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Rotator cuff surgery in patients older than 75 years with large and massive tears
ARTICLE IN PRESS J Shoulder Elbow Surg (2016) ■■, ■■–■■
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Rotator cuff surgery in patients older than 75 years with large and massive tears Hong Jun Jung, MD, Gyeong-Bo Sim, MD, Kun Hyung Bae, MD, Aashay L. Kekatpure, MBBS, DNB, Jae-Myeung Chun, MD, In-Ho Jeon, MD* Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, Seoul, Republic of Korea Background: The purpose of this study was to evaluate whether rotator cuff repair improves subjective and functional outcomes in patients aged ≥75 years. Methods: From May 2005 to March 2013, 121 elderly patients who underwent rotator cuff repair for large and massive rotator cuff tears were evaluated retrospectively. Patients with an American Society of Anesthesiologists physical status classification system grade ≥4 were excluded. The patients were evaluated using visual analog scales, subjective satisfaction surveys, American Shoulder and Elbow Surgeons scores, and Constant scores. The Katz index of activity of daily living (ADL) and functional independence measure motor score were used to evaluate ADLs. Postoperative magnetic resonance imaging (MRI) was performed to investigate the structural integrity of repaired cuffs. Results: In total, 64 patients were enrolled in the study; 80% were satisfied with their results. Visual analog scale scores improved from 6.4 to 2.3, American Shoulder and Elbow Surgeons scores from 42 to 84, and Constant scores from 42 to 76. Katz ADL scores improved from 3.4 to 5.0. Functional independence measure motor score improved from 22 to 51. Of the 64 patients, 46 underwent MRI 1 year postoperatively. Followup MRI revealed retears in 26% of patients. All patients with retears had improved subjective outcomes and functional scores. No patients died or experienced complications requiring intensive care or extended hospitalization. Conclusions: Surgical treatment for large to massive rotator cuff tears in elderly patients with American Society of Anesthesiologists grade <4 provides good functional outcomes without morbidity, even in those with retears. Level of evidence: Level IV; Case Series; Treatment Study © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Shoulder; rotator cuff tear; rotator cuff repair; retear; geriatric population; functional outcome; morbidity
The Institutional Review Board of Asan Medical Center approved this study: AMC IRB 2014-0478. *Reprint requests: In-Ho Jeon, MD, Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Republic of Korea. E-mail address: [email protected] (I.-H. Jeon).
Rotator cuff tears mostly occur as a result of the degenerative processes associated with aging. Burkhart and Tempelhof reported that >80% of the elderly population aged >80 years have rotator cuff tears.4,36 With increasing life expectancies in the developed world, quality of life is an important issue in the elderly population. Rotator cuff tears
1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2016.07.004
ARTICLE IN PRESS 2 cause pain, weakness, and stiffness, which can reduce the patient’s ability to carry out the activities of daily living (ADLs).32 According to some studies, the quality of life of patients with rotator cuff tears is comparable to that of patients with diabetes, myocardial infarction, or congestive heart failure.11,12,23,26 In elderly patients, rotator cuff tears are a major cause of depression because of the continuous shoulder pain and functional loss.23 Cho et al reported close relationships between chronic shoulder pain lasting >3 months and depression, anxiety, and sleep disturbances.6 There is still debate concerning operative intervention for elderly patients with rotator cuff tears because of the possible complication associated with general anesthesia and the surgery itself. Thus, surgical intervention for rotator cuff tears in elderly patients can be challenging and should be approached carefully and on an individual basis. In small tears (<1 cm),13 the risk of tear progression is minimal and reparability is not affected even if progression occurs, and it is therefore reasonable to attempt conservative treatment first.25 However, in tears larger than medium size (>1 cm),13 surgical intervention is generally considered to achieve better outcomes,33 but it is still underused in elderly patients owing to a lack of clinical evidence.16,19,27,36,39,42 This study was designed to evaluate the subjective and objective surgical outcomes of rotator cuff repair in patients aged ≥75 years with large to massive rotator cuff tears. We also aimed to assess the rates of morbidity and mortality associated with rotator cuff repair in this particular age group. To the best of our knowledge, research concerning this issue in this particular age group is limited. We hypothesized that with careful selection of patients using the American Society of Anesthesiologists (ASA) physical status classification system, elderly patients with large to massive rotator cuff tears can experience significant improvements in subjective and objective parameters without serious complications.
Materials and methods We searched our operative database for patients ≥75 years old who had received rotator cuff surgery with a diagnosis of large or massive rotator cuff tears between May 2005 and March 2013. A total of 121 patients were screened. We evaluated the patient’s preoperative medical condition before surgery using the ASA physical status classification system. The ASA physical status classification system categorizes a surgical candidate’s health into 6 grades of severity in ascending order30 (Table I). If patients had any severe diseases that were poorly controlled or in the end stage (ASA physical status ≥4), they were excluded as surgical candidates. For example, unstable angina or congestive heart failure with a left ventricular ejection fraction <25%, symptomatic chronic obstructive pulmonary disease, and hepatorenal syndrome were regarded as contraindications to surgery. We corrected hemoglobin level to a minimum of 9 g/dL and albumin level to a minimum of 3.0 g/dL. In the case of medical problems such as thyroid, neurovascular, or cardiovascular diseases, we consulted the relevant medical departments before surgery. We performed surgeries after all underlying medical problems had been addressed.
H.J. Jung et al. Table I system
American Society of Anesthesiologists (ASA) grading
Category
Description
1 2 3
Normal healthy patient Mild systemic disease with no functional limitation Severe systemic disease with definite functional limitation Severe systemic disease that is a constant threat to life Moribund patient not expected to survive 24 hours with or without surgery A declared brain-dead person whose organs are being removed for donor purposes
4 5 6
Figure 1
Flow chart for eligible patients. OA, osteoarthritis.
Surgical indications were (1) persistent shoulder pain and weakness unresponsive to at least 6 months of nonoperative treatment (which included anti-inflammatory medication, rehabilitation exercise, and activity modification), (2) large to massive full-thickness rotator cuff tears confirmed by magnetic resonance imaging (MRI) and physical examination, and (3) patients with ASA physical status <4 who were considered medically fit to undergo general anesthesia. The size of the rotator cuff tear was measured according to the classification of DeOrio and Cofield,13 and the tears were categorized as either large (3-5 cm) or massive (>5 cm). We evaluated medical records and excluded 10 patients with a history of previous shoulder infection, 5 noncooperative patients such as those with dementia, and 15 patients with advanced glenohumeral arthritis (Samilson-Prieto classification grades 2 and 3). Radiographic evaluation for glenohumeral arthritis of the shoulder was performed using the Samilson-Prieto method,34 which is known to have excellent interobserver agreement.2 Patients who were not followed up for at least 2 years were also excluded. Sixty-four patients were finally reviewed and analyzed (Fig. 1). Twenty-one patients were men (32.8%), and the mean age was 78.1 ± 4.2 years (range, 75-87 years). The mean postoperative follow-up period was 30.2 ± 5.2 months (range, 24-60 months). Thirty-five patients had large tears, and 29 patients had massive tears. Many patients had comorbidities, with hypertension being the most common (47 patients), followed by diabetes mellitus (31 patients), stable angina (12 patients), hypothyroidism (6 patients), and previous stroke (4 patients).
