JBJS | The Results of Repair of Massive Tears of the Rotator Cuff*†

The Journal of Bone & Joint Surgery, Volume 82, Issue 4

Articles | April 01, 2000

The Results of Repair of Massive Tears of the Rotator Cuff*†

Christian Gerber, M.D.‡; Bruno Fuchs, M.D.‡; Juerg Hodler, M.D.‡

Investigation performed at the University of Zurich, Zurich, Switzerland
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
‡Recipient of the Neer Award of the American Shoulder and Elbow Surgeons, 1998.
Department of Orthopaedics (C. G. and B. F.) and Division of Diagnostic Radiology (J. H.), University of Zurich, Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland. E-mail address for C. Gerber: cgerber@balgrist.unizh.ch.

The Journal of Bone & Joint Surgery. 2000; 82:505-505

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Abstract

Background: Massive tears of the tendons of the rotator cuff cause atrophy and fatty degeneration of the rotator cuff muscles and painful loss of function of the shoulder. Repair of massive rotator cuff tears is often followed by retears of the tendons, additional muscular degeneration, and a poor clinical outcome. The purposes of this study were to determine whether a new method of repair of rotator cuff tendons can yield a lower retear rate and a better clinical outcome than previously reported methods, to assess the muscular changes following repair of massive tears of the musculotendinous units, and to correlate findings on magnetic resonance imaging with the clinical results.

Methods: Twenty-nine massive rotator cuff tears involving complete detachment of at least two tendons were repaired operatively with use of a new laboratory-tested technique in a prospective study. At least two years (average, thirty-seven months; range, twenty-four to sixty-one months) postoperatively, twenty-seven patients were evaluated clinically and with magnetic resonance imaging to determine the clinical outcome, the integrity of the repair, and the condition of the rotator cuff muscles.

Results: The age and gender-adjusted Constant score improved from an average of 49 percent preoperatively to an average of 85 percent postoperatively, corresponding to a subjective shoulder value of 78 percent of that of a normal shoulder. Pain-free flexion improved from an average of 92 degrees to an average of 142 degrees, and abduction improved from an average of 82 degrees to an average of 137 degrees. Pain decreased and performance of activities of daily living improved significantly (p < 0.05). The seventeen patients who had a structurally successful repair all had an excellent clinical outcome. Muscle atrophy could not be reversed except in successfully repaired supraspinatus musculotendinous units. Fatty degeneration increased in all muscles.

Conclusions: The method of repair of massive rotator cuff tears that was used in this study yielded a comparatively low retear rate and good-to-excellent clinical results; however, the repair did not result in substantial reversal of muscular atrophy and fatty degeneration. Retears occurred more often in patients who had had a shorter interval between the onset of the symptoms and the operation (p < 0.05). Patients who had a retear had improvement of the shoulder compared with the preoperative state, but they had less improvement than did those who had a successful repair.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The rotator cuff undergoes progressive degenerative changes with increasing age, which may lead to tears of rotator cuff tendons. Whereas small tears may be observed in elderly asymptomatic individuals, large or very large tears are symptomatic in younger people of working age^27,36. These large or massive tears lead to weakness²⁵, are incompatible with manual labor^29,37, and may be associated with incapacitating, chronic pain and severe functional impairment. They also are often resistant to nonoperative treatment^8,10,33,40.

The term massive tear has been widely used to identify very large tears that are particularly difficult to repair and therefore are associated with an uncertain prognosis. Unfortunately, there is no universal agreement on the definition of a massive rotator cuff tear. In North America, Cofield's definition of a massive tear was a tear of greater than five centimeters in diameter⁸. Because of variations in the sizes of patients and the techniques of measurement, we believe that it is more appropriate to define the size of a tear in terms of the amount of tendon that has been detached from the tuberosities^32,33. In the current study, rotator cuff tears were defined as massive if they involved the detachment of at least two entire tendons. Most massive tears involve the supraspinatus and the infraspinatus, but anterosuperior tears involving the supraspinatus and the subscapularis also occur moderately frequently^30,33.

Repairs of tears of the rotator cuff have been reported to be highly successful, yielding durable results that are superior to the natural history of the untreated disease^{1,4,8,11,21,22,33}. The clinical outcome for patients who have a massive rotator cuff tear, however, is distinctly less satisfactory than that for patients who have a smaller tear^{1,4,8,11,14,39}, and repair may not always be warranted for massive tears.

Two important factors appear to explain the different outcomes associated with massive and smaller tears. First, the rate of retear after repair of massive tears, as assessed with imaging methods, has been reported to be between 50 and 70 percent^14,21,34,38, whereas it has been substantially lower after repair of smaller tears^{1,11,14,22,34,39}. Although retear may not be associated with frank clinical failure, the clinical result of a shoulder with a structurally successful repair is significantly superior to that of a shoulder with a retear^21,38. Second, repairs of massive rotator cuff tears are commonly associated with advanced atrophy and degeneration of the rotator cuff muscles^18,28,42. These changes, demonstrated on imaging, reflect loss of the contractile elements and changes in the physiological properties of the remaining musculotendinous units²³.

These muscular changes may be irreversible. The development of a quantitative magnetic resonance imaging method for assessment of the rotator cuff muscles, and the availability of age and gender-related normal values⁴², have made it possible to address this question with use of a noninvasive method.

