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

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.