Surgical procedure and rehabilitation All surgeries were performed by a single senior surgeon (I.-H.J.) using an open procedure with the patients in the beach chair
ARTICLE IN PRESS Rotator cuff surgery in geriatric population
Figure 2
3
Intraoperative photograph of open rotator cuff repair using a double mattress suture technique.
position under general anesthesia. A 7-cm skin incision was made along the Langer lines from 1 cm medial to the coracoid process along the lateral-third margin of the acromion. The deltoid was split longitudinally between the anterior and middle deltoid, from the anterior edge of the acromion to a distance of 5 cm beyond the lateral edge of the acromion. Open acromioplasty was performed, and multiple traction sutures were subsequently placed into the lateral edge of the torn rotator cuff to assist mobilization. The bursa overlying the cuff was removed, and the retracted tendon was mobilized. If excess tension was still present, anterior and posterior release was considered. First, anterior release was performed using the rotator interval between the supraspinatus and subscapularis. If still tight, posterior release was performed between the posterior edge of the torn cuff and the intact cuff. Once adequately mobilized, the rotator cuff was repaired with multiple tendon-totendon repair sutures using No. 2 Ethibond (Ethicon, Cincinnati, OH, USA) and tendon-to-bone repair to the prepared greater tuberosity using transosseous rotator cuff repair with a double mattress suture technique (Fig. 2). All patients were admitted for surgery. After surgery, a shoulder abduction brace was applied for 7 to 8 weeks. The patients started passive forward elevation on the first postoperative day. On the third postoperative day, stretching exercises including pendulum exercises and passive external rotation were started. The average hospital stay was 4.6 days. After 4 weeks, pulley exercises to gain full forward elevation were started. Strengthening of the rotator cuff and periscapular muscle using TheraBand (Hygenic Corporation, Akron, OH, USA) and wall pushups were started immediately after removal of the shoulder abduction brace at postoperative week 8. Posterior capsular stretching exercises and internal rotation stretching were initiated after approximately 3 months of strengthening exercise.
Clinical evaluation Patients were regularly followed up in the outpatient clinic at 3, 6, 9, and 12 months. After 12 months, an annual checkup visit was recommended. During this period, we checked the morbidity, mortality, and readmission rates of the cohort. At the 12-month followup visit and annual visits thereafter, visual analog scale (VAS), patient satisfaction, functional, and ADL scores were documented. The VAS score was recorded preoperatively and yearly after surgery. For the subjective satisfaction survey, we asked the patients how satisfied they were with their results. The answers were
recorded as very satisfied, moderately satisfied, or not satisfied. We evaluated the functional outcomes of surgery using the American Shoulder and Elbow Surgeons (ASES) score and Constant score. Muscle power and range of motion were evaluated preoperatively and each year after the surgery. Muscle strength tests were performed using the Nottingham Mecmesin Myometer (Mecmesin Co, Nottingham, UK) separately for shoulder elevation and external rotation, and the values were recorded as percentages compared with the unaffected shoulder. Maximum shoulder elevation strength was measured with the patient in the seated position with the arm flexed to 90° in the scapular plane, and maximum external rotation strength was measured with the shoulder in a neutral position with the arm at the side and the elbow at 90° of flexion. Quality of life indices such as the Katz index of ADL (Katz ADL; Table II)20 and functional independence measure (FIM) motor score (Table III)18 were used to assess quality of life before and yearly after surgery. MRI evaluation was recommended to all patients at 12 months. Of the 64 patients, 46 underwent MRI at the 1-year follow-up. The remaining 18 patients were not available to undergo MRI. Radiologists trained in musculoskeletal MRI interpretation and a fellowship-trained shoulder surgeon who was independent from the index surgery evaluated the images. Fluid-filled signal changes in the repaired tendon were deemed to represent retears.
Statistical analysis A paired t-test was performed to analyze the difference between preoperative and postoperative strength, range of motion, and VAS, ASES, Constant, Katz ADL, and FIM scores. We also analyzed the differences between preoperative and postoperative outcomes in the retear group. Outcomes were compared between the intact group and the retear group. A P value < .05 with a 95% confidence interval was considered statistically significant.
Results The VAS scores improved from 6.4 ± 2.2 (range, 4-10) to 2.3 ± 1.1 (range, 0-5) postoperatively (P < .05). In the subjective satisfaction survey, 41% of the patients replied that they were very satisfied with the surgical outcome, 39% reported that they were moderately satisfied, and 20% reported
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H.J. Jung et al. Table II
Katz index of activity of daily living (Katz ADL)
Activity
Independence
1. 2. 3. 4. 5. 6.
Does not receive help or needs help for only part of the body Picks up clothes and dresses without any help, except for tying shoes Goes to the bathroom, uses the bathroom, dresses, and returns without any help (may use a cane or walker) Manages to lie down in the bed, sit in the chair, and get up without help (may use a cane or walker) Completely controls urine and feces Eats without help (except for cutting meat or buttering)
Bathe Dress Personal hygiene Mobility Continence Food
The number of points is the sum of yes answers: independence, 6 points; partial dependence, 4 points; important dependence, 2 points.
Table III
Functional independence measurement motor (FIM motor)
Categories
Items
Self-care
a. b. c. d. e. f. g. h. i. j. k. l. m.
Sphincter control Mobility
Locomotion
Eating Grooming Bathing Dress upper body Dress lower body Toileting Bladder management Bowel management Transfers—bed/chair/wheelchair Transfers—toilet Transfers—bath/shower Walking Stairs
7 points: Complete independence without helper 6 points: Modified independence (patient requires use of a device but no physical assistance) without helper 5 points: Supervision or setup with helper 4 points: Minimal contact assistance (patient can perform 75% or more of task) with helper 3 points: Moderate assistance (patient can perform 50% to 74% of task) with helper 2 points: Maximal assistance (patient can perform 25% to 49% of task) with helper 1 point: Total assistance (patient can perform <25% of the task or requires >1 person to assist) with helper Each item is scored on a 7-point ordinal scale, ranging from a score of 1 to a score of 7. The higher the score, the more independent the patient is in performing the task associated with that item. Tasks are rated on a 7-point ordinal scale that ranges from total assistance (or complete dependence) to complete independence. The total score for the FIM motor subscale (the sum of the individual motor subscale items) will be a value between 13 (lowest) and 91 (highest) indicating level of motor function.