The purposes of this study were to prospectively assess the results of a recently developed laboratory-tested technique^15,17 for the repair of massive tears of the rotator cuff, to determine whether or not the rotator cuff muscles recover after repair, and to correlate the structural results of magnetic resonance imaging studies with the clinical outcome.

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: TABLE IClinical Parameters in Relation to Which Rotator Cuff Tendons Were Torn Preoperatively

*The values are given as the average.†In relation to age and gender-matched normal values.‡No pain = 15 points and intolerable pain = 0 points, according to a visual analog scale.§According to the scoring system of Constant and Murley¹⁰.#Full overhead use = 10 points and elevation to less than waist level = 0 points.**Measured with an electronic dynamometer with the arm in 90 degrees of abduction in the scapular plane, the elbow extended, resistance applied at the wrist, and the forearm pronated. (Patients with active abduction of less than 90 degrees have a strength of zero.)

	Tear of Supraspinatus and Infraspinatus (N = 17)	Tear of Supraspinatus and Subscapularis (N = 10)
Preop.*	Postop.*	P Value	Preop.*	Postop.*	P Value
Constant score
Absolute¹⁰ (points)	40	73.8	0.291	48.3	74.5	0.0011
Relative†⁹ (percent)	60.6	89.3	0.123	58.3	90.5	0.0019
Pain‡(points)	7.6	14.4	0.034	3.8	12.7	0.0001
Activities of daily living§ (points)	5.8	9.3	0.0084	4.9	9.8	0.0003
Functional use of arm# (points)	6.4	8.6	0.144	7.1	9.5	0.036
Active motion
Flexion (degrees)	83	143	0.048	121	147	0.005
Abduction (degrees)	74	148	0.018	105	149	0.0043
External rotation (degrees)	41	29.3	0.74	58	52	0.54
Internal rotation§ (points)	6.8	8.6	0.122	5.6	7.6	0.05
Strength in abduction** (kg)	0.8	3.3	0.1002	3.1	3.9	0.039

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: TABLE IClinical Parameters in Relation to Which Rotator Cuff Tendons Were Torn Preoperatively

	Tear of Supraspinatus and Infraspinatus (N = 17)	Tear of Supraspinatus and Subscapularis (N = 10)
Preop.*	Postop.*	P Value	Preop.*	Postop.*	P Value
Constant score
Absolute¹⁰ (points)	40	73.8	0.291	48.3	74.5	0.0011
Relative†⁹ (percent)	60.6	89.3	0.123	58.3	90.5	0.0019
Pain‡(points)	7.6	14.4	0.034	3.8	12.7	0.0001
Activities of daily living§ (points)	5.8	9.3	0.0084	4.9	9.8	0.0003
Functional use of arm# (points)	6.4	8.6	0.144	7.1	9.5	0.036
Active motion
Flexion (degrees)	83	143	0.048	121	147	0.005
Abduction (degrees)	74	148	0.018	105	149	0.0043
External rotation (degrees)	41	29.3	0.74	58	52	0.54
Internal rotation§ (points)	6.8	8.6	0.122	5.6	7.6	0.05
Strength in abduction** (kg)	0.8	3.3	0.1002	3.1	3.9	0.039

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: TABLE IIClinical Parameters in Relation to Whether the Tear Involved Two or Three Tendons

	Tear Involving Two Tendons (N = 17)			Tear Involving Three Tendons (N = 10)
Preop.*	Postop.*	P Value	Preop.*	Postop.*	P Value
Constant score
Absolute¹⁰ (points)	47.6	74.2	0.0002	27	64.3	0.0034
Relative†⁹ (percent)	59.1	90	0.0133	31.8	76.4	0.0024
Pain‡(points)	5.2	13.4	0.0001	6.8	12.1	0.0077
Activities of daily living§ (points)	5.2	9.6	0.0001	3.4	8.8	0.001
Functional use of arm# (points)	6.9	9.1	0.0043	4.8	8.2	0.0263
Active motion
Flexion (degrees)	107	145	0.0008	66	136	0.0019
Abduction (degrees)	94	149	0.002	59	117	0.0097
External rotation (degrees)	52	43	0.59	46	38	0.625
Internal rotation§ (points)	6	8	0.01	5.8	6.4	0.42
Strength in abduction** (kg)	2.3	3.6	0.011	0.2	2.6	0.42

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: TABLE IIClinical Parameters in Relation to Whether the Tear Involved Two or Three Tendons

	Tear Involving Two Tendons (N = 17)			Tear Involving Three Tendons (N = 10)
Preop.*	Postop.*	P Value	Preop.*	Postop.*	P Value
Constant score
Absolute¹⁰ (points)	47.6	74.2	0.0002	27	64.3	0.0034
Relative†⁹ (percent)	59.1	90	0.0133	31.8	76.4	0.0024
Pain‡(points)	5.2	13.4	0.0001	6.8	12.1	0.0077
Activities of daily living§ (points)	5.2	9.6	0.0001	3.4	8.8	0.001
Functional use of arm# (points)	6.9	9.1	0.0043	4.8	8.2	0.0263
Active motion
Flexion (degrees)	107	145	0.0008	66	136	0.0019
Abduction (degrees)	94	149	0.002	59	117	0.0097
External rotation (degrees)	52	43	0.59	46	38	0.625
Internal rotation§ (points)	6	8	0.01	5.8	6.4	0.42
Strength in abduction** (kg)	2.3	3.6	0.011	0.2	2.6	0.42

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: TABLE IIIComparison of the Findings on Two Follow-up Examinations*

*The values are given as the average, for twelve patients.†The values indicate the cross-sectional area of the muscle.

