- Email: [email protected]
A new instrument to measure the activity profile of elderly shoulder pathology patients: The Senior Shoulder Activity score (SSA score)
Orthopaedics & Traumatology: Surgery & Research (2013) 99S, S367—S370
Available online at
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
A new instrument to measure the activity profile of elderly shoulder pathology patients: The Senior Shoulder Activity score (SSA score) J. Deranlot a,∗, P.-H. Flurin b, P. Hardy a, S. Klouche a , and the French Arthroscopy Society (SFA)c a
CHU Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France Clinique du Sport de Bordeaux-Mérignac, 2, rue Georges-Negrevergne, 33700 Mérignac, France c Cabinet médical, 18, rue Marbeuf, 75008 Paris, France b
Accepted: 9 October 2013
KEYWORDS Shoulder assessment; Quality of life; Senior activity level
∗
Summary Introduction: Whether rotator cuff repair is indicated in an elderly subject depends on the patient’s activity profile and functional demand. A Senior Shoulder Activity (SSA) score is described, as a support for indications and analysis of clinical results according to activity level. Material and method: The SSA score, comprising 4 levels from ‘‘sedentary’’ to ‘‘very active’’, was validated by comparison against a control group of 113 asymptomatic patients. It was included in the protocol of the French Arthroscopy Society’s comparative study of repair versus simple decompression in 143 rotator cuff tears. Recovery of activity was assessed according to procedure. Results: At 1-year follow-up, suturing was associated with recovery of previous activity level in 87% of the cases and in 80% for decompression, a non-significant difference. When, however, less active patients (SSA 1 and 2) were contrasted with the more active (SSA 3 and 4), clinical results with suture versus decompression on Constant score showed a greater difference in the SSA 3—4 group. Discussion: The SSA score is not the same as the activity item of the Constant score, as it assesses the patient’s usual activity level, before symptom onset, whereas the Constant item assesses activity at a given moment, independently of the patient’s normal activity profile. Conclusion: The Senior Shoulder Activity score is a simple, reproducible complement to the Constant score, revealing differences in clinical results on the latter, according to activity profile. Rotator cuff repair or simple decompression provided recovery of previous SSA activity
Corresponding author. E-mail address: [email protected] (J. Deranlot).
1877-0568/$ – see front matter © 2013 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.otsr.2013.10.004
S368
J. Deranlot et al. level in more than 80% of the cases. The difference in clinical results between the two was significantly greater in more active patients. It would seem to follow that suture is more beneficial for more active subjects while simple decompression may be suitable for those with lower functional demand. Level of evidence II: Prospective, randomized, low-power study. © 2013 Published by Elsevier Masson SAS.
Introduction Many studies have demonstrated better functional recovery with tendon repair than decompression alone in elderly patients with rotator cuff tear [1—10]. Population aging and the more active life of the elderly lead to higher expectations of functional recovery; the French Arthroscopy Society (SFA) therefore conducted a clinical study of rotator cuff repair in the over 70s. Some 40-shoulder assessment scales are to be found in the literature [11], but none are especially adapted for the elderly and none quantify an individual patient’s usual activity profile. We felt that it was important to be able to determine activity profiles, as they represent the patient’s functional demand and set the postoperative target [12]. We therefore drew up a Senior Shoulder Activity (SSA) score to assess shoulder function demand in the elderly and compare results between cuff suture and decompression in terms of resumption of activities in a comparative study for the SFA symposium.
The SSA score was of course incorporated in the SFA symposium’s prospective comparative study of cuff repair versus decompression. At the first consultation, the examiner sought to establish the patient’s activity level before the onset of cuff pathology, and it was reassessed at the final follow-up consultation at 1 year. Preliminary analysis checked activity level distribution homogeneity between the control (general population) and study patient groups. Secondly, the efficacy of the 2 types of treatment was analyzed in terms of individual recovery of pre-onset activity level. Finally, results in terms of Constant score were compared between suture and decompression at each level of activity [13—17], indicating suture for the more active patients and simple decompression in the more sedentary. IT data follow-up was performed by N. Richardet (Calimed, Marseille, France) and statistical analysis by M. Pitterman (CNRS, Aix-en-Provence, France). Correlation analysis used the non-parametric Kruskal—Wallis test. The significance threshold was set at P < 0.05.