that they were not satisfied. Most unsatisfied patients complained about the restriction of activity and rehabilitation period being longer than they had expected. ASES scores improved significantly from 42 ± 16 (range, 10-72) to 84 ± 8 (range, 50-93) postoperatively. Seventy percent of patients (45 cases) presented with functional scores >80. The Constant scores improved significantly from 44 ± 18 (range, 18-71) to 76 ± 7 (range, 68-92) postoperatively. The mean supraspinatus muscle strength increased from 51% ± 19% (range, 21%-92%) preoperatively to 78% ± 14% (range, 44%-113%) postoperatively, and external rotator muscle strength increased from 59% ± 14% (range, 22%-85%) to 81% ± 13% (range, 40%-105%). The improvements in supraspinatus and external rotator muscle strength were statistically significant. The mean range of active forward elevation increased from 101° ± 25° preoperatively to 132° ± 14°
postoperatively. The mean external rotation in the neutral position increased from 18° ± 11° preoperatively to 33° ± 7° postoperatively. Katz ADL score improved significantly from 3.4 ± 1.1 to 5.0 ± 0.8 postoperatively and mostly in bathing, dressing, and personal hygiene scores. FIM motor scores showed significant improvement from 25 ± 6 preoperatively to 54 ± 7 postoperatively, mainly in bathing, dressing, and transfers (Table IV). Follow-up MRI was performed in 46 patients at 1 year after the operation, and 12 patients (26%) were found to have retears. Retears occurred in 11 patients with massive tears and in 1 patient with a large tear. Postoperative strength, range of motion, and VAS, ASES, Constant, Katz ADL, and FIM motor scores improved significantly in both the intact and retear groups (Table V). Compared with the intact group, the retear group showed no significant differences with respect
ARTICLE IN PRESS Rotator cuff surgery in geriatric population
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Table IV Comparison between preoperative and postoperative VAS score, ASES score, Constant score, rotator cuff muscle strength, shoulder ROM, FIM motor, and Katz ADL score (N = 64)
VAS score ASES score Constant score Strength, SST (%) Strength, external rotator (%) ROM, FE (degrees) ROM, ER (degrees) Katz ADL FIM motor
Preoperative (mean ± SD)
Postoperative (mean ± SD)
P value
6.4 ± 2.2 42 ± 16 44 ± 18 51 ± 19 59 ± 14
2.3 ± 1.1 84 ± 8 76 ± 7 78 ± 14 81 ± 13
<.001 <.001 <.001 <.001 <.001
101 ± 25 18 ± 11 3.4 ± 1.1 25 ± 6
132 ± 14 33 ± 7 5.0 ± 0.8 54 ± 7
<.001 <.001 <.001 <.001
VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; SST, supraspinatus; ROM, range of motion; FE, forward elevation; ER, external rotation; Katz ADL, Katz index of activity of daily living; FIM motor, functional independence measurement motor; SD, standard deviation.
Table V Comparison between preoperative and postoperative VAS score, ASES score, Constant score, rotator cuff muscle strength, shoulder ROM, FIM motor, and Katz ADL score in retear group of patients (n = 12)
VAS score ASES score Constant score Strength, SST (%) Strength, external rotator (%) ROM, FE (degrees) ROM, ER (degrees) Katz ADL FIM motor
Preoperative (mean ± SD)
Postoperative (mean ± SD)
P value
6.7 ± 2.1 47 ± 19 45 ± 20 46 ± 16 52 ± 12
2.6 ± 1.3 78 ± 11 73 ± 12 77 ± 9 78 ± 10
.004 <.001 .011 <.001 <.001
107 ± 19 20 ± 13 3.7 ± 1.3 23 ± 5
137 ± 19 36 ± 4 5.2 ± 0.6 52 ± 6
<.001 <.001 .007 <.001
VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; SST, supraspinatus; ROM, range of motion; FE, forward elevation; ER, external rotation; Katz ADL, Katz index of activity of daily living; FIM motor, functional independence measurement motor; SD, standard deviation.
to range of motion and VAS, ASES, Constant, Katz ADL, and FIM scores. However, the retear group had weaker supraspinatus and external rotator muscle strength postoperatively than the intact group, although the difference was not statistically significant (Table VI). The perioperative mortality rate was 0%, and there were no significant perioperative complications requiring intensive care, delayed hospitalization, or readmission. There were no cases of complication associated with acromioplasty, such as acromial fracture or anterior superior escape of humeral head.
Discussion With life expectancy increasing, the elderly population has an increased need for improvements to their quality of life. However, rotator cuff tears frequently occur in elderly patients, as reported in many studies, and tear size and frequency are known to increase with age.4,10,19,22,35-37,41 Large to massive rotator cuff tears are common in elderly patients. However, surgical treatment is not always successful, and as a result there is uncertainty regarding the optimal treatment strategy for these patients.1,5,8 Charousset et al5 reported that arthroscopic rotator cuff repair was effective in 52% of patients aged >65 years. Boileau et al1 found that patients aged >65 years had a 43% chance of tendon healing, and patients >65 years with delamination of the subscapularis or the infraspinatus had an even lower rate of healing. In elderly patients, large to massive rotator cuff tears may develop into cuff tear arthropathy when neglected,3,17,31,40 and in such cases, patients may require reverse shoulder arthroplasty instead of the relatively less invasive rotator cuff repair. Although there are recent trends toward choosing reverse shoulder arthroplasty for cuff-deficient shoulders,14,29 we still believe that this method should be reserved for cuff tear arthropathy. We propose that rotator cuff repair can be performed safely for elderly patients when ASA grades are used as a guideline and strict preoperative medical management is applied. Thus, we performed this retrospective study to evaluate the efficacy and safety of rotator cuff repair for large and massive rotator cuff tears in elderly patients. Rotator cuff repair is the standard treatment for rotator cuff tears in young patients with acute traumatic injuries.19 In contrast, massive rotator cuff tears in elderly people often present as chronic tears. The natural history of the disease involves the rotator cuff losing its elasticity because of fatty infiltration and superior migration of the humeral head, leading to degenerative arthritis.16 These tears can compromise shoulder function and result in poor quality of life. The results of this study confirm these facts. Preoperative Katz ADL and FIM scores averaged 3.4 ± 1.1 and 25 ± 6 and were particularly low for bathing, dressing, and personal hygiene. Despite these problems, elderly patients tend to avoid surgical intervention because of uncertainty concerning the outcomes and fear of postoperative complications. However, the morbidity, mortality, and readmission rates were 0% when the surgical interventions were performed under the preoperation guidelines used at our center. Under vigilant operative and postoperative care, we demonstrated good functional outcomes and improvements in quality of life postoperatively. Although 20% of the patients felt subjectively that they were not satisfied with the results of surgical intervention, the overall results showed that functional outcomes were significantly improved. Another finding of our study was that using ASA grades and correcting the preoperative general medical condition helped to minimize mortality, postoperative morbidity, and complications postoperatively. In our study, we excluded
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H.J. Jung et al. Table VI Comparison of preoperative and postoperative VAS score, ASES score, Constant score, rotator cuff muscle strength, shoulder ROM, FIM motor, and Katz ADL score between the intact and retear groups Intact (n = 42) VAS score ASES score Constant score Strength, SST (%) Strength, external rotator (%) ROM, FE (degrees) ROM, ER (degrees) Katz ADL FIM motor
Retear (n = 12)
P value (intact vs. retear)
Preoperative
Postoperative
P value
Preoperative
Postoperative
P value
Preoperative
Postoperative
6.1 ± 1.7 49 ± 14 46 ± 15 58 ± 21 64 ± 23
2.3 ± 1.2 85 ± 10 77 ± 4 84 ± 17 86 ± 20
<.001 <.001 <.001 <.001 <.001
6.7 ± 2.1 47 ± 19 45 ± 20 46 ± 16 52 ± 12
2.6 ± 1.3 78 ± 11 73 ± 12 77 ± 9 78 ± 10
.004 <.001 .011 <.001 <.001
.475 .388 .216 .217 .060
.642 .843 .169 .021* .039*
124 ± 18 30 ± 10 3.5 ± 1.6 26 ± 5
143 ± 13 38 ± 11 5.4 ± 0.7 58 ± 8
<.001 <.001 <.001 <.001
107 ± 19 20 ± 13 3.7 ± 1.3 23 ± 5
137 ± 19 36 ± 4 5.2 ± 0.6 52 ± 6
<.001 <.001 .007 <.001
.134 .216 .231 .138
.344 .278 .412 .216
VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; SST, supraspinatus; ROM, range of motion; FE, forward elevation; ER, external rotation; Katz ADL, Katz index of activity of daily living; FIM motor, functional independence measurement motor. * Statistically significant, P < .05.