	Intact Repair			Retear			Total
First Exam.	Second Exam.	P Value	First Exam.	Second Exam.	P Value	First Exam.	Second Exam.	P Value
Duration of follow-up (mos.)	16.5	39.8		16.5	39.6		16.5	39.7
Subjective shoulder value (percent)	90	90.8	0.87	76.6	65.8	0.57	83.3	78.3	0.73
Relative Constant score⁹ (percent)	95.6	95.5	0.87	63.1	69.6	0.52	79.4	82.6	0.69
Fatty degeneration^18,19 (stage)
Supraspinatus	1.66	1.33	0.52	2.5	2.8	0.57	2.08	2.1	0.97
Infraspinatus	1.6	1.5	0.63	2.5	2.0	0.37	2.08	1.75	0.32
Subscapularis	0.53	0.5	0.06	1.33	1.16	0.93	1.13	0.83	0.15
Atrophy†(mm²)
Supraspinatus	405	411	0.87	257	227	0.57	331	319	0.54
Infraspinatus	1033	1160	0.68	1028	913	0.68	1031	1036	0.72
Subscapularis	1228	1033	0.52	1192	949	0.17	1210	991	0.15

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: TABLE IIIComparison of the Findings on Two Follow-up Examinations*

*The values are given as the average, for twelve patients.†The values indicate the cross-sectional area of the muscle.

	Intact Repair			Retear			Total
First Exam.	Second Exam.	P Value	First Exam.	Second Exam.	P Value	First Exam.	Second Exam.	P Value
Duration of follow-up (mos.)	16.5	39.8		16.5	39.6		16.5	39.7
Subjective shoulder value (percent)	90	90.8	0.87	76.6	65.8	0.57	83.3	78.3	0.73
Relative Constant score⁹ (percent)	95.6	95.5	0.87	63.1	69.6	0.52	79.4	82.6	0.69
Fatty degeneration^18,19 (stage)
Supraspinatus	1.66	1.33	0.52	2.5	2.8	0.57	2.08	2.1	0.97
Infraspinatus	1.6	1.5	0.63	2.5	2.0	0.37	2.08	1.75	0.32
Subscapularis	0.53	0.5	0.06	1.33	1.16	0.93	1.13	0.83	0.15
Atrophy†(mm²)
Supraspinatus	405	411	0.87	257	227	0.57	331	319	0.54
Infraspinatus	1033	1160	0.68	1028	913	0.68	1031	1036	0.72
Subscapularis	1228	1033	0.52	1192	949	0.17	1210	991	0.15

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: TABLE IVIntegrity of the Rotator Cuff as Seen on Magnetic Resonance Imaging*

*The values are given as the number of patients.

	Supraspinatus and Infraspinatus	Supraspinatus and Subscapularis	All Three Tendons
Preop. tear	7	10	10
Postop.
Intact	4	8	5
Retear
<1.5 cm	0	0	1
1.5-3.0 cm	2	1	2
3.1-5.0 cm	1	1	2
5.0 cm	0	0	0

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: TABLE IVIntegrity of the Rotator Cuff as Seen on Magnetic Resonance Imaging*

*The values are given as the number of patients.

	Supraspinatus and Infraspinatus	Supraspinatus and Subscapularis	All Three Tendons
Preop. tear	7	10	10
Postop.
Intact	4	8	5
Retear
<1.5 cm	0	0	1
1.5-3.0 cm	2	1	2
3.1-5.0 cm	1	1	2
5.0 cm	0	0	0

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: TABLE VClinical Results as a Function of the Integrity of the Rotator Cuff

*The values are given as the average.†According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop. Two-Tendon Tear			Preop. Three-Tendon Tear
Intact Repair*(N = 12)	Retear*(N = 5)	P Value†	Intact Repair*(N = 5)	Retear*(N = 5)	P Value†
Subjective shoulder value (percent)	84.2	74	0.08	91	56	0.022
Constant score
Absolute¹⁰ (points)	76.9	67.8	0.37	77.2	51.4	0.0088
Relative⁹ (percent)	94.4	79.4	0.126	91	61.8	0.016
Pain (points)	13.1	14.2	0.67	14.2	10	0.094
Flexion (degrees)	149.5	135	0.75	158	113	0.012
Strength in abduction (kg)	4.3	2.0	0.05	4.4	0.7	0.011

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: TABLE VClinical Results as a Function of the Integrity of the Rotator Cuff

*The values are given as the average.†According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop. Two-Tendon Tear			Preop. Three-Tendon Tear
Intact Repair*(N = 12)	Retear*(N = 5)	P Value†	Intact Repair*(N = 5)	Retear*(N = 5)	P Value†
Subjective shoulder value (percent)	84.2	74	0.08	91	56	0.022
Constant score
Absolute¹⁰ (points)	76.9	67.8	0.37	77.2	51.4	0.0088
Relative⁹ (percent)	94.4	79.4	0.126	91	61.8	0.016
Pain (points)	13.1	14.2	0.67	14.2	10	0.094
Flexion (degrees)	149.5	135	0.75	158	113	0.012
Strength in abduction (kg)	4.3	2.0	0.05	4.4	0.7	0.011

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: TABLE VIPostoperative Muscle Atrophy as a Function of the Preoperative and Postoperative Integrity of the Tendons

*According to the Mann-Whitney U test, with the level of significance set at p < 0.05.†In the group that had an intact repair of the supraspinatus, the preoperative cross-sectional area had been 364 square millimeters and the postoperative cross-sectional area was 434 square millimeters (p = 0.234). In the group that had a failure of the repair of the supraspinatus, the preoperative cross-sectional area had been 408 square millimeters and the postoperative cross-sectional area was 247 square millimeters (p = 0.174). The p value for the difference between the preoperative cross-sectional areas of the two groups (intact repair and failure of the repair) was 0.99, and that for the difference between the postoperative cross-sectional areas was 0.0088.

