideration when predicting rotator cuff repair reparability and healing rates. The poorer healing encountered in older patients has been attributed to the limited capacity to store local reserves of various growth factors involved in the healing process or to the failure of the repair due to the osteoporotic bone found in elderly persons.7 Our findings support these results. Specifically, we found that complete healing was noted in 95% of patients younger than 50 years (a partial-thickness retear was observed in only 2 shoulders). In contrast, in patients older than 70 years, who exhibited greater retraction, fatty infiltration, and supraspinatus involvement, complete healing was achieved in only 82.5% (a partial-thickness retear was observed in 5 patients and a full-thickness retear in 2). Our results concerning decreased healing rates in older patients are consistent with the literature. This finding supports our hypothesis. Boileau et al.7 showed that an isolated supraspinatus tear exhibits a healing rate of up to 95% after rotator cuff repair in patients younger than 55 years and that this percentage drops to 43% for patients older than 65 years. In a 5-year follow-up with ultrasound assessment, Djahangiri et al.11 showed that healing occurs in 70% of cases in patients older than 65 years. Charousset et al.16 showed that 54 of 88 patients older than 65 years (61.36%) had complete or partial rerupture 6 months after arthroscopic rotator cuff repair. Robinson et al.12 assessed healing with ultrasound 1 year postoperatively in patients older than 70 years and showed a retear rate of 32%. Age at operation reversely correlated with rotator cuff healing. Dezaly et al.34 found a rerupture rate of 47.6% in patients older than 70 years. Our results are closer to those presented by Flurin et al.17 They showed that 1 year after arthroscopic rotator cuff repair, there is a healing rate of 89% in patients older than 70 years.
They found no correlation between healing and retraction or the fatty infiltration stage. The inconsistency of these results could be because of the differences in surgical techniques and rehabilitation protocols or the existence of other factors (dominance, smoking, use of cortisone injections, osteoarthritis) that may have an influence on healing after rotator cuff repair.11,35 Despite the differences in healing rate in our study, both groups were satisfied and had improved Constant and modified Constant scores. Many studies have shown that there is a correlation between healing and the functional outcome after rotator cuff repair.7,8,17,34 However, Lafosse et al.4 found only a trend without statistical significance between these parameters. Boughebri et al.32 examined patients with arthroscopically repaired small infraspinatus tears and showed that no correlation exists between tendon healing and patient satisfaction or shoulder function according to the Constant score, which is consistent with our results. What is quite interesting and refutes our hypothesis is that the elderly patients exhibited greater functional gain after rotator cuff repair than the younger patients based on the results of the modified Constant score. However, no difference was found for the improvement in Constant scores. This is certainly due to the age and sex modifications of the normalized Constant score. Thus, according to the results of our study, patients older than 70 years benefit from rotator cuff repair. However, our knowledge base is still evolving. There have been other studies that have proposed, because of muscle atrophy, tear size, and poor healing rates, that rotator cuff tears in elderly patients be treated with acromioplasty and biceps tenotomy alone. However, in a randomized study, Dezaly et al.34 showed that there is a benefit of repair in intermediate-size rotator cuff tears over acromioplasty and biceps tenotomy in patients older than 60 years, which supports our study’s findings. Limitations This is a multicenter study, signifying that there was not only 1 surgeon. However, all of the surgeons were experienced shoulder surgeons, and arthroscopic tendon-to-bone repair was performed in all cases. In addition, the same rehabilitation program was applied in all patients. Second, the evaluation of healing was performed by ultrasound, an operator-dependent examination, and not by the same radiologist. All ultrasound examinations took place in imaging centers specializing in musculoskeletal ultrasound and shoulder pathology. Third, the mean follow-up period was 12.9 months in group A and 13.8 months in group B. However, in all cases the latest evaluation took place at least 12 months postoperatively. It has been shown that a minimum of 6 months is appropriate to assess secure tendon healing.24,36 Moreover, Heikenfeld et al.37
AGE-RELATED CUFF REPAIR OUTCOMES
showed that after arthroscopic repair of subscapularis tears, there is no difference in the Constant score between 12 and 24 months postoperatively.
