Preoperative Fatty Degeneration as a Key Determinant of Surgical Strategy and Outcomes in Revision Rotator Cuff Surgery

Preoperative Fatty Degeneration as a Key Determinant of Surgical Strategy and Outcomes in Revision Rotator Cuff Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Preoperative Fatty Degeneration as a Key Determinant of Surgical Strategy and Outcomes in Revision Rotator Cuff Surgery Tarık Elma, Orkun Büyüksayın, Furkan Aral, Ahmet Yiğit Kaptan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8492225/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Revision rotator cuff surgery remains a significant clinical challenge due to tendon retraction, compromised tissue quality, muscle atrophy, and extensive scarring, all of which adversely affect reparability and postoperative outcomes. Although the prognostic value of rotator cuff muscle fatty degeneration is well established in primary repairs, its influence in the revision setting has not been fully clarified. Methods: This retrospective cohort study included 47 patients (mean age, 54.1 ± 9.3 years) who underwent revision rotator cuff surgery between 2015 and 2024. Preoperative magnetic resonance imaging (MRI) was used to assess rotator cuff muscle fatty degeneration according to the Goutallier classification. Patients were stratified into mild-to-moderate (grades 0–2) and advanced (grades 3–4) degeneration groups. Surgical strategies and postoperative functional outcomes, including the University of California, Los Angeles (UCLA) shoulder score and Visual Analog Scale (VAS) pain score, were compared between groups. Results: Of the 47 patients, 27 (57.4%) demonstrated mild-to-moderate fatty degeneration, whereas 20 patients (42.6%) had advanced degeneration. Arthroscopic revision or debridement was performed in 81.5% of patients with mild-to-moderate degeneration, while reconstructive procedures, including latissimus dorsi tendon transfer or reverse total shoulder arthroplasty, were performed in 85.0% of patients with advanced degeneration (p < 0.001). Patients in the mild-to-moderate group achieved significantly better functional outcomes, with higher mean UCLA scores (21.1 ± 4.8 vs. 17.2 ± 4.1; p = 0.040) and lower mean VAS pain scores (4.3 ± 1.2 vs. 6.1 ± 1.4; p = 0.020). Conclusions: The severity of preoperative rotator cuff muscle fatty degeneration appears to be a key factor in guiding surgical strategy selection and is associated with postoperative functional outcomes in revision rotator cuff surgery. Routine MRI-based assessment of muscle quality may support individualized surgical planning, optimize clinical outcomes, and improve patient counseling in complex revision cases. Study Design: Retrospective cohort study; Level of Evidence, 3. Health sciences/Diseases Health sciences/Medical research revision rotator cuff surgery fatty degeneration Goutallier classification magnetic resonance imaging latissimus dorsi tendon transfer reverse shoulder arthroplasty Introduction Revision rotator cuff surgery remains one of the most complex challenges in shoulder surgery due to the multifactorial nature of biological and mechanical influences that compromise outcomes. Factors such as tendon retraction, muscle atrophy, poor tissue quality, and extensive scar formation significantly reduce reparability and increase the risk of postoperative complications.[ 6 , 25 ] Despite advances in arthroscopic techniques, improved biomaterials, and structured rehabilitation protocols, clinical results after revision procedures are consistently inferior to those following primary repair.[ 1 , 3 , 19 ] Understanding the key prognostic factors that influence surgical decision-making is therefore essential to improve outcomes in this demanding clinical scenario. Among these prognostic variables, fatty degeneration of the rotator cuff muscles is widely recognized as one of the most decisive. Initially described by Goutallier et al.[ 9 ], fatty degeneration represents a pathological shift in muscle composition that compromises mechanical strength and biological healing potential. Its clinical significance has been well established in primary rotator cuff surgery, where higher degrees of fatty infiltration correlate with increased re-tear rates, reduced tendon healing capacity, and worse functional outcomes.[ 4 , 8 ] Importantly, the presence of fatty degeneration is also associated with persistent postoperative dysfunction, highlighting the importance of accurate preoperative assessment.[ 26 ] Preoperative evaluation, most commonly based on magnetic resonance imaging (MRI), provides critical information about muscle quality and is now considered a cornerstone of surgical planning.[ 10 , 15 ] The Goutallier classification, which stratifies muscle fatty infiltration into five grades (0–4), remains the most widely used system.[ 9 ] Higher grades indicate diminished healing potential and compromised muscle performance, which are essential considerations when planning revision procedures.[ 24 ] Recent literature emphasizes that the degree of fatty degeneration should directly guide surgical decision-making, influencing not only whether a repair is attempted but also the type of procedure selected. In cases with low to moderate fatty degeneration (Goutallier grades 0–2), revision arthroscopic repair or debridement can achieve satisfactory outcomes and pain relief.[ 11 , 21 ] Conversely, in patients with advanced degeneration (grades 3–4), direct tendon repair is often infeasible due to severe retraction and poor tissue quality, necessitating alternative reconstructive strategies. Procedures such as latissimus dorsi tendon transfer (LDTT) or reverse total shoulder arthroplasty (RTSA) have shown promising results in restoring function and alleviating pain, even in cases considered irreparable.[ 7 , 16 , 18 , 27 ] Despite this growing body of evidence, the existing literature is heavily skewed toward primary rotator cuff repair, with relatively few studies specifically addressing revision settings. The biological environment in revision surgery is significantly more complex, often characterized by altered anatomy, scar tissue, and changes in tendon excursion that further exacerbate the negative impact of fatty degeneration.[ 14 , 28 ] Moreover, there is a lack of comprehensive analyses comparing surgical strategies and outcomes across different grades of fatty degeneration in revision cases, limiting the availability of evidence-based guidelines for clinical decision-making.