	Preop. Cross-Sectional Area(mm²)	Postop. Cross-Sectional Area (mm²)			P Value for Difference Between Preop. and Postop. Values in Entire Series*
Intact Preop.	Torn Preop.	Entire Series
Supraspinatus†
Entire series	382	-	374	-	0.841
Intact repair	-	-	435	-	-
Failure	382	-	247	-	0.1002
P value for difference between intact repair and failure*	-	-	0.008	-	-
Subscapularis
Entire series	1516	1913	1416	1516	0.1949
Intact repair	1913	2135	1240	1496	0.1109
Failure	1416	1692	1107	1705	0.1893
P value for difference between intact repair and failure*	0.2963	-	0.655	0.83	-
Infraspinatus
Entire series	919	1193	1044	1163	0.0662
Intact repair	843	1168	1316	1219	0.0549
Failure	1046	1307	909	1092	0.698
P value for difference between intact repair and failure*	0.584	0.34	0.071	0.547	-

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: TABLE VIPostoperative Muscle Atrophy as a Function of the Preoperative and Postoperative Integrity of the Tendons

	Preop. Cross-Sectional Area(mm²)	Postop. Cross-Sectional Area (mm²)			P Value for Difference Between Preop. and Postop. Values in Entire Series*
Intact Preop.	Torn Preop.	Entire Series
Supraspinatus†
Entire series	382	-	374	-	0.841
Intact repair	-	-	435	-	-
Failure	382	-	247	-	0.1002
P value for difference between intact repair and failure*	-	-	0.008	-	-
Subscapularis
Entire series	1516	1913	1416	1516	0.1949
Intact repair	1913	2135	1240	1496	0.1109
Failure	1416	1692	1107	1705	0.1893
P value for difference between intact repair and failure*	0.2963	-	0.655	0.83	-
Infraspinatus
Entire series	919	1193	1044	1163	0.0662
Intact repair	843	1168	1316	1219	0.0549
Failure	1046	1307	909	1092	0.698
P value for difference between intact repair and failure*	0.584	0.34	0.071	0.547	-

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: TABLE VIIFatty Muscle Degeneration as a Function of the Preoperative and Postoperative Integrity of the Tendons

*According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop. Stage^18,19	Postop. Stage^18,19				P Value for Difference Between Preop. and Postop. Stage in Entire Series*
Intact Preop.	Torn Preop.	P Value for Difference Between Intact and Torn Preop.*	Entire Series
Supraspinatus
Entire series	1.50	-	2.04		2.037	0.062
Intact repair	-	-	1.79		1.79
Failure	1.50	-	2.63		2.63	0.0062
P value for difference between intact repair and failure*			0.017		0.017
Subscapularis
Entire series	1.14	0.83	2.07	0.0084	1.79	0.052
Intact repair	1.125	0.83	2.03	0.007	1.71	0.477
Failure	1.143	-	2.25		2.25	0.0495
P value for difference between intact repair and failure*	0.957		0.68		0.337
Infraspinatus
Entire series	1.735	1.70	2.47	0.027	2.093	0.1229
Intact repair	1.375	1.70	2.46	0.033	2.06	0.056
Failure	2.056	-	2.5		2.5	0.41
P value for difference between intact repair and failure*	0.1124		0.999		0.517

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: TABLE VIIFatty Muscle Degeneration as a Function of the Preoperative and Postoperative Integrity of the Tendons

*According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop. Stage^18,19	Postop. Stage^18,19				P Value for Difference Between Preop. and Postop. Stage in Entire Series*
Intact Preop.	Torn Preop.	P Value for Difference Between Intact and Torn Preop.*	Entire Series
Supraspinatus
Entire series	1.50	-	2.04		2.037	0.062
Intact repair	-	-	1.79		1.79
Failure	1.50	-	2.63		2.63	0.0062
P value for difference between intact repair and failure*			0.017		0.017
Subscapularis
Entire series	1.14	0.83	2.07	0.0084	1.79	0.052
Intact repair	1.125	0.83	2.03	0.007	1.71	0.477
Failure	1.143	-	2.25		2.25	0.0495
P value for difference between intact repair and failure*	0.957		0.68		0.337
Infraspinatus
Entire series	1.735	1.70	2.47	0.027	2.093	0.1229
Intact repair	1.375	1.70	2.46	0.033	2.06	0.056
Failure	2.056	-	2.5		2.5	0.41
P value for difference between intact repair and failure*	0.1124		0.999		0.517

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: TABLE VIIIAnalysis of Failures