Material and method
Population
Method
The control group comprised 113 patients, with a mean age of 78 years, with the following distribution: 15 patients (13%) level 1 (sedentary), 52 patients (46%) level 2 (occasionally active), 35 patients (31%) level 3 (active) and 11 patients (10%) level 4 (very active). The prospective randomized study of rotator cuff suture in over 70-year-olds comprised 143 patients (73 decompressions, 70 sutures), with a minimum 1-year’s follow-up, and a mean age of 74.6 years (± 3.3). Preoperative assessment focused on pre-onset activity level: there were (5%) at level 1 (sedentary), 54 (38%) at level 2 (occasionally active), 55 (38%) at level 3 (active) and 27 (19%) at level 4 (very active). Fig. 1 compares the control and comparison groups: activity level distribution appeared comparable (Fig. 1). Statistical analysis also found good homogeneity between suture and decompression groups, with respectively 2% and 8% level 1, 36% and 40% level 2, 38% and 38% level 3, and 17% and 10% level 4 (Fig. 2).
A preliminary survey of patients undergoing rotator cuff surgery identified a certain number of physical activities that are important to resume postoperatively for patients aged over 70 years: housework, handiwork, gardening and sports. These were classified into 4 levels, describing activity profiles ranging from most sedentary to most active: • level 1: sedentary: no housework, handiwork, gardening or sport involving the shoulder; • level 2: occasionally active: occasional light housework, handiwork and gardening, but no sport involving the shoulder; • level 3: active: daily housework, regular (2—3 times per week) gardening or handiwork, but no sport involving the shoulder; • level 4: very active: daily gardening or handiwork, and sports involving the shoulder. We then investigated whether the activity level distribution of rotator cuff tear patients matched that of the general population. SSA was scored in a control group of 113 asymptomatic patients aged more than 70 years, who were questioned in the waiting rooms of the various surgery departments taking part in the SFA symposium for a locomotor condition not involving the shoulder.
Results Recovery of activity level At latest follow-up, 16% of the overall comparison group (suture plus decompression) had fallen by 1 activity level, 65% had recovered their usual level and 19% had actually risen by 1 level over their previous situation: i.e., 84% of
Activity profile assessment in the elderly: The Senior Shoulder Activity score
S369
Table 1 Correlation between Constant score (mean ± SD) and activity level at 1 year.
Level Level Level Level Figure 1 level.
1 2 3 4
Postoperative weighted Constant score
P value
97.2 (± 17) 101.1 (± 17.6) 110.2 (± 11.2) 117.2 (± 10.8)
0.0001
Comparison versus control groups per SSA activity
Constant scores associated with the two techniques differed significantly in both activity level subgroups, but much more significantly in the ‘‘more active’’ group (SSA 3 and 4): tendon repair appeared to provide greater benefit for more active patients (Table 2).
Discussion
Figure 2
Suture versus decompression.
Figure 3
Recovery of activity level.
the patients, whether managed by suture or decompression, recovered their senior activity; suture allowed recovery in 87% of cases and decompression in 80%. This difference was not significant, but pointed to a tendency for better recovery with suture (Fig. 3).
Correlations between Constant and SSA scores SSA profile was compared to weighted Constant score at 1 year, revealing a strong correlation [13—17] (Table 1). To analyze differential clinical results in terms of Constant score [13—17] between suture and decompression with respect to activity level, the patients were grouped as less (levels 1 and 2) versus more active (levels 3 and 4).
