Rationale

When deciding on the management of a rotator cuff tear, the patient’s age is an important variable to assess.¹ A number of studies have evaluated the role of age as a prognostic factor when repairing chronic rotator cuff pathology.² An analysis of the published evidence about this topic will help us to decide if there is an age limit after which the patient does not benefit from surgical repair.

Clinical comment

In order to focus properly the management of a degenerative rotator cuff tear, we must decide whether the lesion is surgical or should be treated conservatively.³ In this sense, age has been suggested not only as a predisposing factor but also as prognostic of outcome of the result, being associated with a higher rate of repair failure.⁴,⁵

It is critical to first determine if a tear is of a traumatic or degenerative nature. Hybrid lesions often exist, that is traumatic injuries on a background of an already degenerative rotator cuff. The intrinsic structure of the tendon can be affected by many factors, but primarily by professional activity, gender, and age. The degeneration of the tendon fibers not only predisposes the patient to a rotator cuff tear but also has a decisive influence on the tendon’s healing after surgical repair.⁶

Given this relationship between age, fibrillar degeneration, and lower healing potential, the question arises regarding the age cutoff, if one exists, above which the net benefit does not exceed the surgical risk. Other critical prognostic factors include size of the lesion, the degree of muscular atrophy, fatty infiltration at the time of diagnosis, and the tendon’s retraction distance.⁷

Available literature and quality of the evidence

In spite of the high number of publications that try to offer some light to this question, only a few reach a high level of evidence. Although the majority of the studies are of level IV evidence, in the last 10 years there have been some level III studies, numerous studies of level IIB, a systematic review (IIA), and a randomized controlled trial (RCT; level IB).

Findings

In the only blinded RCT (multicenter study) conducted thus far, Flurin et al. compared bursectomy and subacromial decompression versus bursectomy, decompression, and arthroscopic repair in 143 patients older than 70 years (70 and 73, respectively).⁸ This study concluded that both groups presented a significant clinical improvement at one‐year follow‐up. However, the group undergoing arthroscopic repair obtained better clinical results in all evaluation scales, with a statistically significant difference. Interestingly, this difference was accentuated in the patients who presented a greater retraction of the tendon cape and was smaller in the patients who presented a greater degree of fat infiltration based on the Goutallier classification.⁹

Along the same lines, Dezaly et al. performed a very similar RCT (level IIB) in which they reached the same conclusion after randomizing 142 patients: acromioplasty and biceps tenotomy group versus acromioplasty, biceps tenotomy, and cuff repair group.¹⁰ The acromioplasty, biceps tenotomy, and rotator cuff group obtained statistically significant improvements in clinical scores and overall satisfaction.

In a 2017 study, Silva et al. conducted a literature review of studies published involving patients over 65 years of age.¹¹ They concluded that, despite the lack of RCTs, the data obtained in the different studies are consistent. The healing rate after one year varies depending on the studies from 58%¹² to 81.5%,⁷ obtaining an average of 71.7%. However, the improvement in the clinical evaluation scales and in overall patient satisfaction is even higher.

Oh et al. published in 2010 a case series that, despite being level IV evidence, was very statistically robust.¹³ They demonstrated that in a multivariate regression analysis, age is not an independent determining factor of Constant score, while the degree of retraction of the proximal end and the fatty degeneration of the infraspinatus were indeed independent factors affecting the integrity of the repair.

Rationale

In general terms, when we treat an acute tendon injury, we understand that early repair is a key factor to be taken into account to avoid muscle hypotrophy and tendon retraction.¹⁴ Some clinical guidelines recommend that acute lesions should be repaired in a period of less than three weeks.¹⁵ But is there true evidence to support such a claim? And if so, what is the critical period for treating it?

Clinical comment

Making a distinction between an acute rupture, acute symptoms of a chronic rupture or the acute extension of an existing chronic rupture are very difficult, if not impossible.¹⁶ We define acute ruptures as those in which a previously asymptomatic patient identifies a traumatic incident leading to a sudden onset of symptoms such as severe pain, functional limitation, and loss of strength in the affected limb.¹⁷ However, the diagnosis is rarely immediate, either because it takes time to consult a physician or due to delays in referrals and wait times for nonurgent issues.¹⁸

Extrapolating the pathophysiology of tendon lesions in other parts of the body, several studies have tried to provide scientific support to the hypothesis that truly acute tendon ruptures should be treated immediately, similar to how they are for other parts of the body (e.g. Achilles, flexor tendons).¹⁹,²⁰