[ 17 ] Given these limitations, there is a clear need for studies that systematically investigate how the severity of fatty degeneration influences both surgical strategy and postoperative outcomes in revision rotator cuff surgery. The present study aims to address this gap by analyzing the relationship between fatty degeneration severity, surgical approach, and functional recovery in a cohort of patients undergoing revision procedures. We hypothesize that the extent of fatty degeneration as determined by preoperative MRI is a decisive factor in guiding surgical treatment and is strongly correlated with functional outcomes. Furthermore, we aim to propose a practical, evidence-based treatment algorithm tailored to the degree of muscle degeneration to support more individualized and effective surgical decision-making. Materials and Methods This retrospective cohort study was conducted at the This retrospective cohort study was conducted at a tertiary referral academic center. All revision shoulder surgeries included in this investigation were performed at the same institution between January 2015 and December 2024. Ethical approval was obtained from the institutional review board of Gazi University Ethics Committee (Approval No: E-77082166-604.01-140872), and the study was conducted in accordance with the principles outlined in the Declaration of Helsinki. A total of 47 patients who underwent revision shoulder surgery following a failed rotator cuff repair were included in the analysis. Eligible patients were required to be 18 years of age or older, have a documented history of prior rotator cuff repair with persistent shoulder pain, functional limitation, or imaging-confirmed structural failure necessitating revision surgery, possess preoperative magnetic resonance imaging (MRI) suitable for the assessment of fatty degeneration, and have a minimum follow-up duration of 12 months. Patients presenting with acute traumatic tears without previous surgery, those with advanced glenohumeral osteoarthritis requiring primary arthroplasty, individuals with neuromuscular disorders affecting shoulder function, or cases with incomplete clinical or radiological data were excluded from the study. Preoperative MRI scans were evaluated to determine the degree of fatty degeneration in the rotator cuff muscles, including the supraspinatus, infraspinatus, subscapularis, and teres minor. Fatty infiltration was graded using the Goutallier classification (grades 0–4) [ 6 ], which stratifies muscle quality based on the extent of fatty replacement. To ensure objectivity and minimize bias, all MRI assessments were independently conducted by two blinded observers: a fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Inter-observer reliability was calculated using Cohen’s kappa coefficient (κ), and any discrepancies were resolved through consensus discussion. Based on the severity of fatty degeneration, patients were categorized into two groups: mild-to-moderate degeneration (Goutallier grades 0–2) and advanced degeneration (grades 3–4). All surgical procedures were performed by the same surgical team with expertise in shoulder reconstruction. The choice of surgical intervention was determined by a combination of preoperative clinical findings, MRI results, and intraoperative tissue quality assessment. Revision arthroscopic repair or debridement was performed in cases with reparable tendons and low-grade fatty degeneration, while implant removal and scar tissue excision were conducted when symptomatic hardware or extensive fibrosis contributed to clinical symptoms. Latissimus dorsi tendon transfer (LDTT) was considered for irreparable posterosuperior rotator cuff tears in the presence of preserved glenohumeral joint integrity. Reverse total shoulder arthroplasty (RTSA) was indicated for massive, irreparable rotator cuff tears associated with pseudoparalysis, severe fatty degeneration, or advanced muscular atrophy, where direct tendon repair was not feasible. Clinical outcomes were assessed both preoperatively and at the final follow-up (minimum 12 months) using two validated scoring systems: the University of California, Los Angeles (UCLA) Shoulder Score, which evaluates pain, function, range of motion, strength, and patient satisfaction, and the Visual Analog Scale (VAS) for pain intensity (0 = no pain, 10 = worst pain). Postoperative complications, including infection, nerve injury, implant-related problems, re-tear, and the need for reoperation, were also recorded for all patients. Statistical analyses were performed using IBM SPSS Statistics, version 26.0 (IBM Corp., Armonk, NY, USA). Data normality was evaluated using the Shapiro–Wilk test. Continuous variables were expressed as mean ± standard deviation (SD) and range, and were compared using the Student’s t-test or Mann–Whitney U test, depending on distribution. Categorical variables were presented as number and percentage [n (%)] and compared using the chi-square test or Fisher’s exact test. A p-value < 0.05 was considered statistically significant. Post hoc power analysis was conducted using the pwr package in R to evaluate the adequacy of the current sample size. Results A total of 47 patients who underwent revision shoulder surgery following failed rotator cuff repair were included in this study. The cohort consisted of 30 males (63.8%) and 17 females (36.2%), with a mean age of 54.1 ± 9.3 years (range, 38–71 years). The minimum follow-up period was 12 months, with a mean follow-up duration of 18.6 ± 4.2 months (range, 12–26 months). According to preoperative magnetic resonance imaging (MRI) assessment based on the Goutallier classification, 27 patients (57.4%) were classified as having mild-to-moderate fatty degeneration (grades 0–2), while 20 patients (42.6%) demonstrated advanced degeneration (grades 3–4). There were no statistically significant differences between the two groups regarding demographic characteristics, including age, sex distribution, follow-up duration, or involvement of the dominant extremity (all p > 0.05), indicating good baseline comparability Table 1 . The distribution of surgical procedures differed significantly according to the severity of fatty degeneration Table 2 . Table 1 Baseline demographics and clinical characteristics Variable Overall (n = 47) Mild–Moderate (0–2) (n = 27) Advanced (3–4) (n = 20) p-value Age (years) 54.1 ± 9.3 52.8 ± 8.7 55.9 ± 9.8 0.28 Sex, male 30 (63.8%) 17 (63.0%) 13 (65.0%) 0.87 Follow-up (months) 18.6 ± 4.2 18.2 ± 3.9 19.1 ± 4.5 0.52 Dominant side involved 32 (68.1%) 18 (66.7%) 14 (70.0%) 0.79 Table 2 Surgical procedures by fatty degeneration severity Procedure Overall (n = 47) Mild–Moderate (0–2) (n = 27) Advanced (3–4) (n = 20) p-value Arthroscopic revision / debridement 25 (53.2%) 22 (81.5%) 3 (15.0%) < 0.001 Implant removal / scar excision 5 (10.6%) 5 (18.5%) 0 (0.0%) 0.041 Latissimus dorsi tendon transfer (LDTT) 8 (17.0%) 0 (0.0%) 8 (40.0%) < 0.001 Reverse total shoulder arthroplasty (RTSA) 9 (19.1%) 0 (0.0%) 9 (45.0%) < 0.001 Patients with mild-to-moderate degeneration predominantly underwent arthroscopic revision or debridement, whereas those with advanced degeneration were more likely to undergo reconstructive interventions. Specifically, arthroscopic revision or debridement was performed in 22 of 27 patients (81.5%) in the mild group, compared with only 3 of 20 patients (15.0%) in the advanced group (p < 0.001). Implant removal or scar excision was performed exclusively in the mild group (5 patients, 18.5%), whereas no such procedures were required in the advanced group (p = 0.041). Conversely, latissimus dorsi tendon transfer (LDTT) and reverse total shoulder arthroplasty (RTSA) were significantly more common among patients with advanced degeneration. LDTT was performed in 8 of 20 patients (40.0%), and RTSA in 9 of 20 patients (45.0%), whereas neither procedure was performed in the mild group (both p < 