Table 2
In 2005, in a meta-analysis of 1106 reports published between 1992 and 2002, Harvie et al. found 44 different shoulder scales [11]. These scores are well suited to assess individual clinical and functional results, but do not take account of patients’ usual activity profile, which nevertheless varies greatly from patient to patient. For the SFA symposium, the European Constant score [13—17] was associated to the American ASES [18,19] and SST [20] scores, plus the new SSA score which does not assess clinical results but allows estimation of functional recovery of the patient’s usual level of activity and comparison of results between differing activity profiles. In 2003, Kirkley et al. gave a precise description of 12 of the most widely used scores in clinical research [21]. None, however, were particularly adapted to the most elderly patients or took account of the importance of activity for the individual [11,21—30]. The SSA score might at first glance seem redundant with respect to the activity item of the Constant scale [13—17]. Preoperatively, the latter [13—17] assesses the degree of loss of activity against the patient’s baseline, whereas SSA ranks the patient’s usual activity before symptom onset. Postoperatively, the Constant activity item assesses recovery of usual activity [13—17], but without taking account of the sedentary versus active profile of the patient, whereas SSA reveals return to baseline, loss or gain. To establish a pre-onset SSA score in a patient consulting after onset, the assessor needs to direct the interview so that the present symptoms and functional impairment do not bias the estimate of the patient’s usual level of activity. As numbers in certain levels were small, 2 subpopulations (more versus less active) were defined so as
Mean Constant score for suture vs decompression according to SSA sub-group. Levels 1 + 2
Constant
Levels 3 + 4
Suture
Decompression
P value
Suture
Decompression
P value
75.62
69.02
0.018
82.66
77.35
0.0012
S370 to achieve sufficient power for significant differences to be able to emerge between suture and decompression in each.
Conclusion The Senior Shoulder Activity (SSA) score is a simple and reproducible complement to the Constant score, introducing an individual activity profile. It reveals differences in clinical results on Constant score according to activity level. Treatment, whether in the form of rotator cuff repair or decompression alone, restored the previous SSA activity level in more than 80% of over 70-year-old patients. The differential in clinical results between suture and decompression was significantly greater in patients graded as more active on SSA. It probably follows that rotator cuff suturing is of greater benefit in more active patients and that decompression alone may be sufficient in more sedentary patients with lower functional demand.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Worland RL, Arredondo J, Angles F, Lopez-Jimenez F. Repair of massive rotator cuff tears in patients older than 70 years. J Shoulder Elbow Surg 1999;8(1):26—30. [2] Grondel RJ, Savoie 3rd FH, Field LD. Rotator cuff repairs in patients 62 years of age or older. J Shoulder Elbow Surg 2001;10(2):97—9. [3] Rebuzzi E, Coletti N, Schiavetti S, Giusto F. Arthroscopic rotator cuff repair in patients older than 60 years. Arthroscopy 2005;21(1):48—54. [4] Fehringer EV, Sun J, VanOeveren LS, Keller BK, Matsen 3rd FA. Full thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older. J Shoulder Elbow Surg 2008;17(6):881—5. [5] Fehringer EV, Sun J, Cotton J, Carlson MJ, Burns EM. Healed cuff repairs impart normal shoulder scores in those 65 years of age and older. Clin Orthop Relat Res 2009;468(6):1521—5. [6] Verma NN, Bhatia S, Baker CL, 3rd, Cole BJ, Boniquit N, et al. Outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older. Arthroscopy 2010;26(10):1273—80. [7] Dezaly C, Sirveaux F, Philippe R, Wein-Remy F, Sedaghatian J, Roche O, et al. Arthroscopic treatment of rotator cuff tear in the over-60s: repair is preferable to isolated acromioplastytenotomy in the short term. Orthop Traumatol Surg Res 2011;97(6 Suppl):S125—30, 10.1016/j.otsr.2011.06.006. Epub 2011 Jul 27. [8] Downie BK, Miller BS. Treatment of rotator cuff tears in older individuals: a systematic review. J Shoulder Elbow Surg 2012;21:1255—61. [9] Djahangiri A, Cozzolino A, Zanetti M, Helmy N, Rufibach K, Jost B, et al. Outcome of single-tendon rotator cuff repair in patients aged older than 65 years. J Shoulder Elbow Surg 2013;22(1):45—51. [10] Robinson PM, Wilson J, Dalal S, Parker RA, Norburn P, Roy BR. Rotator cuff repair in patients over 70 years of age. Bone Joint J 2013;95—B(2):199—205.