patients in poor general medical condition (ASA grade ≥4) and managed the patients before surgery; we corrected hemoglobin level to a minimum of 9 g/dL and albumin level to a minimum of 3.0 g/dL and performed preoperative consultations for underlying medical conditions such as thyroid, neurovascular, or cardiovascular problems. Under our strict guidelines, there were no cases of mortality and no significant complications like cardiovascular event or pulmonary embolism postoperatively. On the basis of our results, we think that patients ≥75 years old can be safely treated with surgery if the aforementioned guidelines are followed. Worland et al39 evaluated the open repair of massive rotator cuff tears in 69 patients older than 70 years. They reported satisfactory results in 78.3% of patients, with improvements in University of California–Los Angeles (UCLA) scores from 9.4 preoperatively to 30.9 at the final follow-up. Furthermore, 79.7% of patients (55 patients) achieved good bonetendon repair. Yel et al42 evaluated 51 shoulders in patients >65 years old and reported satisfactory results in 94.1% of patients, a Constant score of 82 points, and excellent and satisfactory results in 90% of patients using the Neer scale. The authors focused only on shoulder and elbow scores rather than on quality of life in the perioperative period. In contrast, in our study, we evaluated not only subjective and functional outcomes and the structural integrity of repaired tendon but also Katz ADL and FIM motor scores, representing a more comprehensive assessment of outcomes. Débridement and subacromial decompression have been suggested as effective alternative treatments for chronic rotator cuff tears, but these methods have been shown to be ineffective in mitigating long-term pain and improving functional ability in some studies.27,28,38 In contrast to our study, these previous reports did not focus on elderly patients. In our study, we found significant improvements in functional outcomes after rotator cuff repair and subacromial decompression.
MRI is used to evaluate rotator cuff tendon integrity and retear size after surgery because it can be performed noninvasively and is more accurate than arthrography. In this study, we assessed the occurrence of retears using MRI 1 year after surgery. In a recent study evaluating the repaired cuff integrity after arthroscopic suture bridge technique, 53.3% of patients with massive cuff tears showed retearing on followup MRI.7 It is unclear how retears affect clinical outcomes, but it is generally thought that clinical outcomes still improve despite retearing. Klepps et al21 reported that postoperative cuff integrity did not have a significant effect on outcomes compared with intact cuffs in 32 patients. Liu and Baker24 also demonstrated that repair integrity did not influence functional outcomes. In contrast, Flurin et al15 reported that retorn cuffs were associated with worse overall Constant and ASES scores. Cole et al9 reported that range of motion and muscle strength were inversely correlated with recurrent tears. Yoo et al43 reported that the physical components of the 36-Item Short Form Health Survey as well as the UCLA and ASES scores were significantly higher in the healed group, even though there was no significant difference in mental component summary scores. Thus, controversy persists concerning whether structural integrity affects functional outcomes. In our study, all clinical outcomes improved in the retear group; however, muscle power was significantly lower compared with that in the intact cuff group, although the clinical significance of this difference is questionable. In our study, all clinical results except for muscle power improved in the retear group in patients who underwent open acromioplasty and rotator cuff repair. We believe that structural integrity after cuff repair did not affect clinical outcomes in the patients in this study. However, regarding the risk of progression to cuff tear arthropathy, patients with massive retears may experience problems in the future, and longer follow-up will be necessary for these patients.
ARTICLE IN PRESS Rotator cuff surgery in geriatric population Being retrospective in nature, this study has some inherent limitations. First, not all patients agreed to undergo MRI after surgery. However, our finding that patients who had retears still experienced significant improvements is consistent with the results of other studies, and the results would not be different if all patients had agreed to undergo MRI. Second, all patients received surgery at a tertiary university hospital, so this group of patients may not represent the general elderly community. Third, we excluded patients with ASA grades ≥4 before surgery, so we have no data related to these patients. Fourth, we did not use a matched control group and therefore could not make comparisons between surgical and conservative treatment. However, this study is one of the few studies that have attempted to evaluate functional outcomes and quality of life indices in elderly patients after rotator cuff repair, and the results are therefore important in the context of current clinical practice.
Conclusion Satisfactory functional outcomes, quality of life, and pain relief can be achieved with rotator cuff repair in elderly patients with large to massive rotator cuff tears. Careful preoperative examination, surgical intervention, and postoperative management can help achieve good functional outcomes.
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Disclaimer
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The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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disturbance? J Shoulder Elbow Surg 2013;22:222-8. http://dx.doi.org/ 10.1016/j.jse.2012.04.001 Choi S, Kim MK, Kim GM, Roh YH, Hwang IK, Kang H. Factors associated with clinical and structural outcomes after arthroscopic rotator cuff repair with a suture bridge technique in medium, large, and massive tears. J Shoulder Elbow Surg 2014;23:1675-81. http://dx.doi.org/10.1016/ j.jse.2014.02.021 Cofield RH. Rotator cuff disease of the shoulder. J Bone Joint Surg Am 1985;67:974-9. Cole BJ, McCarty LP 3rd, Kang RW, Alford W, Lewis PB, Hayden JK. Arthroscopic rotator cuff repair: prospective functional outcome and repair integrity at minimum 2-year follow-up. J Shoulder Elbow Surg 2007;16:579-85. http://dx.doi.org/10.1016/j.jse.2006.12.011 Cordasco FA, Bigliani LU. The rotator cuff. Large and massive tears. Technique of open repair. Orthop Clin North Am 1997;28:179-93. Das-Munshi J, Stewart R, Ismail K, Bebbington PE, Jenkins R, Prince MJ. Diabetes, common mental disorders, and disability: findings from the UK National Psychiatric Morbidity Survey. Psychosom Med 2007;69:543-50. http://dx.doi.org/10.1097/PSY.0b013e3180cc3062 de Jonge P, Spijkerman TA, van den Brink RH, Ormel J. Depression after myocardial infarction is a risk factor for declining health related quality of life and increased disability and cardiac complaints at 12 months. Heart 2006;92:32-9. http://dx.doi.org/10.1136/hrt.2004.059451 DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am 1984;66: 563-7. Ek ET, Neukom L, Catanzaro S, Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elbow Surg 2013;22:1199-208. http://dx.doi.org/10.1016/j.jse.2012.11.016 Flurin PH, Hardy P, Abadie P, Boileau P, Collin P, Deranlot J, et al. 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:S379-84. http://dx.doi.org/10.1016/j.otsr.2013.10.007 Gerber C, Wirth SH, Farshad M. Treatment options for massive rotator cuff tears. J Shoulder Elbow Surg 2011;20:S20-9. http://dx.doi.org/ 10.1016/j.jse.2010.11.028 Halder AM, Zhao KD, Odriscoll SW, Morrey BF, An KN. Dynamic contributions to superior shoulder stability. J Orthop Res 2001;19:206-12. Hamilton BB, Granger CV, Sherwin FS. A uniform national data system for medical rehabilitation. In: Fuhrer MJ, editor. Rehabilitation outcomes: analysis and measurement. Baltimore: Brookes; 1987. p. 137-47 ISBN 9780933716773. Hattrup SJ. Rotator cuff repair: relevance of patient age. J Shoulder Elbow Surg 1995;4:95-100. Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc 1983;31:7217. Klepps S, Bishop J, Lin J, Cahlon O, Strauss A, Hayes P, et al. Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs. Am J Sports Med 2004;32:1716-22. http://dx.doi.org/10.1177/0363546504265262 Lehman C, Cuomo F, Kummer FJ, Zuckerman JD. The incidence of full thickness rotator cuff tears in a large cadaveric population. Bull Hosp Jt Dis 1995;54:30-1. Lépine JP, Briley M. The increasing burden of depression. Neuropsychiatr Dis Treat 2011;7:3-7. http://dx.doi.org/10.2147/ NDT.S19617 Liu SH, Baker CL. Arthroscopically assisted rotator cuff repair: correlation of functional results with integrity of the cuff. Arthroscopy 1994;10:54-60. Maman E, Harris C, White L, Tomlinson G, Shashank M, Boynton E. Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. J Bone Joint Surg Am 2009;91:1898-906. http://dx.doi.org/10.2106/JBJS.G.01335 Masoudi FA, Rumsfeld JS, Havranek EP, House JA, Peterson ED, Krumholz HM, et al. Age, functional capacity, and health-related quality
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H.J. Jung et al. of life in patients with heart failure. J Card Fail 2004;10:368-73. http://dx.doi.org/10.1016/j.cardfail.2004.01.009 Melillo AS, Savoie FH 3rd, Field LD. Massive rotator cuff tears: debridement versus repair. Orthop Clin North Am 1997;28:11724. Montgomery TJ, Yerger B, Savoie FH 3rd. Management of rotator cuff tears: a comparison of arthroscopic debridement and surgical repair. J Shoulder Elbow Surg 1994;3:70-8. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am 2010;92:2544-56. http://dx.doi.org/10.2106/JBJS.I.00912 Owens WD. American Society of Anesthesiologists Physical Status Classification System in not a risk classification system. Anesthesiology 2001;94:378. Parsons IM, Apreleva M, Fu FH, Woo SL. The effect of rotator cuff tears on reaction forces at the glenohumeral joint. J Orthop Res 2002;20:439-46. http://dx.doi.org/10.1016/S0736-0266(01)00137-1 Razmjou H, Bean A, van Osnabrugge V, MacDermid JC, Holtby R. Cross-sectional and longitudinal construct validity of two rotator cuff disease–specific outcome measures. BMC Musculoskelet Disord 2006;7:26. http://dx.doi.org/10.1186/1471-2474-7-26 Safran O, Schroeder J, Bloom R, Weil Y, Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med 2011;39:710-4. http://dx.doi.org/ 10.1177/0363546510393944 Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am 1983;65:456-60.
35. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-5. 36. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-9. 37. Uhthoff HK, Sano H. Pathology of failure of the rotator cuff tendon. Orthop Clin North Am 1997;28:31-41. 38. Weber SC. Arthroscopic debridement and acromioplasty versus miniopen repair in the management of significant partial-thickness tears of the rotator cuff. Orthop Clin North Am 1997;28:79-82. 39. 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;8:26-30. 40. Yamaguchi K, Sher JS, Andersen WK, Garretson R, Uribe JW, Hechtman K, et al. Glenohumeral motion in patients with rotator cuff tears: a comparison of asymptomatic and symptomatic shoulders. J Shoulder Elbow Surg 2000;9:6-11. 41. Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 2001;10:199-203. 42. Yel M, Shankwiler JA, Noonan JE Jr, Burkhead WZ Jr. Results of decompression and rotator cuff repair in patients 65 years old and older: 6- to 14-year follow-up. Am J Orthop 2001;30:347-52. 43. Yoo JH, Cho NS, Rhee YG. Effect of postoperative repair integrity on health-related quality of life after rotator cuff repair: healed versus retear group. Am J Sports Med 2013;41:2637-44. http://dx.doi.org/10.1177/ 0363546513499152
www.elsevier.com/locate/ymse
Rotator cuff surgery in patients older than 75 years with large and massive tears Hong Jun Jung, MD, Gyeong-Bo Sim, MD, Kun Hyung Bae, MD, Aashay L. Kekatpure, MBBS, DNB, Jae-Myeung Chun, MD, In-Ho Jeon, MD* Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, Seoul, Republic of Korea Background: The purpose of this study was to evaluate whether rotator cuff repair improves subjective and functional outcomes in patients aged ≥75 years. Methods: From May 2005 to March 2013, 121 elderly patients who underwent rotator cuff repair for large and massive rotator cuff tears were evaluated retrospectively. Patients with an American Society of Anesthesiologists physical status classification system grade ≥4 were excluded. The patients were evaluated using visual analog scales, subjective satisfaction surveys, American Shoulder and Elbow Surgeons scores, and Constant scores. The Katz index of activity of daily living (ADL) and functional independence measure motor score were used to evaluate ADLs. Postoperative magnetic resonance imaging (MRI) was performed to investigate the structural integrity of repaired cuffs. Results: In total, 64 patients were enrolled in the study; 80% were satisfied with their results. Visual analog scale scores improved from 6.4 to 2.3, American Shoulder and Elbow Surgeons scores from 42 to 84, and Constant scores from 42 to 76. Katz ADL scores improved from 3.4 to 5.0. Functional independence measure motor score improved from 22 to 51. Of the 64 patients, 46 underwent MRI 1 year postoperatively. Followup MRI revealed retears in 26% of patients. All patients with retears had improved subjective outcomes and functional scores. No patients died or experienced complications requiring intensive care or extended hospitalization. Conclusions: Surgical treatment for large to massive rotator cuff tears in elderly patients with American Society of Anesthesiologists grade <4 provides good functional outcomes without morbidity, even in those with retears. Level of evidence: Level IV; Case Series; Treatment Study © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Shoulder; rotator cuff tear; rotator cuff repair; retear; geriatric population; functional outcome; morbidity
The Institutional Review Board of Asan Medical Center approved this study: AMC IRB 2014-0478. *Reprint requests: In-Ho Jeon, MD, Department of Orthopaedic Surgery, Asan Medical Center, School of Medicine, University of Ulsan, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Republic of Korea. E-mail address: [email protected] (I.-H. Jeon).
Rotator cuff tears mostly occur as a result of the degenerative processes associated with aging. Burkhart and Tempelhof reported that >80% of the elderly population aged >80 years have rotator cuff tears.4,36 With increasing life expectancies in the developed world, quality of life is an important issue in the elderly population. Rotator cuff tears
1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2016.07.004
ARTICLE IN PRESS 2 cause pain, weakness, and stiffness, which can reduce the patient’s ability to carry out the activities of daily living (ADLs).32 According to some studies, the quality of life of patients with rotator cuff tears is comparable to that of patients with diabetes, myocardial infarction, or congestive heart failure.11,12,23,26 In elderly patients, rotator cuff tears are a major cause of depression because of the continuous shoulder pain and functional loss.23 Cho et al reported close relationships between chronic shoulder pain lasting >3 months and depression, anxiety, and sleep disturbances.6 There is still debate concerning operative intervention for elderly patients with rotator cuff tears because of the possible complication associated with general anesthesia and the surgery itself. Thus, surgical intervention for rotator cuff tears in elderly patients can be challenging and should be approached carefully and on an individual basis. In small tears (<1 cm),13 the risk of tear progression is minimal and reparability is not affected even if progression occurs, and it is therefore reasonable to attempt conservative treatment first.25 However, in tears larger than medium size (>1 cm),13 surgical intervention is generally considered to achieve better outcomes,33 but it is still underused in elderly patients owing to a lack of clinical evidence.16,19,27,36,39,42 This study was designed to evaluate the subjective and objective surgical outcomes of rotator cuff repair in patients aged ≥75 years with large to massive rotator cuff tears. We also aimed to assess the rates of morbidity and mortality associated with rotator cuff repair in this particular age group. To the best of our knowledge, research concerning this issue in this particular age group is limited. We hypothesized that with careful selection of patients using the American Society of Anesthesiologists (ASA) physical status classification system, elderly patients with large to massive rotator cuff tears can experience significant improvements in subjective and objective parameters without serious complications.