*The values are given as the average and represent the integrity of the repair on follow-up magnetic resonance imaging.†According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop.			Postop.			P Value for Difference Between Preop. and Postop. Values†
Failure*	Intact Repair*	P Value†	Failure*	Intact Repair*	P Value†	Failure	Intact Repair
Age (yrs.)	56.8	56.2	0.51
Durat. of symptoms preop. (mos.)	11	28.1	0.021
Durat. of follow-up (mos.)				36.9	37.1	0.404
Constant score
Absolute¹⁰ (points)	34.6	43.8	0.35	59.6	77	0.0112	0.0099	0.0001
Relative⁹ (percent)	40.1	54.1	0.26	70.6	93.4	0.0077	0.037	0.0001
Pain (points)	4.4	6.3	0.34	12.1	13.4	0.64	0.0087	0.0004
Activities of daily living (points)	4.5	4.28	0.758	8.4	9.8	0.075	0.0045	0.0001
Functional use of arm (points)	5.3	6.6	0.261	7.6	9.47	0.108	0.109	0.001
Flexion (degrees)	80	98.9	0.246	124	152.1	0.0038	0.012	0.0001
Abduction (degrees)	72.6	86.8	0.53	119	147.4	0.157	0.032	0.0001
External rotation (degrees)	45.6	52.1	0.707	32.5	45.8	0.16	0.53	0.47
Internal rotation (points)	5.3	6.28	0.339	7.2	7.5	0.911	0.056	0.122

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: TABLE VIIIAnalysis of Failures

	Preop.			Postop.			P Value for Difference Between Preop. and Postop. Values†
Failure*	Intact Repair*	P Value†	Failure*	Intact Repair*	P Value†	Failure	Intact Repair
Age (yrs.)	56.8	56.2	0.51
Durat. of symptoms preop. (mos.)	11	28.1	0.021
Durat. of follow-up (mos.)				36.9	37.1	0.404
Constant score
Absolute¹⁰ (points)	34.6	43.8	0.35	59.6	77	0.0112	0.0099	0.0001
Relative⁹ (percent)	40.1	54.1	0.26	70.6	93.4	0.0077	0.037	0.0001
Pain (points)	4.4	6.3	0.34	12.1	13.4	0.64	0.0087	0.0004
Activities of daily living (points)	4.5	4.28	0.758	8.4	9.8	0.075	0.0045	0.0001
Functional use of arm (points)	5.3	6.6	0.261	7.6	9.47	0.108	0.109	0.001
Flexion (degrees)	80	98.9	0.246	124	152.1	0.0038	0.012	0.0001
Abduction (degrees)	72.6	86.8	0.53	119	147.4	0.157	0.032	0.0001
External rotation (degrees)	45.6	52.1	0.707	32.5	45.8	0.16	0.53	0.47
Internal rotation (points)	5.3	6.28	0.339	7.2	7.5	0.911	0.056	0.122

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

We reviewed the results of twenty-nine operative repairs of massive tears of the rotator cuff that had been performed between 1992 and 1995. The criteria for operative repair included (1) failure of at least three months of nonoperative treatment, with the patient continuing to complain of subjectively unacceptable pain or disability, or both; (2) the desire or need of the patient to use the arm at or above the level of the head; (3) good motivation to comply with a postoperative treatment regimen; (4) an acromiohumeral distance of at least six millimeters, as seen on an anteroposterior radiograph of the shoulder, made with the patient standing, the arm in neutral rotation, and the muscles relaxed (shoulders with static superior subluxation of the humeral head were excluded from this series); and (5) the absence of moderate-to-marked osteoarthritis.

These criteria were met by twenty-nine (45 percent) of the sixty-four patients who were treated operatively for a massive tear during the period of the study. The other thirty-five patients were treated either with arthroscopic dè¡²idement or with repair including tendon transfers and therefore were not enrolled in the study. Two patients who had a complete clinical and magnetic resonance imaging examination at twelve and nineteen months after the operation refused additional imaging because the first examination had shown an intact cuff and the clinical result (a subjective shoulder value of 100 and 95 percent and a relative Constant score^9,10 of 108 and 110 percent) had remained unchanged subjectively.

The remaining twenty-seven patients were followed clinically and with magnetic resonance imaging for at least two years (average, thirty-seven months; range, twenty-four to sixty-one months). The ages of the eighteen men and nine women averaged fifty-six years (range, forty-one to seventy-two years). The dominant limb was involved in twenty-three patients. The preoperative symptoms had lasted for an average of twenty-two months (range, three to eighty-three months).

The final diagnosis of the lesion was made on the basis of the intraoperative findings. If a very small muscular strand of the subscapularis was still attached to the most distal part of the crista of the lesser tuberosity, the subscapularis tear was considered complete. The infraspinatus insertion zone was identified by laying the two branches of the forceps over the scapular spine so that the forceps were in line with the fibers of the cuff. Fibers coming from a level inferior to the scapular spine are infraspinatus fibers. The teres minor insertion was identified by locating its insertion on the respective tubercle, which lies inferior and slightly medial to the infraspinatus insertion.

The clinical assessment was based on a structured interview and a detailed physical examination that was carried out in a standardized fashion (Table Iand Table II). The objective assessment of active pain-free flexion and abduction was carried out with the patient sitting. The range of pain-free flexion (in the sagittal plane) was measured as the angle between the humeral shaft and the midthoracic line (not the vertical). Abduction always was measured, with simultaneous maximal abduction of both arms, as the angle formed by the humeral shaft and the midthoracic line.