0.001). These findings indicate that the extent of fatty degeneration strongly influenced surgical decision-making and the choice of revision strategy. Functional outcomes at the final follow-up demonstrated significant differences between the two groups Table 3 . Table 3 Functional outcomes at final follow-up Outcome measure Mild–Moderate (0–2) (n = 27) Advanced (3–4) (n = 20) p-value UCLA Shoulder Score 21.1 ± 4.8 17.2 ± 4.1 0.040 VAS Pain Score 4.3 ± 1.2 6.1 ± 1.4 0.020 Patients with mild-to-moderate fatty degeneration achieved significantly higher University of California, Los Angeles (UCLA) shoulder scores compared to those with advanced degeneration (21.1 ± 4.8 vs. 17.2 ± 4.1, p = 0.040). Similarly, Visual Analog Scale (VAS) scores for pain were significantly lower in the mild group (4.3 ± 1.2) than in the advanced group (6.1 ± 1.4, p = 0.020), indicating better pain control and superior functional recovery among patients with lower degrees of fatty infiltration. These results suggest that the severity of fatty degeneration is closely correlated with postoperative outcomes, with higher grades associated with poorer functional results and persistent pain despite revision surgery. The study demonstrated high statistical power (> 95%) for detecting differences in major surgical interventions between fatty degeneration groups, with large effect sizes for LDTT (w = 0.53, power = 95.0%), RTSA (w = 0.57, power = 97.2%), and arthroscopic revision (w = 0.66, power = 99.5%). VAS pain scores similarly achieved adequate power (d = 1.40, power = 99.0%). These findings indicate that the study was adequately powered to detect clinically significant differences in surgical strategy selection, while secondary outcomes warrant validation in larger cohorts. The inter-observer reliability for Goutallier grading between the orthopedic surgeon and musculoskeletal radiologist was excellent Table 4 . Table 4 Inter-observer reliability for Goutallier grading Measure κ p-value Goutallier classification (grades 0–4) 0.86 < 0.001 The agreement yielded a Cohen’s kappa coefficient of 0.86 (p < 0.001), confirming the reproducibility and reliability of the imaging-based grading system. This high level of agreement supports the objectivity of preoperative evaluation and strengthens the validity of the study findings.The overall postoperative complication rate was 10.6% (5/47), and detailed outcomes are presented in Table 5 . Table 5 Postoperative complications (overall, n = 47) Complication n (%) Superficial wound infection 2 (4.3%) Transient axillary nerve palsy 1 (2.1%) Postoperative stiffness requiring manipulation under anesthesia 1 (2.1%) Implant-related irritation requiring reoperation 1 (2.1%) Total complications 5 (10.6%) Complications included two cases of superficial wound infection, one transient axillary nerve palsy, one case of postoperative shoulder stiffness requiring manipulation under anesthesia, and one case of implant-related irritation necessitating revision surgery. No cases of deep infection, prosthesis dislocation, or neurovascular injury were observed during the follow-up period. The complication rates did not differ significantly between the mild and advanced degeneration groups (p > 0.05). Discussion Our findings indicate that patients with mild-to-moderate fatty degeneration achieve significantly better functional outcomes and experience lower postoperative pain following revision arthroscopy, including procedures such as debridement and implant removal whereas those with advanced fatty degeneration more often require reconstructive procedures such as latissimus dorsi tendon transfer (LDTT) or reverse total shoulder arthroplasty (RTSA) to achieve satisfactory clinical results. Fatty degeneration is a pathological process characterized by the replacement of contractile muscle fibers with adipose tissue, resulting in impaired muscle strength, reduced tendon healing capacity, and poorer postoperative recovery.[ 5 , 9 ] Its negative prognostic impact on primary rotator cuff repair outcomes is well established, with higher Goutallier grades consistently associated with increased re-tear rates, decreased tendon integrity, and inferior functional outcomes.[ 4 , 20 ] Our findings extend these observations to revision settings, where the biological environment is more complex and less favorable due to previous surgical interventions, scar formation, and altered biomechanics. Notably, patients with Goutallier grade 3–4 degeneration exhibited significantly lower UCLA scores and higher pain levels, emphasizing the detrimental role of advanced degeneration on postoperative results. The choice of surgical technique in revision rotator cuff surgery should be guided by the extent of fatty degeneration. In our series, patients with Goutallier grades 0–2 benefited most from revision arthroscopic repair and debridement, consistent with previous studies reporting satisfactory outcomes in cases with preserved tendon quality and muscle integrity.[ 8 , 13 ] Conversely, LDTT and RTSA were frequently required in cases with advanced fatty infiltration, where direct repair was not feasible due to severe retraction, poor tissue quality, and compromised muscle function. These findings align with the work of Gerber et al.[ 7 ] and Mihata et al.[ 22 ], who demonstrated that tendon transfer and superior capsule reconstruction can achieve functional restoration in irreparable cuff tears with significant fatty degeneration. Moreover, our data support the conclusion of Kanatlı et al.[ 12 ], who emphasized that tailoring the surgical approach according to muscle quality significantly reduces the risk of revision failure and improves long-term functional outcomes. Another key observation from this study is the high level of inter-observer agreement in Goutallier grading between the orthopedic surgeon and the radiologist. The excellent kappa coefficient (κ = 0.86) reflects the reproducibility and clinical utility of MRI-based evaluation, supporting its routine use in preoperative planning.[ 26 ] This is particularly important in revision cases, where intraoperative decision-making can be challenging due to scarring, distorted anatomy, and compromised tissue quality. A reliable preoperative grading system provides surgeons with critical information for anticipating reparability and planning the most appropriate surgical intervention. Our findings also have implications for patient counseling and expectation management. Patients with advanced fatty degeneration should be informed about the limited potential of arthroscopic revision procedures and the possible need for more complex reconstructive techniques such as LDTT or RTSA. Furthermore, understanding the relationship between fatty degeneration and outcomes may also guide rehabilitation strategies, as patients with advanced degeneration may require more intensive postoperative rehabilitation or adjunctive biologic treatments to optimize recovery. This study is not without limitations. Its retrospective design introduces the potential for selection bias, and the sample size, while comparable to similar studies, may limit the statistical power to detect smaller differences. The follow-up duration, with a mean of 18.6 months, may not be sufficient to capture long-term outcomes such as implant survival or late re-tear rates. Additionally, we did not evaluate muscle strength or quality-of-life measures beyond UCLA and VAS scores, which could provide additional insights into functional recovery. Despite these limitations, the homogeneous patient cohort, objective imaging-based assessment, and standardized surgical protocols strengthen the validity of our findings. Future research should focus on prospective, multicenter studies with larger sample sizes and longer follow-up periods. Moreover, exploring preoperative interventions aimed at improving muscle quality including biologic augmentation, regenerative therapies, or targeted prehabilitation may further enhance surgical outcomes in patients with advanced fatty degeneration.