Materials and methods We searched our operative database for patients ≥75 years old who had received rotator cuff surgery with a diagnosis of large or massive rotator cuff tears between May 2005 and March 2013. A total of 121 patients were screened. We evaluated the patient’s preoperative medical condition before surgery using the ASA physical status classification system. The ASA physical status classification system categorizes a surgical candidate’s health into 6 grades of severity in ascending order30 (Table I). If patients had any severe diseases that were poorly controlled or in the end stage (ASA physical status ≥4), they were excluded as surgical candidates. For example, unstable angina or congestive heart failure with a left ventricular ejection fraction <25%, symptomatic chronic obstructive pulmonary disease, and hepatorenal syndrome were regarded as contraindications to surgery. We corrected hemoglobin level to a minimum of 9 g/dL and albumin level to a minimum of 3.0 g/dL. In the case of medical problems such as thyroid, neurovascular, or cardiovascular diseases, we consulted the relevant medical departments before surgery. We performed surgeries after all underlying medical problems had been addressed.
H.J. Jung et al. Table I system
American Society of Anesthesiologists (ASA) grading
Category
Description
1 2 3
Normal healthy patient Mild systemic disease with no functional limitation Severe systemic disease with definite functional limitation Severe systemic disease that is a constant threat to life Moribund patient not expected to survive 24 hours with or without surgery A declared brain-dead person whose organs are being removed for donor purposes
4 5 6
Figure 1
Flow chart for eligible patients. OA, osteoarthritis.
Surgical indications were (1) persistent shoulder pain and weakness unresponsive to at least 6 months of nonoperative treatment (which included anti-inflammatory medication, rehabilitation exercise, and activity modification), (2) large to massive full-thickness rotator cuff tears confirmed by magnetic resonance imaging (MRI) and physical examination, and (3) patients with ASA physical status <4 who were considered medically fit to undergo general anesthesia. The size of the rotator cuff tear was measured according to the classification of DeOrio and Cofield,13 and the tears were categorized as either large (3-5 cm) or massive (>5 cm). We evaluated medical records and excluded 10 patients with a history of previous shoulder infection, 5 noncooperative patients such as those with dementia, and 15 patients with advanced glenohumeral arthritis (Samilson-Prieto classification grades 2 and 3). Radiographic evaluation for glenohumeral arthritis of the shoulder was performed using the Samilson-Prieto method,34 which is known to have excellent interobserver agreement.2 Patients who were not followed up for at least 2 years were also excluded. Sixty-four patients were finally reviewed and analyzed (Fig. 1). Twenty-one patients were men (32.8%), and the mean age was 78.1 ± 4.2 years (range, 75-87 years). The mean postoperative follow-up period was 30.2 ± 5.2 months (range, 24-60 months). Thirty-five patients had large tears, and 29 patients had massive tears. Many patients had comorbidities, with hypertension being the most common (47 patients), followed by diabetes mellitus (31 patients), stable angina (12 patients), hypothyroidism (6 patients), and previous stroke (4 patients).
Surgical procedure and rehabilitation All surgeries were performed by a single senior surgeon (I.-H.J.) using an open procedure with the patients in the beach chair
ARTICLE IN PRESS Rotator cuff surgery in geriatric population
Figure 2
3
Intraoperative photograph of open rotator cuff repair using a double mattress suture technique.
position under general anesthesia. A 7-cm skin incision was made along the Langer lines from 1 cm medial to the coracoid process along the lateral-third margin of the acromion. The deltoid was split longitudinally between the anterior and middle deltoid, from the anterior edge of the acromion to a distance of 5 cm beyond the lateral edge of the acromion. Open acromioplasty was performed, and multiple traction sutures were subsequently placed into the lateral edge of the torn rotator cuff to assist mobilization. The bursa overlying the cuff was removed, and the retracted tendon was mobilized. If excess tension was still present, anterior and posterior release was considered. First, anterior release was performed using the rotator interval between the supraspinatus and subscapularis. If still tight, posterior release was performed between the posterior edge of the torn cuff and the intact cuff. Once adequately mobilized, the rotator cuff was repaired with multiple tendon-totendon repair sutures using No. 2 Ethibond (Ethicon, Cincinnati, OH, USA) and tendon-to-bone repair to the prepared greater tuberosity using transosseous rotator cuff repair with a double mattress suture technique (Fig. 2). All patients were admitted for surgery. After surgery, a shoulder abduction brace was applied for 7 to 8 weeks. The patients started passive forward elevation on the first postoperative day. On the third postoperative day, stretching exercises including pendulum exercises and passive external rotation were started. The average hospital stay was 4.6 days. After 4 weeks, pulley exercises to gain full forward elevation were started. Strengthening of the rotator cuff and periscapular muscle using TheraBand (Hygenic Corporation, Akron, OH, USA) and wall pushups were started immediately after removal of the shoulder abduction brace at postoperative week 8. Posterior capsular stretching exercises and internal rotation stretching were initiated after approximately 3 months of strengthening exercise.
Clinical evaluation Patients were regularly followed up in the outpatient clinic at 3, 6, 9, and 12 months. After 12 months, an annual checkup visit was recommended. During this period, we checked the morbidity, mortality, and readmission rates of the cohort. At the 12-month followup visit and annual visits thereafter, visual analog scale (VAS), patient satisfaction, functional, and ADL scores were documented. The VAS score was recorded preoperatively and yearly after surgery. For the subjective satisfaction survey, we asked the patients how satisfied they were with their results. The answers were
recorded as very satisfied, moderately satisfied, or not satisfied. We evaluated the functional outcomes of surgery using the American Shoulder and Elbow Surgeons (ASES) score and Constant score. Muscle power and range of motion were evaluated preoperatively and each year after the surgery. Muscle strength tests were performed using the Nottingham Mecmesin Myometer (Mecmesin Co, Nottingham, UK) separately for shoulder elevation and external rotation, and the values were recorded as percentages compared with the unaffected shoulder. Maximum shoulder elevation strength was measured with the patient in the seated position with the arm flexed to 90° in the scapular plane, and maximum external rotation strength was measured with the shoulder in a neutral position with the arm at the side and the elbow at 90° of flexion. Quality of life indices such as the Katz index of ADL (Katz ADL; Table II)20 and functional independence measure (FIM) motor score (Table III)18 were used to assess quality of life before and yearly after surgery. MRI evaluation was recommended to all patients at 12 months. Of the 64 patients, 46 underwent MRI at the 1-year follow-up. The remaining 18 patients were not available to undergo MRI. Radiologists trained in musculoskeletal MRI interpretation and a fellowship-trained shoulder surgeon who was independent from the index surgery evaluated the images. Fluid-filled signal changes in the repaired tendon were deemed to represent retears.
Statistical analysis A paired t-test was performed to analyze the difference between preoperative and postoperative strength, range of motion, and VAS, ASES, Constant, Katz ADL, and FIM scores. We also analyzed the differences between preoperative and postoperative outcomes in the retear group. Outcomes were compared between the intact group and the retear group. A P value < .05 with a 95% confidence interval was considered statistically significant.
Results The VAS scores improved from 6.4 ± 2.2 (range, 4-10) to 2.3 ± 1.1 (range, 0-5) postoperatively (P < .05). In the subjective satisfaction survey, 41% of the patients replied that they were very satisfied with the surgical outcome, 39% reported that they were moderately satisfied, and 20% reported
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H.J. Jung et al. Table II
Katz index of activity of daily living (Katz ADL)
Activity
Independence
1. 2. 3. 4. 5. 6.
