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Rotator cuff tears in the elderly

Age is a risk factor for rotator cuff tear, with almost 50%  of people over 60 and almost 95% of those over 80 with some form of rotator cuff tear. Risks are increased for smokers, people in certain occupations and those with a family history. Although not technically a degenerative condition, rotator cuff injury often occurs alongside degenerative diseases and is simply more likely to occur through 'wear and tear' as the body ages.

A cursory glance at the Google results for the search 'rotator cuff older patients' shows a number of articles asking if rotator cuff repair in older patients is 'appropriate' or 'worthwhile'. Here we have a look at the varying viewpoints from a range of studies conducted between 2014 and 2018.

The first of these studies[1] was published in 2014 and was a randomised trial involving 103 patients over 60 years old over a four year period. The trial was conducted to compare surgery to repair the rotator cuff against the (surgical) alternatives – decompression by acromioplasty and biceps tenotomy. Results of the study indicated that rotator cuff tendon repair was more effective in the mid-term than where only acromioplasty was carried out. The researchers also concluded that acromioplasty-tenotomy was the simpler procedure and also produced good outcomes, particularly for patients with low functional demands or where patients were not able or willing to go through a rehabilitation program after the procedure.

The following year an article on rotator cuff tears in the elderly was published in Geriatric Orthopaedic Surgery & Rehabilitation[2] which acknowledged that older patients are increasingly active and wanting to continue 'high functioning lifestyles' and that studies had shown that surgical rotator cuff repair in elderly patients showed satisfactory results, with decompression surgery - although more straightforward - provided only shorter term relief of symptoms. Rotator cuff repair was found to be less effective where large or massive tears were present or where there were higher levels of fatty infiltration.

A smaller study in 2016[3] - 25 patients over 75 followed up over a ~3 year period - backed up these conclusions, stating significant improvements in overall outcomes after rotator cuff repair surgery – 64% did not suffer any retears, but of the 36% that did have a retear, 87% had an original tear classed as 'large' or 'massive'.

Two more recent studies[4],[5], published in 2017 and 2018 respectively, continued to bear out the results of previous studies. Both followed elderly patients (over 70 in one study and over 75 in the other) who had undergone rotator cuff repair surgery and confirmed the connection between the size of tear and higher risk of complication. However, both studies also recorded better overall results, even in those patients that had suffered retears. Using the Constant-Murley Shoulder Outcome Score, one study recorded an increase in this score of an average of 12 points in patients that had experienced retears, and the other study noted that 'all patients with retears had improved subjective outcomes and functional scores'.

This review focuses only on surgical approaches to rotator cuff injuries, which would only be recommended where non-surgical approaches have been optimised and have not provided the desired outcome. Although controversy continues in the medical community on whether rotator cuff surgery is appropriate in older patients, these studies clearly show that surgery improves overall outcomes in most cases, even where retears occur. And if rotator cuff surgery allows people to continue to be active in later life, this is surely a good thing!

[1] Is rotator cuff repair appropriate in patients older than 60 years of age? Prospective, randomised trial in 103 patients with a mean four-year follow-up
[2] Rotator Cuff Tears in the Elderly Patients
[3] Rotator Cuff Repair in Patients over 75 Years of Age: Clinical Outcome and Repair Integrity
[4] Rotator cuff surgery in patients older than 75 years with large and massive tears
[5] Should we repair rotator cuff tears in the elderly? Review of 69 arthroscopic cuff repairs in patients over 70 years