[ 2 , 23 ] Conclusion This study highlights the pivotal role of rotator cuff muscle fatty degeneration in guiding surgical decision-making and determining postoperative outcomes in revision shoulder surgery. Stratifying patients according to the degree of fatty infiltration enables more accurate preoperative planning, individualized treatment strategies, and improved patient counseling. While arthroscopic revision procedures, including debridement and implant removal, are often sufficient for cases with mild-to-moderate degeneration, advanced fatty degeneration typically necessitates more complex interventions such as latissimus dorsi tendon transfer or reverse total shoulder arthroplasty. Incorporating preoperative MRI-based assessment of muscle quality into routine clinical practice may enhance functional outcomes, reduce failure rates, and optimize surgical strategies in complex revision cases. Declarations Human Ethics and Consent to Participate declarations This study was approved by the Ethics Committee of Gazi University (Decision No: E-77082166-604.01-140872; Research Code: 2025-2134). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent to participate was obtained from all human participants included in the study. Clinical Trial Number Clinical trial number: not applicable. Funding This research did not receive any specific funding from public, commercial, or not-for-profit funding agencies. Author Contribution Tarık Elma, MD, and Orkun Büyüksayın, MD contributed to study conception, surgical treatment of patients, and critical revision of the manuscript.Ahmet Yiğit Kaptan, MD, Furkan Aral, MD, Toygun Kağan Eren, MD, and Ulunay Kanatlı, MD were involved in surgical procedures, data acquisition, clinical follow-up, and interpretation of the results.Seda Nur Tosun, MD, as a musculoskeletal radiologist, performed the MRI-based assessment of rotator cuff muscle fatty degeneration using the Goutallier classification and contributed to radiological data interpretation.All authors contributed to manuscript preparation, reviewed the final version, and approved the submission. 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Shoulder Elb. 16 (5), 474–480 (2024). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8492225","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":581429930,"identity":"63cfa556-2598-4f6c-99a8-ba7d2f74ab2a","order_by":0,"name":"Tarık Elma","email":"","orcid":"","institution":"Private Medline Adana Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tarık","middleName":"","lastName":"Elma","suffix":""},{"id":581429931,"identity":"4562b3ff-1d67-409e-9151-7c8a12e981e2","order_by":1,"name":"Orkun Büyüksayın","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Orkun","middleName":"","lastName":"Büyüksayın","suffix":""},{"id":581429932,"identity":"8996b323-6003-4a49-a880-af602b7402fa","order_by":2,"name":"Furkan Aral","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYDCCA4wPgASYyXjgA5BkYyeohdkApoXh4AyQFmZStBzmAZGEtPDdPswmXXHGLo9/9uEHh21+bZPnY2Zg/PAxB7cWyXPJbJJnbiQXS5xLMzic23fbsI2ZgVly5jbcWgzO8B+TbPjAnNhwhgGopec2I1ALGzMvXi3MbEAt9Ynzz7B/OGzZc9ueSC03DiduOMNjcJjhx+1EglokzzAzWzacOZ648QxPwcHehtvJbcyMzXj9wneGmfFmw7HqxHln2Dc++PHntu389uaDHz7i0YIKGNvAZAOx6kHgDymKR8EoGAWjYKQAAPyuV5jcbelTAAAAAElFTkSuQmCC","orcid":"","institution":"Gazi University","correspondingAuthor":true,"prefix":"","firstName":"Furkan","middleName":"","lastName":"Aral","suffix":""},{"id":581429933,"identity":"30cf9190-565f-4910-a648-ac79d3fb6e09","order_by":3,"name":"Ahmet Yiğit Kaptan","email":"","orcid":"","institution":"Harran University","correspondingAuthor":false,"prefix":"","firstName":"Ahmet","middleName":"Yiğit","lastName":"Kaptan","suffix":""},{"id":581429934,"identity":"0fc59c37-6ded-4c1b-94d8-dfae9704bc70","order_by":4,"name":"Seda Nur Tosun","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Seda","middleName":"Nur","lastName":"Tosun","suffix":""},{"id":581429935,"identity":"771d1264-eb6b-4feb-97cb-8d10b2a5eec6","order_by":5,"name":"Toygun Kağan Eren","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Toygun","middleName":"Kağan","lastName":"Eren","suffix":""},{"id":581429936,"identity":"bdeea849-f5c3-428f-a7f9-34ec576f86a3","order_by":6,"name":"Ulunay Kanatlı","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Ulunay","middleName":"","lastName":"Kanatlı","suffix":""}],"badges":[],"createdAt":"2025-12-31 21:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8492225/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8492225/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108112668,"identity":"86c33414-6c0b-4d5b-81e5-a2019a5daced","added_by":"auto","created_at":"2026-04-29 13:10:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":257140,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8492225/v1/7258da55-415b-4204-b186-4748dd7a91fa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preoperative Fatty Degeneration as a Key Determinant of Surgical Strategy and Outcomes in Revision Rotator Cuff Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRevision rotator cuff surgery remains one of the most complex challenges in shoulder surgery due to the multifactorial nature of biological and mechanical influences that compromise outcomes. Factors such as tendon retraction, muscle atrophy, poor tissue quality, and extensive scar formation significantly reduce reparability and increase the risk of postoperative complications.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Despite advances in arthroscopic techniques, improved biomaterials, and structured rehabilitation protocols, clinical results after revision procedures are consistently inferior to those following primary repair.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Understanding the key prognostic factors that influence surgical decision-making is therefore essential to improve outcomes in this demanding clinical scenario.\u003c/p\u003e \u003cp\u003eAmong these prognostic variables, fatty degeneration of the rotator cuff muscles is widely recognized as one of the most decisive. Initially described by Goutallier et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], fatty degeneration represents a pathological shift in muscle composition that compromises mechanical strength and biological healing potential. Its clinical significance has been well established in primary rotator cuff surgery, where higher degrees of fatty infiltration correlate with increased re-tear rates, reduced tendon healing capacity, and worse functional outcomes.