Does not receive help or needs help for only part of the body Picks up clothes and dresses without any help, except for tying shoes Goes to the bathroom, uses the bathroom, dresses, and returns without any help (may use a cane or walker) Manages to lie down in the bed, sit in the chair, and get up without help (may use a cane or walker) Completely controls urine and feces Eats without help (except for cutting meat or buttering)
Bathe Dress Personal hygiene Mobility Continence Food
The number of points is the sum of yes answers: independence, 6 points; partial dependence, 4 points; important dependence, 2 points.
Table III
Functional independence measurement motor (FIM motor)
Categories
Items
Self-care
a. b. c. d. e. f. g. h. i. j. k. l. m.
Sphincter control Mobility
Locomotion
Eating Grooming Bathing Dress upper body Dress lower body Toileting Bladder management Bowel management Transfers—bed/chair/wheelchair Transfers—toilet Transfers—bath/shower Walking Stairs
7 points: Complete independence without helper 6 points: Modified independence (patient requires use of a device but no physical assistance) without helper 5 points: Supervision or setup with helper 4 points: Minimal contact assistance (patient can perform 75% or more of task) with helper 3 points: Moderate assistance (patient can perform 50% to 74% of task) with helper 2 points: Maximal assistance (patient can perform 25% to 49% of task) with helper 1 point: Total assistance (patient can perform <25% of the task or requires >1 person to assist) with helper Each item is scored on a 7-point ordinal scale, ranging from a score of 1 to a score of 7. The higher the score, the more independent the patient is in performing the task associated with that item. Tasks are rated on a 7-point ordinal scale that ranges from total assistance (or complete dependence) to complete independence. The total score for the FIM motor subscale (the sum of the individual motor subscale items) will be a value between 13 (lowest) and 91 (highest) indicating level of motor function.
that they were not satisfied. Most unsatisfied patients complained about the restriction of activity and rehabilitation period being longer than they had expected. ASES scores improved significantly from 42 ± 16 (range, 10-72) to 84 ± 8 (range, 50-93) postoperatively. Seventy percent of patients (45 cases) presented with functional scores >80. The Constant scores improved significantly from 44 ± 18 (range, 18-71) to 76 ± 7 (range, 68-92) postoperatively. The mean supraspinatus muscle strength increased from 51% ± 19% (range, 21%-92%) preoperatively to 78% ± 14% (range, 44%-113%) postoperatively, and external rotator muscle strength increased from 59% ± 14% (range, 22%-85%) to 81% ± 13% (range, 40%-105%). The improvements in supraspinatus and external rotator muscle strength were statistically significant. The mean range of active forward elevation increased from 101° ± 25° preoperatively to 132° ± 14°
postoperatively. The mean external rotation in the neutral position increased from 18° ± 11° preoperatively to 33° ± 7° postoperatively. Katz ADL score improved significantly from 3.4 ± 1.1 to 5.0 ± 0.8 postoperatively and mostly in bathing, dressing, and personal hygiene scores. FIM motor scores showed significant improvement from 25 ± 6 preoperatively to 54 ± 7 postoperatively, mainly in bathing, dressing, and transfers (Table IV). Follow-up MRI was performed in 46 patients at 1 year after the operation, and 12 patients (26%) were found to have retears. Retears occurred in 11 patients with massive tears and in 1 patient with a large tear. Postoperative strength, range of motion, and VAS, ASES, Constant, Katz ADL, and FIM motor scores improved significantly in both the intact and retear groups (Table V). Compared with the intact group, the retear group showed no significant differences with respect
ARTICLE IN PRESS Rotator cuff surgery in geriatric population
5
Table IV Comparison between preoperative and postoperative VAS score, ASES score, Constant score, rotator cuff muscle strength, shoulder ROM, FIM motor, and Katz ADL score (N = 64)
VAS score ASES score Constant score Strength, SST (%) Strength, external rotator (%) ROM, FE (degrees) ROM, ER (degrees) Katz ADL FIM motor
Preoperative (mean ± SD)
Postoperative (mean ± SD)
P value
6.4 ± 2.2 42 ± 16 44 ± 18 51 ± 19 59 ± 14
2.3 ± 1.1 84 ± 8 76 ± 7 78 ± 14 81 ± 13
<.001 <.001 <.001 <.001 <.001
101 ± 25 18 ± 11 3.4 ± 1.1 25 ± 6
132 ± 14 33 ± 7 5.0 ± 0.8 54 ± 7
<.001 <.001 <.001 <.001
VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; SST, supraspinatus; ROM, range of motion; FE, forward elevation; ER, external rotation; Katz ADL, Katz index of activity of daily living; FIM motor, functional independence measurement motor; SD, standard deviation.
Table V Comparison between preoperative and postoperative VAS score, ASES score, Constant score, rotator cuff muscle strength, shoulder ROM, FIM motor, and Katz ADL score in retear group of patients (n = 12)
VAS score ASES score Constant score Strength, SST (%) Strength, external rotator (%) ROM, FE (degrees) ROM, ER (degrees) Katz ADL FIM motor
Preoperative (mean ± SD)
Postoperative (mean ± SD)
P value
6.7 ± 2.1 47 ± 19 45 ± 20 46 ± 16 52 ± 12
2.6 ± 1.3 78 ± 11 73 ± 12 77 ± 9 78 ± 10
.004 <.001 .011 <.001 <.001
107 ± 19 20 ± 13 3.7 ± 1.3 23 ± 5
137 ± 19 36 ± 4 5.2 ± 0.6 52 ± 6
<.001 <.001 .007 <.001
VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; SST, supraspinatus; ROM, range of motion; FE, forward elevation; ER, external rotation; Katz ADL, Katz index of activity of daily living; FIM motor, functional independence measurement motor; SD, standard deviation.
to range of motion and VAS, ASES, Constant, Katz ADL, and FIM scores. However, the retear group had weaker supraspinatus and external rotator muscle strength postoperatively than the intact group, although the difference was not statistically significant (Table VI). The perioperative mortality rate was 0%, and there were no significant perioperative complications requiring intensive care, delayed hospitalization, or readmission. There were no cases of complication associated with acromioplasty, such as acromial fracture or anterior superior escape of humeral head.