J. Deranlot et al. [11] Harvie P, Pollard TCB, Chennagiri RJ, Carr AJ. The use of outcome scores in surgery of the shoulder. J Bone Joint Surg Br 2005;87—B:151—4. [12] Scarlat M, Florescu A. Scores fonctionnels de l’épaule asymptomatique dans une population de 180 patients âgés de plus de 75 ans. Rev Chir Orthop 2005;91:502—7. [13] Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160—4. [14] Conboy VB, Morris RW, Kiss J, Carr AJ. An evaluation of the Constant-Murley shoulder assessment. J Bone Joint Surg (Br) 1996;78—B:229—32. [15] Blonna D, Scelsi M, Marini E, Bellato E, Tellini A, Rossi R, et al. Can we improve the reliability of the Constant-Murley score? J Shoulder Elbow Surg 2012;21:4—12. [16] Kempf JF. Cotation fonctionnelle de l’épaule selon Constant. Encycl Med Chir 2001:3, Éditions scientifiques et Médicales Elsevier SAS, Paris Appareil locomoteur, Fa 14-001-M-10. [17] Livain T, Pichon H, Vermeulen J, Vaillant J, Saragaglia D, Poisson MF, et al. Étude de reproductibilité intra- et inter-observateur ¸aise du score de Constant au cours de la de la version franc rééducation des coiffes opérées. Rev Chir Orthop 2007;93: 142—9. [18] Kocher MS, Horan MP, Briggs KK, Richardson TR, O’Holeeran J, Hawkins RJ. Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease and glenohumeral arthritis. J Bone Joint Surg Am 2005;87(9):2006—11. [19] Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons standardized shoulder assessment form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg 2002;11:587—94. [20] Lippitt SB, Harryman DT, Matsen III FA. A practical tool for evaluating function: the simple shoulder test. In: Mattsen III FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility and stability. Rosemont: American Academy of Orthopaedic Surgeons; 1993. p. 519—29. [21] Kirkley A, Griffin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy 2003;19(10):1109—20. [22] Amstutz HC, Sew Hoy AL, Clarke IC. UCLA Anatomic total shoulder arthroplasty. Clin Orthop Relat Res 1981;155: 7—20. [23] Dawson J, Hill G, Fitzpatrick R, Carr A. The benefits of using patient-based methods of assessment. J Bone Joint Surg (Br) 2001;83—B:877—82. [24] Dawson J, Fitzpatrick R, Carr A. Questionnaire on the perceptions of patients about shoulder surgery. J Bone Joint Surg (Br) 1996;78—B:593—600. [25] L’Insalata JC, Warren RF, Cohen SB, Altcheck DW, Peterson MG. A self-administered questionnaire for assessment of symptoms and function of the shoulder. J Bone Joint Surg Am 1997;79(5):738—48. [26] Pynsent PB. Choosing an outcome measure. J Bone Joint Surg (Br) 2001;83—B:792—4. [27] Richards RR, An KN, Bigliani LU, Friedman RJn Gartsman GM, Gristina AG, Iannotti JP, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994;3(6):347—52. [28] Romeo AA, Mazzocca A, Hang DW, Shott S, Bach BR. Shoulder scoring scale for the evaluation of Rotator Cuff Repair. Clin Orthop Relat Res 2013;427:107—14. [29] Suk M, Norvel DC, Dettori JR, Helfet D. Evidence-based orthopaedic surgery: what is evidence without the outcomes? Perspectives on Moderns Orthopaedics, 16; 2008. p. 3. [30] Watson EM, Sonnabend DH. Outcome of rotator cuff repair. J Shoulder Elbow Surg 2002;11:201—11.