Functional external rotation was measured according to the method of Constant and Murley¹⁰. This method represents an attempt to measure the patient's ability to externally rotate the arm in the functional positions necessary in daily living. Two points are given for each of the following activities: bringing the hand actively behind the neck with the elbow above the acromion, bringing the elbow straight forward from that position, actively positioning the hand on top of the head with the elbow over the acromion, bringing the elbow straight forward from that position, and fully elevating the arm from that position. The hand is not allowed to touch the head or neck during these functional movements.

The amount of active internal rotation was determined according to the spinous process that the patient could actively reach with the thumb without pain.

Abduction strength was assessed with use of an Isobex dynamometer (Cursor SA, Bern, Switzerland) with the patient standing and the arm abducted to 90 degrees in the scapular plane, the elbow extended, and the forearm pronated. The resistance was applied at the wrist. Three measurements of five seconds' duration (the B mode of the device) were averaged. One point was attributed to each pound (0.45 kilogram) of strength that was measured. If 90 degrees of abduction in the scapular plane was not reached, the abduction strength automatically was considered to be zero.

The total Constant score was recorded. In addition, the score for each patient was related to the age and gender-matched normal values that were established by Constant⁹. The patients also were asked to estimate the value of the shoulder as a percentage of the value of an entirely normal shoulder (subjective shoulder value).

Preoperatively, anteroposterior, lateral, and axial radiographs were made for each patient. All but one patient had either a magnetic resonance imaging study or an arthro-computerized tomographic scan.

An independent examiner reviewed the results for all twenty-seven patients at an average of thirty-seven months (range, twenty-four to sixty-one months) postoperatively. Twenty-five patients had a standardized magnetic resonance imaging scan; the two remaining patients refused to have magnetic resonance imaging because of claustrophobia and underwent ultrasonographic examination of the repaired cuff. Twelve patients had already undergone the same clinical and magnetic resonance imaging examinations between twelve and twenty-three months after the operation. Magnetic resonance imaging was performed with use of a 1.0-tesla scanner (Siemens, Erlangen, Germany). Parasagittal T1-weighted turbo-spin-echo magnetic resonance images (repetition time, 700 milliseconds; echo time, twelve milliseconds), made parallel to the glenohumeral joint, were obtained for qualitative and quantitative assessment of the rotator cuff muscles. The slice thickness was five millimeters, with an interslice gap of 1.5 millimeters. The sequence covered the rotator cuff from the humeral tuberosities to the medial third of the scapula. The field of view was eighteen centimeters, the image matrix was 210 by 256, and the echo train length was three. For quantitative assessment, the cross-sectional areas of the rotator cuff muscles and the fossa supraspinata were measured on the most lateral image on which the scapular spine was in contact with the remainder of the scapula. High intrasubject and interobserver reliability has been documented with use of this technique of magnetic resonance imaging interpretation⁴² for cross-sectional areas of the supraspinatus, the subscapularis, and the infraspinatus and the teres minor combined. Intrasubject and interobserver reliability has been found to be substantially lower for the infraspinatus alone, but it has been found that it is more reasonable to report the values of the infraspinatus than those of the infraspinatus and the teres minor together, as the infraspinatus often is torn whereas the teres minor is not⁴².

In addition to the quantitative assessment of cross-sectional areas of the muscles, intramuscular fatty degeneration was assessed with use of the criteria established by Goutallier et al. for determining the amount of fatty degeneration on computerized tomographic scans^18,19. This classification was applied to parasagittal and axial T1-weighted turbo-spin-echo magnetic resonance images¹².

Retear of the tendon also was assessed with angled, coronal T2-weighted, proton-density-weighted, and short tau inversion recovery (STIR) sequences, according to established magnetic resonance imaging criteria^26,31.

Operative Technique

The patient was positioned in the beach-chair position. In seventeen patients with a tear involving mostly the supraspinatus and the infraspinatus, a superolateral approach was used, with elevation of the anterolateral deltoid origin with a bone chisel and splitting of the deltoid between the anterior and lateral portions along its fibers over a distance of less than six centimeters. In the other twelve patients, severe atrophy and retraction of the subscapularis were expected to require extensive dissection in the vicinity of the plexus in order to mobilize the subscapularis, so a deltopectoral approach was used. The lesions involved the supraspinatus and the infraspinatus in nine patients (31 percent), the supraspinatus and the subscapularis in ten patients (34 percent), and all three tendons in ten patients.

The infraspinatus and the supraspinatus then were mobilized with use of a subacromial spreader (Sulzer Medica AG, Baar, Switzerland) to subluxate or even dislocate the humeral head anteroinferiorly; the subscapularis was mobilized and repaired as described previously¹⁶. The musculotendinous units were mobilized to allow repair to their original area of insertion, with the arm abducted to no more than 30 to 45 degrees. The area of insertion was only cleaned of soft tissue; a deep osseous trough was not created.

To obtain optimal initial fixation strength and minimal gap formation upon postoperative movement, a transosseous repair technique that was validated in vitro and in vivo^15,17 was utilized. With this technique, the tendons are freed up extensively with release of the interval between the tendons to be repaired and capsulotomy performed between the capsule and the labrum from inside, with the joint distracted with use of a subacromial spreader. Number-3 braided polyester sutures and a modified Mason-Allen tendon stitch are used¹⁵; the latter improves the suture pullout strength by a factor of at least two. A thin titanium plate with seven round holes (Stratec Synthes SA, Waldenburg, Switzerland) was used as a cortical bone-augmentation device. Both strands of a single Mason-Allen stitch are brought through the tuberosity and through two holes of the plate. The suture then is tied under optimal tension over the bridge between the two holes of the plate. The plate and holes are designed not to cut the sutures, and the titanium does not interfere with magnetic resonance assessment of the affected shoulder.

