Picking Patients Over 65 for Rotator Cuff Repair

What’s the Claim

A recent study among patients older than 65 found that arthroscopic repair of full- or >50%-thickness rotator cuff tears that surgeons deemed repairable — in patients with a history of a traumatic event, whose shoulders were previously asymptomatic and fully functional — generally worked very well at 2 years of follow-up. Patients with subscapularis involvement or ≥ 50% muscle involvement (fatty infiltration/atrophy) on MRI were excluded, so these results do not apply to them. The authors reported large improvements in patient-reported outcomes scores, and — kudos to the authors — they reported their findings in terms of effect sizes, not just p values. They found that high proportions of patients achieved treatment effects larger than the minimum clinically important difference (MCID; 78% of patients hit this benchmark), achieved a Patient Acceptable Symptom State (PASS; 79%), and realized predefined substantial clinical benefits (SCB; 70%). The authors suggested these findings held regardless of whether the patient had < 3 months of symptoms, 3 to 6 months of symptoms, or > 6 months of symptoms.  

How’s It Stack Up?

This work jumps right into the deep end of controversy, and it’s a good and important study. Some have suggested that cuff repair in older patients is rarely indicated, but this paper makes a strong case for the procedure in the right patients. The study was about as strong as retrospective, observational research gets on a topic like this — clear inclusion and exclusion criteria, and near-complete follow-up. Only about 10% of patients were missing at two years, so even if they did not do as well, the main claims here likely would hold up. The findings were all the more impressive given that almost half of the patients in the early group (< 3 months of symptoms) had large or massive tears.

What’s Our Take?

We believe you can apply these findings with confidence to patients who present within 3 months of injury. Although there were no statistical differences between that group and those with symptoms of longer duration, that no-difference finding seemed likely to be a function of insufficient numbers of patients to compare. The point estimate of the proportion of patients who achieved the MCID, PASS, and SCB were in every instance higher in the < 3 months group than the patients whose symptoms were of longer duration; that’s hard to ignore. Two other things to make sure of before quoting these results to patients — because the authors did so — were whether the shoulder was truly “asymptomatic and fully functional” before the traumatic event, and that there isn’t much fatty atrophy (Goutallier 2 or less). These things matter because we’ve all seen patients attribute the onset of pain from chronic tears to traumatic events. Finally, it’s not always possible before surgery to know what is “repairable,” and so it can be hard to make firm promises to patients. But if you’re confident the tear will come together and the symptoms are of short duration, this study suggests that the patient's age is a much smaller deal than we previously thought.  

Source

Lu Y, Sun B, Yang G, Li S, Jiang C. Arthroscopic Repair Benefits Reparable Rotator Cuff Tear Patients Older Than 65 Years With a History of Traumatic Events. Arthroscopy. 2023;39:1150-1158.

Further Commentary
Amini MH. Editorial Commentary: Repair Is Efficacious for Acute Rotator Cuff Tears in Patients Over 65 Despite Advanced Age, and Early Repair Is Better. Arthroscopy. 2023;39:1159-1160.