Available online at
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
A new instrument to measure the activity profile of elderly shoulder pathology patients: The Senior Shoulder Activity score (SSA score) J. Deranlot a,∗, P.-H. Flurin b, P. Hardy a, S. Klouche a , and the French Arthroscopy Society (SFA)c a
CHU Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France Clinique du Sport de Bordeaux-Mérignac, 2, rue Georges-Negrevergne, 33700 Mérignac, France c Cabinet médical, 18, rue Marbeuf, 75008 Paris, France b
Accepted: 9 October 2013
KEYWORDS Shoulder assessment; Quality of life; Senior activity level
∗
Summary Introduction: Whether rotator cuff repair is indicated in an elderly subject depends on the patient’s activity profile and functional demand. A Senior Shoulder Activity (SSA) score is described, as a support for indications and analysis of clinical results according to activity level. Material and method: The SSA score, comprising 4 levels from ‘‘sedentary’’ to ‘‘very active’’, was validated by comparison against a control group of 113 asymptomatic patients. It was included in the protocol of the French Arthroscopy Society’s comparative study of repair versus simple decompression in 143 rotator cuff tears. Recovery of activity was assessed according to procedure. Results: At 1-year follow-up, suturing was associated with recovery of previous activity level in 87% of the cases and in 80% for decompression, a non-significant difference. When, however, less active patients (SSA 1 and 2) were contrasted with the more active (SSA 3 and 4), clinical results with suture versus decompression on Constant score showed a greater difference in the SSA 3—4 group. Discussion: The SSA score is not the same as the activity item of the Constant score, as it assesses the patient’s usual activity level, before symptom onset, whereas the Constant item assesses activity at a given moment, independently of the patient’s normal activity profile. Conclusion: The Senior Shoulder Activity score is a simple, reproducible complement to the Constant score, revealing differences in clinical results on the latter, according to activity profile. Rotator cuff repair or simple decompression provided recovery of previous SSA activity
Corresponding author. E-mail address: [email protected] (J. Deranlot).
1877-0568/$ – see front matter © 2013 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.otsr.2013.10.004
S368
J. Deranlot et al. level in more than 80% of the cases. The difference in clinical results between the two was significantly greater in more active patients. It would seem to follow that suture is more beneficial for more active subjects while simple decompression may be suitable for those with lower functional demand. Level of evidence II: Prospective, randomized, low-power study. © 2013 Published by Elsevier Masson SAS.
Introduction Many studies have demonstrated better functional recovery with tendon repair than decompression alone in elderly patients with rotator cuff tear [1—10]. Population aging and the more active life of the elderly lead to higher expectations of functional recovery; the French Arthroscopy Society (SFA) therefore conducted a clinical study of rotator cuff repair in the over 70s. Some 40-shoulder assessment scales are to be found in the literature [11], but none are especially adapted for the elderly and none quantify an individual patient’s usual activity profile. We felt that it was important to be able to determine activity profiles, as they represent the patient’s functional demand and set the postoperative target [12]. We therefore drew up a Senior Shoulder Activity (SSA) score to assess shoulder function demand in the elderly and compare results between cuff suture and decompression in terms of resumption of activities in a comparative study for the SFA symposium.
The SSA score was of course incorporated in the SFA symposium’s prospective comparative study of cuff repair versus decompression. At the first consultation, the examiner sought to establish the patient’s activity level before the onset of cuff pathology, and it was reassessed at the final follow-up consultation at 1 year. Preliminary analysis checked activity level distribution homogeneity between the control (general population) and study patient groups. Secondly, the efficacy of the 2 types of treatment was analyzed in terms of individual recovery of pre-onset activity level. Finally, results in terms of Constant score were compared between suture and decompression at each level of activity [13—17], indicating suture for the more active patients and simple decompression in the more sedentary. IT data follow-up was performed by N. Richardet (Calimed, Marseille, France) and statistical analysis by M. Pitterman (CNRS, Aix-en-Provence, France). Correlation analysis used the non-parametric Kruskal—Wallis test. The significance threshold was set at P < 0.05.
