Rotator cuff repair vs. reverse arthroplasty for massive tears: A patient-centered outcome analysis

The management of massive rotator cuff tears (MRCTs) without glenohumeral arthritis presents a significant clinical challenge. The choice between primary arthroscopic rotator cuff repair (RCR) and reverse shoulder arthroplasty (RSA) remains controversial, with limited comparative data on patient-centered outcomes.

To compare functional outcomes, patient-priority outcome domains, and complication rates between primary arthroscopic RCR and primary RSA in patients with massive rotator cuff tears.

This retrospective cohort study included 70 patients (36 RCR, 34 RSA) treated between 2022-2024 with minimum 12-month follow-up (mean 24.3 ± 6.7 months). Patient demographics, preoperative imaging findings (Goutallier fatty infiltration, Patte retraction, Hamada staging), traditional functional scores (ASES, Constant, DASH, VAS), range of motion, and patient-priority outcome domains (pain-free sleep, overhead activity, internal rotation tasks, heavy work capacity, return to sports) were compared using appropriate statistical methods.

RCR patients were significantly younger (64.8 ± 7.2 vs. 72.1 ± 6.9 years, p < 0.001) with lower Goutallier grades (Grade≥3: 44.7% vs. 94.4%, p < 0.001). Both groups achieved significant pain reduction and functional improvement. At final follow-up, RCR demonstrated superior active flexion (146.3° ± 24.8° vs. 117.2° ± 27.3°, p < 0.001), internal rotation (L3 vs. S1 level, p = 0.001), and ASES scores (79.2 ± 23.4 vs. 69.8 ± 26.1, p = 0.042). RCR showed significant advantages in patient-priority domains including overhead activity (3.2 ± 0.8 vs. 2.6 ± 0.9, p = 0.002), internal rotation tasks (3.3 ± 0.7 vs. 2.2 ± 1.0, p < 0.001), and return to sports (2.6 ± 1.1 vs. 1.8 ± 0.9, p = 0.001). Complication rates were similar (11.1% vs. 8.8%, p = 0.734).

In younger, active patients with adequate tissue quality, primary arthroscopic RCR provides superior range of motion and patient-centered functional outcomes. RSA remains a reliable option for elderly patients with advanced fatty infiltration and chronic pseudoparalysis. Careful evaluation of these factors is critical for optimal patient selection.