A resection of the acromioclavicular joint also was performed if the joint was painful (fourteen patients). An anterior acromioplasty was avoided if the likelihood of postoperative anterosuperior subluxation seemed high due to difficulty in obtaining an optimal closure of the rotator interval (ten patients).

Postoperative Regimen

Postoperatively, the patients wore a sling if the subscapularis had been the most retracted musculotendinous unit and the supraspinatus and the infraspinatus were not under relevant tension in the adducted position (ten patients), and they wore an abduction splint for six weeks if the surgeon thought that the supraspinatus and the infraspinatus were under relevant tension with the arm in adduction (nineteen patients). Immediately postoperatively, passive range-of-motion exercises were begun within the range that had been found to be safe intraoperatively. Active range-of-motion exercises were started after six weeks.

Results

Introduction | Materials and Methods | Results | Discussion | References

Preoperative Findings

Patients who had a tear involving all three tendons were much more disabled functionally, with poorer performance of the activities of daily living; decreased flexion, abduction, and strength in abduction; and a poorer overall shoulder score according to the criteria of Constant and Murley¹⁰ (Table II). Interestingly, tears involving all three tendons tended to be less painful than those involving two tendons, and they were clearly less painful than the anterosuperior variant of the two-tendon tears.

Of the two-tendon tears, those that were posterosuperior caused a distinctly greater functional handicap in terms of decreased abduction, external rotation, and abduction strength. However, the anterosuperior tears tended to be more painful, so they were not associated with significantly better overall shoulder scores (Table I).

Neither atrophy, measured as cross-sectional area, nor fatty degeneration of the subscapularis and the infraspinatus was much more advanced if the subscapularis and infraspinatus musculotendinous units were torn than if they were intact (Table IV and Table VII). The areas of muscle were, however, always smaller than those of an age and gender-matched healthy population⁴².

Complications

There were no relevant complications in this series of patients. Specifically, we did not observe hematoma, wound dehiscence or infection, stiffness requiring manipulation, deltoid dehiscence, or nerve injury. No complications related to the titanium plate were observed.

Clinical Outcome

In the entire series, the relative Constant score increased from 49 percent of that of a normal shoulder preoperatively to 85 percent postoperatively. The postoperative value corresponded well with a subjective shoulder value of 78 percent. Pain-free flexion improved from an average of 92 degrees to an average of 142 degrees, and abduction improved from an average of 82 degrees to an average of 137 degrees.

All of the clinical parameters that were studied, with the exception of active internal and external rotation and strength in abduction, improved significantly after the operations for both the two and the three-tendon tears (Table I and Table II). Except for pain, the parameters showed greater improvement in the shoulders with a three-tendon tear than in those with a two-tendon tear. Postoperatively, the shoulders with a three-tendon tear had, on the average, increases of 45 percent in the relative Constant score (p = 0.0024), 5.3 points on the 15-point visual analog assessment of pain (p = 0.0077), 70 degrees of flexion (p = 0.0019), and 2.3 kilograms of abduction strength (p = 0.42), whereas the increases for the shoulders with a two-tendon tear were 31 percent (p = 0.0133), 8.2 points (p = 0.0001), 38 degrees (p = 0.0008), and 1.3 kilograms (p = 0.011), respectively (Table II). Nonetheless, the subjective shoulder value (the subjective value as a percentage of that of a normal shoulder), the relative Constant score, the pain score, and abduction remained better in the shoulders with a two-tendon tear. The differences between function associated with anterosuperior two-tendon tears and that associated with posterosuperior two-tendon tears disappeared after operative repair (Table I).

Seventeen (63 percent) of the twenty-seven shoulders, as well as the two that were evaluated at less than twenty-four months, had an unequivocally intact rotator cuff at the time of the latest follow-up. It is notable that the results of the follow-up examination at more than two years were no different from those between one and two years and, specifically, that neither healing of a retear nor the presence of an additional retear were observed during this interval (Table III). In the group of patients who had an intact repair at the time of the latest follow-up examination, the results for those who had had a two-tendon tear were as excellent as the results for those who had had a three-tendon tear. The patients who had had a two-tendon tear had an average relative Constant score of 94 percent, an average pain score of 13 points, an average flexion of 150 degrees, and an average abduction strength of 4.3 kilograms, whereas those who had had a three-tendon tear had average values of 91 percent, 14 points, 158 degrees, and 4.4 kilograms, respectively (Table V). Thus, successful repair restored almost normal shoulder function in these patients and, notably, also restored good abduction strength.

There were ten retears: five in the two-tendon-tear group and five in the three-tendon-tear group (Table IV). When the patients who had a subsequent retear were compared with those who had an intact repair, they differed significantly with regard to only one preoperative variable: the duration of shoulder pain and dysfunction before the operation had been significantly shorter (eleven compared with twenty-eight months; p = 0.021) for the patients who had a retear. In addition, the onset of the symptoms in those patients often had been associated with a minor traumatic event. The clinical status of the patients who had a subsequent retear was worse preoperatively with regard to all other variables that were studied, but these differences did not reach significance (Table VIII).