Material and method
Population
Method
The control group comprised 113 patients, with a mean age of 78 years, with the following distribution: 15 patients (13%) level 1 (sedentary), 52 patients (46%) level 2 (occasionally active), 35 patients (31%) level 3 (active) and 11 patients (10%) level 4 (very active). The prospective randomized study of rotator cuff suture in over 70-year-olds comprised 143 patients (73 decompressions, 70 sutures), with a minimum 1-year’s follow-up, and a mean age of 74.6 years (± 3.3). Preoperative assessment focused on pre-onset activity level: there were (5%) at level 1 (sedentary), 54 (38%) at level 2 (occasionally active), 55 (38%) at level 3 (active) and 27 (19%) at level 4 (very active). Fig. 1 compares the control and comparison groups: activity level distribution appeared comparable (Fig. 1). Statistical analysis also found good homogeneity between suture and decompression groups, with respectively 2% and 8% level 1, 36% and 40% level 2, 38% and 38% level 3, and 17% and 10% level 4 (Fig. 2).
A preliminary survey of patients undergoing rotator cuff surgery identified a certain number of physical activities that are important to resume postoperatively for patients aged over 70 years: housework, handiwork, gardening and sports. These were classified into 4 levels, describing activity profiles ranging from most sedentary to most active: • level 1: sedentary: no housework, handiwork, gardening or sport involving the shoulder; • level 2: occasionally active: occasional light housework, handiwork and gardening, but no sport involving the shoulder; • level 3: active: daily housework, regular (2—3 times per week) gardening or handiwork, but no sport involving the shoulder; • level 4: very active: daily gardening or handiwork, and sports involving the shoulder. We then investigated whether the activity level distribution of rotator cuff tear patients matched that of the general population. SSA was scored in a control group of 113 asymptomatic patients aged more than 70 years, who were questioned in the waiting rooms of the various surgery departments taking part in the SFA symposium for a locomotor condition not involving the shoulder.
Results Recovery of activity level At latest follow-up, 16% of the overall comparison group (suture plus decompression) had fallen by 1 activity level, 65% had recovered their usual level and 19% had actually risen by 1 level over their previous situation: i.e., 84% of
Activity profile assessment in the elderly: The Senior Shoulder Activity score
S369
Table 1 Correlation between Constant score (mean ± SD) and activity level at 1 year.
Level Level Level Level Figure 1 level.
1 2 3 4
Postoperative weighted Constant score
P value
97.2 (± 17) 101.1 (± 17.6) 110.2 (± 11.2) 117.2 (± 10.8)
0.0001
Comparison versus control groups per SSA activity
Constant scores associated with the two techniques differed significantly in both activity level subgroups, but much more significantly in the ‘‘more active’’ group (SSA 3 and 4): tendon repair appeared to provide greater benefit for more active patients (Table 2).
Discussion
Figure 2
Suture versus decompression.
Figure 3
Recovery of activity level.
the patients, whether managed by suture or decompression, recovered their senior activity; suture allowed recovery in 87% of cases and decompression in 80%. This difference was not significant, but pointed to a tendency for better recovery with suture (Fig. 3).
Correlations between Constant and SSA scores SSA profile was compared to weighted Constant score at 1 year, revealing a strong correlation [13—17] (Table 1). To analyze differential clinical results in terms of Constant score [13—17] between suture and decompression with respect to activity level, the patients were grouped as less (levels 1 and 2) versus more active (levels 3 and 4).