Discussion With life expectancy increasing, the elderly population has an increased need for improvements to their quality of life. However, rotator cuff tears frequently occur in elderly patients, as reported in many studies, and tear size and frequency are known to increase with age.4,10,19,22,35-37,41 Large to massive rotator cuff tears are common in elderly patients. However, surgical treatment is not always successful, and as a result there is uncertainty regarding the optimal treatment strategy for these patients.1,5,8 Charousset et al5 reported that arthroscopic rotator cuff repair was effective in 52% of patients aged >65 years. Boileau et al1 found that patients aged >65 years had a 43% chance of tendon healing, and patients >65 years with delamination of the subscapularis or the infraspinatus had an even lower rate of healing. In elderly patients, large to massive rotator cuff tears may develop into cuff tear arthropathy when neglected,3,17,31,40 and in such cases, patients may require reverse shoulder arthroplasty instead of the relatively less invasive rotator cuff repair. Although there are recent trends toward choosing reverse shoulder arthroplasty for cuff-deficient shoulders,14,29 we still believe that this method should be reserved for cuff tear arthropathy. We propose that rotator cuff repair can be performed safely for elderly patients when ASA grades are used as a guideline and strict preoperative medical management is applied. Thus, we performed this retrospective study to evaluate the efficacy and safety of rotator cuff repair for large and massive rotator cuff tears in elderly patients. Rotator cuff repair is the standard treatment for rotator cuff tears in young patients with acute traumatic injuries.19 In contrast, massive rotator cuff tears in elderly people often present as chronic tears. The natural history of the disease involves the rotator cuff losing its elasticity because of fatty infiltration and superior migration of the humeral head, leading to degenerative arthritis.16 These tears can compromise shoulder function and result in poor quality of life. The results of this study confirm these facts. Preoperative Katz ADL and FIM scores averaged 3.4 ± 1.1 and 25 ± 6 and were particularly low for bathing, dressing, and personal hygiene. Despite these problems, elderly patients tend to avoid surgical intervention because of uncertainty concerning the outcomes and fear of postoperative complications. However, the morbidity, mortality, and readmission rates were 0% when the surgical interventions were performed under the preoperation guidelines used at our center. Under vigilant operative and postoperative care, we demonstrated good functional outcomes and improvements in quality of life postoperatively. Although 20% of the patients felt subjectively that they were not satisfied with the results of surgical intervention, the overall results showed that functional outcomes were significantly improved. Another finding of our study was that using ASA grades and correcting the preoperative general medical condition helped to minimize mortality, postoperative morbidity, and complications postoperatively. In our study, we excluded
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H.J. Jung et al. Table VI Comparison of preoperative and postoperative VAS score, ASES score, Constant score, rotator cuff muscle strength, shoulder ROM, FIM motor, and Katz ADL score between the intact and retear groups Intact (n = 42) VAS score ASES score Constant score Strength, SST (%) Strength, external rotator (%) ROM, FE (degrees) ROM, ER (degrees) Katz ADL FIM motor
Retear (n = 12)
P value (intact vs. retear)
Preoperative
Postoperative
P value
Preoperative
Postoperative
P value
Preoperative
Postoperative
6.1 ± 1.7 49 ± 14 46 ± 15 58 ± 21 64 ± 23
2.3 ± 1.2 85 ± 10 77 ± 4 84 ± 17 86 ± 20
<.001 <.001 <.001 <.001 <.001
6.7 ± 2.1 47 ± 19 45 ± 20 46 ± 16 52 ± 12
2.6 ± 1.3 78 ± 11 73 ± 12 77 ± 9 78 ± 10
.004 <.001 .011 <.001 <.001
.475 .388 .216 .217 .060
.642 .843 .169 .021* .039*
124 ± 18 30 ± 10 3.5 ± 1.6 26 ± 5
143 ± 13 38 ± 11 5.4 ± 0.7 58 ± 8
<.001 <.001 <.001 <.001
107 ± 19 20 ± 13 3.7 ± 1.3 23 ± 5
137 ± 19 36 ± 4 5.2 ± 0.6 52 ± 6
<.001 <.001 .007 <.001
.134 .216 .231 .138
.344 .278 .412 .216
VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; SST, supraspinatus; ROM, range of motion; FE, forward elevation; ER, external rotation; Katz ADL, Katz index of activity of daily living; FIM motor, functional independence measurement motor. * Statistically significant, P < .05.
patients in poor general medical condition (ASA grade ≥4) and managed the patients before surgery; we corrected hemoglobin level to a minimum of 9 g/dL and albumin level to a minimum of 3.0 g/dL and performed preoperative consultations for underlying medical conditions such as thyroid, neurovascular, or cardiovascular problems. Under our strict guidelines, there were no cases of mortality and no significant complications like cardiovascular event or pulmonary embolism postoperatively. On the basis of our results, we think that patients ≥75 years old can be safely treated with surgery if the aforementioned guidelines are followed. Worland et al39 evaluated the open repair of massive rotator cuff tears in 69 patients older than 70 years. They reported satisfactory results in 78.3% of patients, with improvements in University of California–Los Angeles (UCLA) scores from 9.4 preoperatively to 30.9 at the final follow-up. Furthermore, 79.7% of patients (55 patients) achieved good bonetendon repair. Yel et al42 evaluated 51 shoulders in patients >65 years old and reported satisfactory results in 94.1% of patients, a Constant score of 82 points, and excellent and satisfactory results in 90% of patients using the Neer scale. The authors focused only on shoulder and elbow scores rather than on quality of life in the perioperative period. In contrast, in our study, we evaluated not only subjective and functional outcomes and the structural integrity of repaired tendon but also Katz ADL and FIM motor scores, representing a more comprehensive assessment of outcomes. Débridement and subacromial decompression have been suggested as effective alternative treatments for chronic rotator cuff tears, but these methods have been shown to be ineffective in mitigating long-term pain and improving functional ability in some studies.27,28,38 In contrast to our study, these previous reports did not focus on elderly patients. In our study, we found significant improvements in functional outcomes after rotator cuff repair and subacromial decompression.
MRI is used to evaluate rotator cuff tendon integrity and retear size after surgery because it can be performed noninvasively and is more accurate than arthrography. In this study, we assessed the occurrence of retears using MRI 1 year after surgery. In a recent study evaluating the repaired cuff integrity after arthroscopic suture bridge technique, 53.3% of patients with massive cuff tears showed retearing on followup MRI.7 It is unclear how retears affect clinical outcomes, but it is generally thought that clinical outcomes still improve despite retearing. Klepps et al21 reported that postoperative cuff integrity did not have a significant effect on outcomes compared with intact cuffs in 32 patients. Liu and Baker24 also demonstrated that repair integrity did not influence functional outcomes. In contrast, Flurin et al15 reported that retorn cuffs were associated with worse overall Constant and ASES scores. Cole et al9 reported that range of motion and muscle strength were inversely correlated with recurrent tears. Yoo et al43 reported that the physical components of the 36-Item Short Form Health Survey as well as the UCLA and ASES scores were significantly higher in the healed group, even though there was no significant difference in mental component summary scores. Thus, controversy persists concerning whether structural integrity affects functional outcomes. In our study, all clinical outcomes improved in the retear group; however, muscle power was significantly lower compared with that in the intact cuff group, although the clinical significance of this difference is questionable. In our study, all clinical results except for muscle power improved in the retear group in patients who underwent open acromioplasty and rotator cuff repair. We believe that structural integrity after cuff repair did not affect clinical outcomes in the patients in this study. However, regarding the risk of progression to cuff tear arthropathy, patients with massive retears may experience problems in the future, and longer follow-up will be necessary for these patients.
ARTICLE IN PRESS Rotator cuff surgery in geriatric population Being retrospective in nature, this study has some inherent limitations. First, not all patients agreed to undergo MRI after surgery. However, our finding that patients who had retears still experienced significant improvements is consistent with the results of other studies, and the results would not be different if all patients had agreed to undergo MRI. Second, all patients received surgery at a tertiary university hospital, so this group of patients may not represent the general elderly community. Third, we excluded patients with ASA grades ≥4 before surgery, so we have no data related to these patients. Fourth, we did not use a matched control group and therefore could not make comparisons between surgical and conservative treatment. However, this study is one of the few studies that have attempted to evaluate functional outcomes and quality of life indices in elderly patients after rotator cuff repair, and the results are therefore important in the context of current clinical practice.
Conclusion Satisfactory functional outcomes, quality of life, and pain relief can be achieved with rotator cuff repair in elderly patients with large to massive rotator cuff tears. Careful preoperative examination, surgical intervention, and postoperative management can help achieve good functional outcomes.
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The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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