Conclusions Rotator cuff tears are characterized by greater retraction in the frontal plane and greater fatty infiltration in patients older than 70 years compared with patients younger than 50 years. After arthroscopic repair, healing is greater for patients younger than 50 years. Functional gain is at least equal between the 2 groups.
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14. Rebuzzi E, Coletti N, Schiavetti S, Giusto F. Arthroscopic rotator cuff repair in patients older than 60 years. Arthroscopy 2005;21:48-54. 15. Verma NN, Bhatia S, Baker CL III, et al. Outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older. Arthroscopy 2010;26:1273-1280. 16. Charousset C, Bellaïche L, Kalra K, Petrover D. Arthroscopic repair of full-thickness rotator cuff tears: Is there tendon healing in patients aged 65 years or older? Arthroscopy 2010;26:302-309. 17. Flurin PH, Hardy P, Abadie P, et al. French Arthroscopy Society (SFA). Arthroscopic repair of the rotator cuff: Prospective study of tendon healing after 70 years of age in 145 patients. Orthop Traumatol Surg Res 2013;99: S379-S384 (suppl). 18. Krishnan SG, Harkins DC, Schiffern SC, Pennington SD, Burkhead WZ. Arthroscopic repair of full-thickness tears of the rotator cuff in patients younger than 40 years. Arthroscopy 2008;24:324-328. 19. Lin EC, Mall NA, Dhawan A, et al. Arthroscopic primary rotator cuff repairs in patients aged younger than 45 years. Arthroscopy 2013;29:811-817. 20. Hawkins RJ, Morin WD, Bonutti PM. Surgical treatment of full-thickness rotator cuff tears in patients 40 years of age or younger. J Shoulder Elbow Surg 1999;8:259-265. 21. Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med 2012;31:589-604. 22. Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am 1983;65:456-460. 23. Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res 1990;254:81-86. 24. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 2007;89:1184-1193. 25. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;304:78-83. 26. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214: 160-164. 27. Katolik LI, Romeo AA, Cole BJ, Verma NN, Hayden JK, Bach BR. Normalization of the Constant score. J Shoulder Elbow Surg 2005;14:279-285. 28. Meyer DC, Farshad M, Amacker NA, Gerber C, Wieser K. Quantitative analysis of muscle and tendon retraction in chronic rotator cuff tears. Am J Sports Med 2012;40:606-610. 29. Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES. Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 1992;74:1505-1515. 30. 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. 31. Gerber C, Schneeberger AG, Hoppeler H, Meyer DC. Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: A study in thirteen patients. J Shoulder Elbow Surg 2007;16:691-696.
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32. Boughebri O, Roussignol X, Delattre O, Kany J, Valenti P. Small supraspinatus tears repaired by arthroscopy: Are clinical results influenced by the integrity of the cuff after two years? Functional and anatomic results of forty-six consecutive cases. J Shoulder Elbow Surg 2012;21: 699-706. 33. Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med 2012;40: 2242-2247. 34. Dezaly C, Sirveaux F, Philippe R, et al. Arthroscopic treatment of rotator cuff tear in the over-60s: Repair is preferable to isolated acromioplasty-tenotomy in the
short term. Orthop Traumatol Surg Res 2011;97: S125-S130. 35. Kukkonen J, Joukainen A, Lehtinen J, Aärimaa V. The effect of glenohumeral osteoarthritis on the outcome of isolated operatively treated supraspinatus tears. J Orthop Sci 2013;18:405-409. 36. Iannotti JP, 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. 37. Heikenfeld R, Gigis I, Chytas A, Listringhaus R, Godolias G. Arthroscopic reconstruction of isolated subscapularis tears: Clinical results and structural integrity after 24 months. Arthroscopy 2012;28:1805-1811.