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Importantly, the presence of fatty degeneration is also associated with persistent postoperative dysfunction, highlighting the importance of accurate preoperative assessment.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePreoperative evaluation, most commonly based on magnetic resonance imaging (MRI), provides critical information about muscle quality and is now considered a cornerstone of surgical planning.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] The Goutallier classification, which stratifies muscle fatty infiltration into five grades (0\u0026ndash;4), remains the most widely used system.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Higher grades indicate diminished healing potential and compromised muscle performance, which are essential considerations when planning revision procedures.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eRecent literature emphasizes that the degree of fatty degeneration should directly guide surgical decision-making, influencing not only whether a repair is attempted but also the type of procedure selected. In cases with low to moderate fatty degeneration (Goutallier grades 0\u0026ndash;2), revision arthroscopic repair or debridement can achieve satisfactory outcomes and pain relief.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Conversely, in patients with advanced degeneration (grades 3\u0026ndash;4), direct tendon repair is often infeasible due to severe retraction and poor tissue quality, necessitating alternative reconstructive strategies. Procedures such as latissimus dorsi tendon transfer (LDTT) or reverse total shoulder arthroplasty (RTSA) have shown promising results in restoring function and alleviating pain, even in cases considered irreparable.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite this growing body of evidence, the existing literature is heavily skewed toward primary rotator cuff repair, with relatively few studies specifically addressing revision settings. The biological environment in revision surgery is significantly more complex, often characterized by altered anatomy, scar tissue, and changes in tendon excursion that further exacerbate the negative impact of fatty degeneration.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] Moreover, there is a lack of comprehensive analyses comparing surgical strategies and outcomes across different grades of fatty degeneration in revision cases, limiting the availability of evidence-based guidelines for clinical decision-making.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eGiven these limitations, there is a clear need for studies that systematically investigate how the severity of fatty degeneration influences both surgical strategy and postoperative outcomes in revision rotator cuff surgery. The present study aims to address this gap by analyzing the relationship between fatty degeneration severity, surgical approach, and functional recovery in a cohort of patients undergoing revision procedures. We hypothesize that the extent of fatty degeneration as determined by preoperative MRI is a decisive factor in guiding surgical treatment and is strongly correlated with functional outcomes. Furthermore, we aim to propose a practical, evidence-based treatment algorithm tailored to the degree of muscle degeneration to support more individualized and effective surgical decision-making.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis retrospective cohort study was conducted at the This retrospective cohort study was conducted at a tertiary referral academic center. All revision shoulder surgeries included in this investigation were performed at the same institution between January 2015 and December 2024. Ethical approval was obtained from the institutional review board of Gazi University Ethics Committee (Approval No: E-77082166-604.01-140872), and the study was conducted in accordance with the principles outlined in the Declaration of Helsinki. A total of 47 patients who underwent revision shoulder surgery following a failed rotator cuff repair were included in the analysis. Eligible patients were required to be 18 years of age or older, have a documented history of prior rotator cuff repair with persistent shoulder pain, functional limitation, or imaging-confirmed structural failure necessitating revision surgery, possess preoperative magnetic resonance imaging (MRI) suitable for the assessment of fatty degeneration, and have a minimum follow-up duration of 12 months. Patients presenting with acute traumatic tears without previous surgery, those with advanced glenohumeral osteoarthritis requiring primary arthroplasty, individuals with neuromuscular disorders affecting shoulder function, or cases with incomplete clinical or radiological data were excluded from the study.\u003c/p\u003e \u003cp\u003ePreoperative MRI scans were evaluated to determine the degree of fatty degeneration in the rotator cuff muscles, including the supraspinatus, infraspinatus, subscapularis, and teres minor. Fatty infiltration was graded using the Goutallier classification (grades 0\u0026ndash;4) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], which stratifies muscle quality based on the extent of fatty replacement. To ensure objectivity and minimize bias, all MRI assessments were independently conducted by two blinded observers: a fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Inter-observer reliability was calculated using Cohen\u0026rsquo;s kappa coefficient (κ), and any discrepancies were resolved through consensus discussion. Based on the severity of fatty degeneration, patients were categorized into two groups: mild-to-moderate degeneration (Goutallier grades 0\u0026ndash;2) and advanced degeneration (grades 3\u0026ndash;4).\u003c/p\u003e \u003cp\u003eAll surgical procedures were performed by the same surgical team with expertise in shoulder reconstruction. The choice of surgical intervention was determined by a combination of preoperative clinical findings, MRI results, and intraoperative tissue quality assessment. Revision arthroscopic repair or debridement was performed in cases with reparable tendons and low-grade fatty degeneration, while implant removal and scar tissue excision were conducted when symptomatic hardware or extensive fibrosis contributed to clinical symptoms. Latissimus dorsi tendon transfer (LDTT) was considered for irreparable posterosuperior rotator cuff tears in the presence of preserved glenohumeral joint integrity. Reverse total shoulder arthroplasty (RTSA) was indicated for massive, irreparable rotator cuff tears associated with pseudoparalysis, severe fatty degeneration, or advanced muscular atrophy, where direct tendon repair was not feasible.\u003c/p\u003e \u003cp\u003eClinical outcomes were assessed both preoperatively and at the final follow-up (minimum 12 months) using two validated scoring systems: the University of California, Los Angeles (UCLA) Shoulder Score, which evaluates pain, function, range of motion, strength, and patient satisfaction, and the Visual Analog Scale (VAS) for pain intensity (0\u0026thinsp;=\u0026thinsp;no pain, 10\u0026thinsp;=\u0026thinsp;worst pain). Postoperative complications, including infection, nerve injury, implant-related problems, re-tear, and the need for reoperation, were also recorded for all patients.