Rotator cuff injuries are common, and morbidity increases with age. The rate of asymptomatic full-thickness tears is 40% in the over 75-year-old population (1, 2). Elderly patients often present various risk factors, including decreased bone quality, poor blood supply, and an increased rate of medical comorbidities. These work against the treatment of rotator cuff injuries (3, 4). Furthermore, the factors affecting tendon healing are the size and extent of the tear, presence of fatty infiltration in the rotator cuff muscle, delamination, smoking, and the rehabilitation protocol (2, 4–8). All these factors may preclude rotator cuff repair (RCR) and could make clinical outcomes less predictable.

Older individuals have a strong desire to maintain a physically active lifestyle and expect an early return to sport and occupational activities (9). These expectations typically warrant surgical management of rotator cuff tears in this population once nonoperative treatments have failed (10). Despite significant advances in arthroscopic RCR over the past 20 years, retear rates remain unacceptably high. Several studies have documented better postoperative functional gain and structural healing of the rotator cuff. Achieving good tendon healing could reasonably be considered one of the primary objectives of the surgery (11–16). Due to the large number of comorbidities observed in the elderly population and the complications and high rates of recurrent tears seen after RCR surgeries, experts have debated whether surgery was an effective treatment for rotator cuff lesions in this population. The management of rotator cuff injuries has been well studied in other age groups; however, little investigation data and no treatment guidelines are available for the over 75-year-old population.

Based on several small case series reporting successful clinical outcomes in patients older than 75 years after repair surgery (11–16), this systematic review aimed to pool these findings and evaluate the clinical outcomes of RCR in patients aged ≥75 years. In doing so, we aim to found that whether surgical treatment was beneficial for structural tendon healing with good clinical outcomes following rotator cuff injuries in this advanced age group, making it the preferred treatment option.

This systematic review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines (17).

With socio-economic development and improved medical conditions, the growing elderly population could now expect to live longer and more vigorously than before. Our population grows increasingly old, there is a larger proportion of patients in their 70 and 80s who remain physically active. It has been found that the rate of asymptomatic full thickness rotator cuff tears in individuals aged ≥70 years is 40% (1). Besides, it has been verified that patients younger than 60 years with rotator cuff tears rate was lower than 10% while for patients older than 80 years, the rotator cuff tear rate was 80% (19). The other studies argued that rotator cuff tears are associated with the aging process; their prevalence increases with age, reaching 80% in individuals aged over 80 years (3, 20, 21). Another study showed that the prevalence of full-thickness rotator cuff tear was at 22% for those older than 65 years, 31–41% in those older than 70, and 51% in those older than 80 (14). Since the etiology of rotator cuff injuries is likely multi-aspect and includes age-associated degeneration. The quality and function of the rotator cuff muscles seem to deteriorate with age (22–25). Based on the results of reports, it could be found that prevalence of rotator cuff tear increases with age. Combined with the epidemiology and etiology of rotator cuff injury in older people, the treatment and prognosis of rotator cuff injury in the elderly are needed to be investigated. In thus, the clinical and radiographic outcomes of RCR in elderly patients aged ≥75 years were reviewed in this study. We summarized the data from all available evidence to better understand (1) whether these older adults were suitable candidates for surgical repair of rotator cuff injuries and (2) whether surgical treatment of rotator cuff injuries in such an older cohort resulted in favorable structural and functional outcomes.

We found in this systematic review that patients older than 75 years could achieve good outcomes (11–16). Their postoperative scores were significantly higher than the preoperative scores. Furthermore, although retear of the repaired rotator cuff was reported, few complications occurred, and RCR could achieve reliable pain and function improvements in selected patients in this age group. Padki et al. performed a propensity score matched-pair analysis to compare the outcome of patients older and younger than 75 years (11). Although the 2-year postoperative OSS was 2 ± 5 points better than before surgery, the 2-year postoperative improvement in VAS, CSS, and UCLASS over the baseline was similar in both groups. Besides, the study by Witney-Lagen et al. showed that elderly patients at a mean age of 78 years benefited as much from arthroscopic RCR as their younger counterparts (mean age, 58 years) (14). Therefore, surgical treatment could be effective for older adults with symptomatic rotator cuff tears and failed conservative management, including those older than 75 years.