Table 2
In 2005, in a meta-analysis of 1106 reports published between 1992 and 2002, Harvie et al. found 44 different shoulder scales [11]. These scores are well suited to assess individual clinical and functional results, but do not take account of patients’ usual activity profile, which nevertheless varies greatly from patient to patient. For the SFA symposium, the European Constant score [13—17] was associated to the American ASES [18,19] and SST [20] scores, plus the new SSA score which does not assess clinical results but allows estimation of functional recovery of the patient’s usual level of activity and comparison of results between differing activity profiles. In 2003, Kirkley et al. gave a precise description of 12 of the most widely used scores in clinical research [21]. None, however, were particularly adapted to the most elderly patients or took account of the importance of activity for the individual [11,21—30]. The SSA score might at first glance seem redundant with respect to the activity item of the Constant scale [13—17]. Preoperatively, the latter [13—17] assesses the degree of loss of activity against the patient’s baseline, whereas SSA ranks the patient’s usual activity before symptom onset. Postoperatively, the Constant activity item assesses recovery of usual activity [13—17], but without taking account of the sedentary versus active profile of the patient, whereas SSA reveals return to baseline, loss or gain. To establish a pre-onset SSA score in a patient consulting after onset, the assessor needs to direct the interview so that the present symptoms and functional impairment do not bias the estimate of the patient’s usual level of activity. As numbers in certain levels were small, 2 subpopulations (more versus less active) were defined so as
Mean Constant score for suture vs decompression according to SSA sub-group. Levels 1 + 2
Constant
Levels 3 + 4
Suture
Decompression
P value
Suture
Decompression
P value
75.62
69.02
0.018
82.66
77.35
0.0012
S370 to achieve sufficient power for significant differences to be able to emerge between suture and decompression in each.
Conclusion The Senior Shoulder Activity (SSA) score is a simple and reproducible complement to the Constant score, introducing an individual activity profile. It reveals differences in clinical results on Constant score according to activity level. Treatment, whether in the form of rotator cuff repair or decompression alone, restored the previous SSA activity level in more than 80% of over 70-year-old patients. The differential in clinical results between suture and decompression was significantly greater in patients graded as more active on SSA. It probably follows that rotator cuff suturing is of greater benefit in more active patients and that decompression alone may be sufficient in more sedentary patients with lower functional demand.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Worland RL, Arredondo J, Angles F, Lopez-Jimenez F. Repair of massive rotator cuff tears in patients older than 70 years. J Shoulder Elbow Surg 1999;8(1):26—30. [2] Grondel RJ, Savoie 3rd FH, Field LD. Rotator cuff repairs in patients 62 years of age or older. J Shoulder Elbow Surg 2001;10(2):97—9. [3] Rebuzzi E, Coletti N, Schiavetti S, Giusto F. Arthroscopic rotator cuff repair in patients older than 60 years. Arthroscopy 2005;21(1):48—54. [4] Fehringer EV, Sun J, VanOeveren LS, Keller BK, Matsen 3rd FA. Full thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older. J Shoulder Elbow Surg 2008;17(6):881—5. [5] Fehringer EV, Sun J, Cotton J, Carlson MJ, Burns EM. Healed cuff repairs impart normal shoulder scores in those 65 years of age and older. Clin Orthop Relat Res 2009;468(6):1521—5. [6] Verma NN, Bhatia S, Baker CL, 3rd, Cole BJ, Boniquit N, et al. Outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older. Arthroscopy 2010;26(10):1273—80. [7] Dezaly C, Sirveaux F, Philippe R, Wein-Remy F, Sedaghatian J, Roche O, et al. Arthroscopic treatment of rotator cuff tear in the over-60s: repair is preferable to isolated acromioplastytenotomy in the short term. Orthop Traumatol Surg Res 2011;97(6 Suppl):S125—30, 10.1016/j.otsr.2011.06.006. Epub 2011 Jul 27. [8] Downie BK, Miller BS. Treatment of rotator cuff tears in older individuals: a systematic review. J Shoulder Elbow Surg 2012;21:1255—61. [9] Djahangiri A, Cozzolino A, Zanetti M, Helmy N, Rufibach K, Jost B, et al. Outcome of single-tendon rotator cuff repair in patients aged older than 65 years. J Shoulder Elbow Surg 2013;22(1):45—51. [10] Robinson PM, Wilson J, Dalal S, Parker RA, Norburn P, Roy BR. Rotator cuff repair in patients over 70 years of age. Bone Joint J 2013;95—B(2):199—205.
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