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics, version 26.0 (IBM Corp., Armonk, NY, USA). Data normality was evaluated using the Shapiro\u0026ndash;Wilk test. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and range, and were compared using the Student\u0026rsquo;s t-test or Mann\u0026ndash;Whitney U test, depending on distribution. Categorical variables were presented as number and percentage [n (%)] and compared using the chi-square test or Fisher\u0026rsquo;s exact test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Post hoc power analysis was conducted using the pwr package in R to evaluate the adequacy of the current sample size.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 47 patients who underwent revision shoulder surgery following failed rotator cuff repair were included in this study. The cohort consisted of 30 males (63.8%) and 17 females (36.2%), with a mean age of 54.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3 years (range, 38\u0026ndash;71 years). The minimum follow-up period was 12 months, with a mean follow-up duration of 18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2 months (range, 12\u0026ndash;26 months). According to preoperative magnetic resonance imaging (MRI) assessment based on the Goutallier classification, 27 patients (57.4%) were classified as having mild-to-moderate fatty degeneration (grades 0\u0026ndash;2), while 20 patients (42.6%) demonstrated advanced degeneration (grades 3\u0026ndash;4). There were no statistically significant differences between the two groups regarding demographic characteristics, including age, sex distribution, follow-up duration, or involvement of the dominant extremity (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating good baseline comparability Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The distribution of surgical procedures differed significantly according to the severity of fatty degeneration Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline demographics and clinical characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMild\u0026ndash;Moderate (0\u0026ndash;2) (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdvanced (3\u0026ndash;4) (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (63.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (63.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (65.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDominant side involved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (68.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (70.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical procedures by fatty degeneration severity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMild\u0026ndash;Moderate (0\u0026ndash;2) (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdvanced (3\u0026ndash;4) (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthroscopic revision / debridement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (53.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (81.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant removal / scar excision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (10.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLatissimus dorsi tendon transfer (LDTT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReverse total shoulder arthroplasty (RTSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (19.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients with mild-to-moderate degeneration predominantly underwent arthroscopic revision or debridement, whereas those with advanced degeneration were more likely to undergo reconstructive interventions. Specifically, arthroscopic revision or debridement was performed in 22 of 27 patients (81.5%) in the mild group, compared with only 3 of 20 patients (15.0%) in the advanced group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Implant removal or scar excision was performed exclusively in the mild group (5 patients, 18.5%), whereas no such procedures were required in the advanced group (p\u0026thinsp;=\u0026thinsp;0.041). Conversely, latissimus dorsi tendon transfer (LDTT) and reverse total shoulder arthroplasty (RTSA) were significantly more common among patients with advanced degeneration. LDTT was performed in 8 of 20 patients (40.0%), and RTSA in 9 of 20 patients (45.0%), whereas neither procedure was performed in the mild group (both p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings indicate that the extent of fatty degeneration strongly influenced surgical decision-making and the choice of revision strategy. Functional outcomes at the final follow-up demonstrated significant differences between the two groups Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFunctional outcomes at final follow-up\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild\u0026ndash;Moderate (0\u0026ndash;2) (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdvanced (3\u0026ndash;4) (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUCLA Shoulder Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Pain Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients with mild-to-moderate fatty degeneration achieved significantly higher University of California, Los Angeles (UCLA) shoulder scores compared to those with advanced degeneration (21.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 vs. 17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1, p\u0026thinsp;=\u0026thinsp;0.040). Similarly, Visual Analog Scale (VAS) scores for pain were significantly lower in the mild group (4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2) than in the advanced group (6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4, p\u0026thinsp;=\u0026thinsp;0.020), indicating better pain control and superior functional recovery among patients with lower degrees of fatty infiltration. These results suggest that the severity of fatty degeneration is closely correlated with postoperative outcomes, with higher grades associated with poorer functional results and persistent pain despite revision surgery. The study demonstrated high statistical power (\u0026gt;\u0026thinsp;95%) for detecting differences in major surgical interventions between fatty degeneration groups, with large effect sizes for LDTT (w\u0026thinsp;=\u0026thinsp;0.53, power\u0026thinsp;=\u0026thinsp;95.0%), RTSA (w\u0026thinsp;=\u0026thinsp;0.57, power\u0026thinsp;=\u0026thinsp;97.2%), and arthroscopic revision (w\u0026thinsp;=\u0026thinsp;0.66, power\u0026thinsp;=\u0026thinsp;99.5%). VAS pain scores similarly achieved adequate power (d\u0026thinsp;=\u0026thinsp;1.40, power\u0026thinsp;=\u0026thinsp;99.0%). These findings indicate that the study was adequately powered to detect clinically significant differences in surgical strategy selection, while secondary outcomes warrant validation in larger cohorts.