Older people tend to suffer from larger rotator cuff tears. Park et al. found that larger tear size was correlated with increased mean age, but the association was insignificant (15). Maman et al. reported that 54% of the symptomatic tears in patients older than 60 years increased in size while only 17% of the tears in those younger than 60 years did so (26). Besides, Gumina et al. found that patients aged >60 years were twice as likely to experience a large tear and three times more likely to experience a massive tear than younger patients (27). Although older people tend to suffer larger rotator cuff tears, clinical studies still showed significant improvements, even in patients with large to massive tears (14, 15). Tears in symptomatic older patients, especially large tears, are likely to result in tear progression and poor outcomes if they cannot be managed by surgery. Furthermore, it was reported that rotator cuff tears were a major cause of depression in the elderly population. Therefore, rotator cuff tears in the elderly, even those older than 75 years, should be treated with surgery when necessary.

It was argued that older patients have a higher risk for retear or persistent defects noted in imaging studies (28). The reported rate of retear in those aged 60 years and older was high (31–51%), with most retears occurring 3 to 6 months after repair (29, 30). However, Rhee et al. (30) reported that age was insignificantly correlated with the retear rate. Even though older patients have a higher potential for retear, the postoperative cuff integrity effect on the outcome was insignificant (31). Another report suggested that RCR significantly decreased pain and improved function and strength, despite evidence of retear on MRI (8), other studies argued that tendon nonhealing does not reflect a poor functional outcome (14, 32). While some studies showed that ROM and muscle strength were inversely correlated with a retear group (33), it has been found that physical component summaries of the UCLA and ASES socres were significantly higher in the healed group while there was no significant difference in mental component summary scores. In this systematic review, patients older than 75 years achieved good outcomes and postoperative scores higher than preoperative scores, even if retear had occurred. Although there were some reports argued that retear might affect the outcome, physical rehabilitation training after surgery might be a good choice to improve the prognosis.

Patients age and initial tear size were significantly associated with the severity of osteoarthritic changes through a long-term follow-up (34). Plachel et al. found that significant progression of secondary glenohumeral osteoarthritis occurred in patients older than 75 years (12). However, they thought that this progression was the natural course of the disease during that period of one's life rather than secondary to a persistent rotator cuff lesion since similar progression occurred in the non-affected shoulder.

The most important result was that patients older than 75 years at the time of surgery achieved good clinical results and reported high patient satisfaction at midterm follow-up. Therefore, RCR offers a joint-preserving option with significant functional and clinical improvement for patients older than 75 years without advanced muscle degeneration. However, it should be noted that massive tears had a higher risk for subsequent reverse total shoulder arthroplasty.

Several limitations remain in the present study. First, heterogeneity should not be underestimated. The interventions and objectives of the included studies were similar, but they differed in population characteristics, tear sizes, repair type (i.e., open or / and arthroscopic), repair construct (i.e., single-row, transosseous equivalent double-row, or arthroscopic transosseous tunnel repair), and outcome scores. Second, due to the limited number of included studies and overall low level of evidence (3 and 4), more case-control design studies are needed to provide better evidence. Furthermore, these studies have different follow-up intervals, which might disturb the observation of effects on function.

RCR could achieve high clinical success rates with good outcomes and pain relief in patients aged over >75 years. Although patients in this age group are susceptible to retears, RCR may offer a good option with significant functional and clinical improvements.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

CH and YR were in charge of the conceptualization, supervision, and project administration. CM, BJ and ML designed and performed the study and were the main writers of the manuscript. FK, LK, CW, TZ, and JW fulfilled validation and formal analysis. All authors read and approved the final manuscript.