A Systematic Review of Preoperative Fatty Infiltration and Rotator Cuff Outcomes

Abstract

Background: Fatty infiltration (FI) of the muscle as graded by the Goutallier classification (GC) is a well-known sequela following rotator cuff injury. The degree to which this predicts the success of rotator cuff repair is unknown.

Questions/purposes: We conducted a systematic review to address the following questions: (1) Does the grade of FI of the rotator cuff muscles present preoperatively predict retear rates postoperatively? (2) Are amounts of preoperative FI predictive of functional outcomes following repair?

Methods: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials online databases were searched for all literature published between January 1966 and March 2015. Keywords were chosen to achieve a broad search category. All articles were reviewed by three of the authors, and those meeting the study inclusion criteria were selected for data abstraction.

Results: The systematic literature review yielded 11 studies reporting on a total of 925 shoulders. Rotator cuffs with moderate or significant FI preoperatively (grades 2-4) had a significantly higher retear rate than those with no or minimal FI (grades 0-1) (59 vs. 25%, p = 0.045). Four studies reported postoperative Constant scores and preoperative GC scores. One study found that lower GC scores were associated with higher Constant scores postoperatively, one found no association, and the data was inconclusive in the other two.

Conclusions: While lower preoperative GC scores are associated with lower rates of rotator cuff retear following repair, there is insufficient data to make conclusions on the effects of FI on functional outcomes following repair.

Keywords: Goutallier score; fatty infiltration; functional outcomes; massive rotator cuff tears; preoperative evaluation; retear rates; rotator cuff tears.

Fig. 1

Flow chart showing methodology of literature search. Literature search: There were 362 articles found with all of the general search terms. The abstracts of each of the combined searches were then reviewed to determine appropriateness for inclusion in the study. There were 26 articles that were deemed appropriate for the analysis. Of the 26 articles, 15 were excluded after a full-text review. Three studies were excluded because they made statements regarding preoperative Goutallier grade and radiographic outcomes but did not provide retear rates for each Goutallier grade individually [26, 29, 34]. Five studies that only compared the average Goutallier grades for intact versus retorn cuffs were excluded [8, 26, 31, 35, 36]. An additional seven studies analyzing the effect of preoperative fatty infiltration on functional outcome were also excluded. Five studies made statements regarding the effects of preoperative Goutallier grade on postoperative functional outcome scores but did not provide data for each Goutallier grade individually [–16, 25]. One study, by Goutallier et al. [19], provided Constant-Murley scores by preoperative Goutallier grade but used classifications of Goutallier grade that did not allow for direct comparison with other reports (i.e., <1, 1–1.49, and ≥1.5). This was similar to another excluded study, by Burkhart et al. [1], which compared functional outcome data of rotator cuffs with 50–75 and >75% fatty infiltration. There were seven studies that met the inclusion criteria and compared radiographic outcome (intact versus retorn) by Goutallier grade [4, 6, 7, 13, 14, 22, 25] and two studies that met the inclusion criteria and compared functional outcome by Goutallier grade [18, 27]. Two studies met the criteria for both radiographic and functional outcomes [3, 11]. This gave a total of 11 studies that were included in the final data analysis (Fig. 1).