\u003c/p\u003e \u003cp\u003eThe inter-observer reliability for Goutallier grading between the orthopedic surgeon and musculoskeletal radiologist was excellent Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInter-observer reliability for Goutallier grading\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eκ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoutallier classification (grades 0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe agreement yielded a Cohen\u0026rsquo;s kappa coefficient of 0.86 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), confirming the reproducibility and reliability of the imaging-based grading system. This high level of agreement supports the objectivity of preoperative evaluation and strengthens the validity of the study findings.The overall postoperative complication rate was 10.6% (5/47), and detailed outcomes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative complications (overall, n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperficial wound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransient axillary nerve palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative stiffness requiring manipulation under anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant-related irritation requiring reoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (10.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComplications included two cases of superficial wound infection, one transient axillary nerve palsy, one case of postoperative shoulder stiffness requiring manipulation under anesthesia, and one case of implant-related irritation necessitating revision surgery. No cases of deep infection, prosthesis dislocation, or neurovascular injury were observed during the follow-up period. The complication rates did not differ significantly between the mild and advanced degeneration groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings indicate that patients with mild-to-moderate fatty degeneration achieve significantly better functional outcomes and experience lower postoperative pain following revision arthroscopy, including procedures such as debridement and implant removal whereas those with advanced fatty degeneration more often require reconstructive procedures such as latissimus dorsi tendon transfer (LDTT) or reverse total shoulder arthroplasty (RTSA) to achieve satisfactory clinical results.\u003c/p\u003e \u003cp\u003eFatty degeneration is a pathological process characterized by the replacement of contractile muscle fibers with adipose tissue, resulting in impaired muscle strength, reduced tendon healing capacity, and poorer postoperative recovery.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Its negative prognostic impact on primary rotator cuff repair outcomes is well established, with higher Goutallier grades consistently associated with increased re-tear rates, decreased tendon integrity, and inferior functional outcomes.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Our findings extend these observations to revision settings, where the biological environment is more complex and less favorable due to previous surgical interventions, scar formation, and altered biomechanics. Notably, patients with Goutallier grade 3\u0026ndash;4 degeneration exhibited significantly lower UCLA scores and higher pain levels, emphasizing the detrimental role of advanced degeneration on postoperative results.\u003c/p\u003e \u003cp\u003eThe choice of surgical technique in revision rotator cuff surgery should be guided by the extent of fatty degeneration. In our series, patients with Goutallier grades 0\u0026ndash;2 benefited most from revision arthroscopic repair and debridement, consistent with previous studies reporting satisfactory outcomes in cases with preserved tendon quality and muscle integrity.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Conversely, LDTT and RTSA were frequently required in cases with advanced fatty infiltration, where direct repair was not feasible due to severe retraction, poor tissue quality, and compromised muscle function. These findings align with the work of Gerber et al.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and Mihata et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], who demonstrated that tendon transfer and superior capsule reconstruction can achieve functional restoration in irreparable cuff tears with significant fatty degeneration. Moreover, our data support the conclusion of Kanatlı et al.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], who emphasized that tailoring the surgical approach according to muscle quality significantly reduces the risk of revision failure and improves long-term functional outcomes.\u003c/p\u003e \u003cp\u003eAnother key observation from this study is the high level of inter-observer agreement in Goutallier grading between the orthopedic surgeon and the radiologist. The excellent kappa coefficient (κ\u0026thinsp;=\u0026thinsp;0.86) reflects the reproducibility and clinical utility of MRI-based evaluation, supporting its routine use in preoperative planning.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] This is particularly important in revision cases, where intraoperative decision-making can be challenging due to scarring, distorted anatomy, and compromised tissue quality. A reliable preoperative grading system provides surgeons with critical information for anticipating reparability and planning the most appropriate surgical intervention.\u003c/p\u003e \u003cp\u003eOur findings also have implications for patient counseling and expectation management. Patients with advanced fatty degeneration should be informed about the limited potential of arthroscopic revision procedures and the possible need for more complex reconstructive techniques such as LDTT or RTSA. Furthermore, understanding the relationship between fatty degeneration and outcomes may also guide rehabilitation strategies, as patients with advanced degeneration may require more intensive postoperative rehabilitation or adjunctive biologic treatments to optimize recovery.\u003c/p\u003e \u003cp\u003eThis study is not without limitations. Its retrospective design introduces the potential for selection bias, and the sample size, while comparable to similar studies, may limit the statistical power to detect smaller differences. The follow-up duration, with a mean of 18.6 months, may not be sufficient to capture long-term outcomes such as implant survival or late re-tear rates. Additionally, we did not evaluate muscle strength or quality-of-life measures beyond UCLA and VAS scores, which could provide additional insights into functional recovery. Despite these limitations, the homogeneous patient cohort, objective imaging-based assessment, and standardized surgical protocols strengthen the validity of our findings. Future research should focus on prospective, multicenter studies with larger sample sizes and longer follow-up periods. Moreover, exploring preoperative interventions aimed at improving muscle quality including biologic augmentation, regenerative therapies, or targeted prehabilitation may further enhance surgical outcomes in patients with advanced fatty degeneration.