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

Background: 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. Purpose: 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. Methods: 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. Results: 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). Conclusion: 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.