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the pivotal role of rotator cuff muscle fatty degeneration in guiding surgical decision-making and determining postoperative outcomes in revision shoulder surgery. Stratifying patients according to the degree of fatty infiltration enables more accurate preoperative planning, individualized treatment strategies, and improved patient counseling. While arthroscopic revision procedures, including debridement and implant removal, are often sufficient for cases with mild-to-moderate degeneration, advanced fatty degeneration typically necessitates more complex interventions such as latissimus dorsi tendon transfer or reverse total shoulder arthroplasty. Incorporating preoperative MRI-based assessment of muscle quality into routine clinical practice may enhance functional outcomes, reduce failure rates, and optimize surgical strategies in complex revision cases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eHuman Ethics and Consent to Participate declarations\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Gazi University (Decision No: E-77082166-604.01-140872; Research Code: 2025-2134). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent to participate was obtained from all human participants included in the study.\u003c/p\u003e\n\u003ch2\u003eClinical Trial Number\u003c/h2\u003e \u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific funding from public, commercial, or not-for-profit funding agencies.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTarık Elma, MD, and Orkun B\u0026uuml;y\u0026uuml;ksayın, MD contributed to study conception, surgical treatment of patients, and critical revision of the manuscript.Ahmet Yiğit Kaptan, MD, Furkan Aral, MD, Toygun Kağan Eren, MD, and Ulunay Kanatlı, MD were involved in surgical procedures, data acquisition, clinical follow-up, and interpretation of the results.Seda Nur Tosun, MD, as a musculoskeletal radiologist, performed the MRI-based assessment of rotator cuff muscle fatty degeneration using the Goutallier classification and contributed to radiological data interpretation.All authors contributed to manuscript preparation, reviewed the final version, and approved the submission.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analysed during the current study were generated with informed consent obtained from all participants and are not publicly available as they are stored in the senior author\u0026rsquo;s institutional database but are available from the senior author on reasonable request.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoileau, P. et al. 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Sports Med.\u003c/em\u003e \u003cb\u003e43\u003c/b\u003e (3), 557\u0026ndash;564 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomazeau, H., Boukobza, E., Morcet, N., Chaperon, J. \u0026amp; Langlais, F. Prediction of Rotator Cuff Repair Results by Magnetic Resonance Imaging. \u003cem\u003eClin. Orthop. Relat. Res.\u003c/em\u003e \u003cb\u003e344\u003c/b\u003e, 275\u0026ndash;283 (1997).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelasquez Garcia, A. et al. Mid- to long-term outcomes of latissimus dorsi tendon transfer for massive irreparable posterosuperior rotator cuff tears: a systematic review and meta-analysis. \u003cem\u003eJ. Shoulder Elb. Surg.\u003c/em\u003e \u003cb\u003e33\u003c/b\u003e (4), 959\u0026ndash;974 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWelch, J. M. et al. Reverse shoulder arthroplasty following failed rotator cuff repair: A systematic review and meta-analysis. \u003cem\u003eShoulder Elb.\u003c/em\u003e \u003cb\u003e16\u003c/b\u003e (5), 474\u0026ndash;480 (2024).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"revision rotator cuff surgery, fatty degeneration, Goutallier classification, magnetic resonance imaging, latissimus dorsi tendon transfer, reverse shoulder arthroplasty","lastPublishedDoi":"10.21203/rs.3.rs-8492225/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8492225/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRevision rotator cuff surgery remains a significant clinical challenge due to tendon retraction, compromised tissue quality, muscle atrophy, and extensive scarring, all of which adversely affect reparability and postoperative outcomes. Although the prognostic value of rotator cuff muscle fatty degeneration is well established in primary repairs, its influence in the revision setting has not been fully clarified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study included 47 patients (mean age, 54.1 ± 9.3 years) who underwent revision rotator cuff surgery between 2015 and 2024. Preoperative magnetic resonance imaging (MRI) was used to assess rotator cuff muscle fatty degeneration according to the Goutallier classification. Patients were stratified into mild-to-moderate (grades 0–2) and advanced (grades 3–4) degeneration groups. Surgical strategies and postoperative functional outcomes, including the University of California, Los Angeles (UCLA) shoulder score and Visual Analog Scale (VAS) pain score, were compared between groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 47 patients, 27 (57.4%) demonstrated mild-to-moderate fatty degeneration, whereas 20 patients (42.6%) had advanced degeneration. Arthroscopic revision or debridement was performed in 81.5% of patients with mild-to-moderate degeneration, while reconstructive procedures, including latissimus dorsi tendon transfer or reverse total shoulder arthroplasty, were performed in 85.0% of patients with advanced degeneration (p \u0026lt; 0.001). Patients in the mild-to-moderate group achieved significantly better functional outcomes, with higher mean UCLA scores (21.1 ± 4.8 vs. 17.2 ± 4.1; p = 0.040) and lower mean VAS pain scores (4.3 ± 1.2 vs. 6.1 ± 1.4; p = 0.020).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe severity of preoperative rotator cuff muscle fatty degeneration appears to be a key factor in guiding surgical strategy selection and is associated with postoperative functional outcomes in revision rotator cuff surgery. Routine MRI-based assessment of muscle quality may support individualized surgical planning, optimize clinical outcomes, and improve patient counseling in complex revision cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design: \u003c/strong\u003eRetrospective cohort study; Level of Evidence, 3.\u003c/p\u003e","manuscriptTitle":"Preoperative Fatty Degeneration as a Key Determinant of Surgical Strategy and Outcomes in Revision Rotator Cuff Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 10:51:56","doi":"10.21203/rs.3.rs-8492225/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"38371894-af55-42af-82f2-88fd9ae717af","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-04-29T13:06:27+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61856250,"name":"Health sciences/Diseases"},{"id":61856251,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-04-29T13:10:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 10:51:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8492225","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8492225","identity":"rs-8492225","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}