Compared with the patients who had a retear, the patients who had a successful repair had significantly better results in terms of strength, active range of motion, the Constant score, and the subjective shoulder value (Table V). Although these patients also did better in terms of pain, this difference did not reach significance.

Neither the intraoperative state of the tendon of the long head of the biceps (normal versus dislocated, hypertrophic, or torn) nor its treatment (tenodesis versus relocation) influenced the outcome.

Structural Results

The structure of the repaired tendons, as judged on magnetic resonance imaging, was never normal. The supraspinatus tendon and infraspinatus tendon especially showed a scarlike signal. The overall rate of retears of the cuff was 34 percent (ten of twenty-nine). Three of the nine patients who had had a posterosuperior two-tendon tear, two of the ten who had had an anterosuperior two-tendon tear, and five of the ten who had had a three-tendon tear had a retear. Four retears were the same size as the original tear, and six were distinctly smaller; none were larger than the initial tear. The clinical results for the patients who had a retear were significantly inferior to those for the patients who had an intact cuff. Interestingly, the clinical results for the six patients who had a small retear were not better than those for the four in whom the retear was as big as the initial tear; the crucial finding was the presence or absence of a retear and not its size. Regardless of the type of tear, all groups of patients, including the four who had a massive retear, had a substantial improvement postoperatively compared with the preoperative state. In the group with a massive retear, the relative Constant score improved from an average of 31 to 70 percent; flexion, from an average of 34 to 116 degrees; and the pain score, from an average of 6.3 to 13.5 points. Only abduction strength did not improve in this group of patients.

The postoperative degree of muscular atrophy of the infraspinatus and the subscapularis did not depend on the integrity of the repair of the tendon (Table VI); however, the square area of the supraspinatus did depend on this factor insofar as atrophy increased if the repair of the supraspinatus failed and the cross-sectional area increased if the repair was successful. Overall, the preoperative muscular atrophy was not reversed postoperatively, but in the patients who had a successful repair the increase in the cross-sectional area of the supraspinatus almost reached significance (p = 0.054).

Fatty degeneration increased postoperatively in all three muscles that were studied. It increased significantly more if the tendon of the respective muscle was found to be torn intraoperatively than if it was found to be intact. It was only for the supraspinatus that we could document statistically that a successful repair had a beneficial effect on fatty degeneration because the repaired musculotendinous units showed significantly less progression of fatty degeneration than the failed repairs (Table VII).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The optimal form of treatment of massive rotator cuff tears is controversial. Whereas operative repair has yielded good-to-excellent clinical results in many studies^4,6,20,21,24, some authors have thought that repairs of massive tears of the rotator cuff fail so often that it may be preferable to treat patients with such tears nonoperatively, with rotator cuff dè¡²idement, or with other operative procedures^2,3,7,13.

The differences in the reported results and opinions may be due to various reasons. First, differences in the definition of the tear size make it difficult to compare the results from different institutions^1,4,8,11,13. The maximum diameter⁸ is possibly not the best indication of the size of a tear. If, at the time of measurement, the humerus is pushed proximally, the diameter of the tear increases, and it decreases if the head is pulled distally. The measured size of the tear also may be affected by rotation of the humerus. In addition, most published reports do not state whether the size of the tear was measured before or after resection of nonviable edges of the tendinous stump. Finally, with the wide variation in the sizes and heights of patients, a given diameter may have very different relevance for different individuals. We believe that the amount of tendon tissue that has become detached from the humerus is a much more reproducible and relevant indicator of tear size^32,33; therefore, we defined a massive tear as one with complete detachment of at least two cuff tendons. This anatomical description of the lesion corresponds generally to a tear size of more than five centimeters, so the current study included only tears that met previously used criteria. Among shoulders with a massive tear, those with static superior subluxation (an acromiohumeral distance of less than six millimeters) appear to have a poorer prognosis after direct repair than do those with a centered head^39,41. Indeed, we tend not to use direct repair for patients with documented static superior subluxation of the humeral head, and in the present study we included only shoulders with an acromiohumeral distance of at least six millimeters as seen on an anteroposterior radiograph made in neutral rotation⁶.

Second, the techniques of repair vary greatly, as shown by the results of an inquiry of leading shoulder surgeons in America and Europe¹⁵. It has been shown that currently recommended standard techniques are mechanically suboptimal and can be improved substantially^15,17. In the current study, we used only a laboratory-tested method of repair with number-3 braided polyester sutures, a special tendon-grasping technique, and augmentation of the osteoporotic cortical bone to allow secure fixation of the transosseous sutures¹⁵. With this method, the retear rate remained high (37 percent [ten of twenty-seven], or 34 percent [ten of twenty-nine] if the two shoulders with less than two years of follow-up are included), but it was distinctly lower than the 50 to 70 percent failure rate that has been reported after other methods of repair of comparable tears^14,21,34,38. The retear was the same size as the preoperative tear in four patients, and it was smaller than the original tear in six²⁷. The clinical results of the patients who had a small retear were similar to those of the patients who had a large retear but were unlike those of the patients who had a successful repair. This finding raises questions about the concept of partial repair of the rotator cuff⁷. Conversely, it reemphasizes that every effort to promote healing of the repaired tendons is justified. The present study does not answer the question regarding the necessity of postoperative protection because an abduction splint was not used by patients with a tear predominantly involving the subscapularis. We think that our experimental data^17,23 sufficiently support the use of an abduction splint when it allows a reduction in the tension on the repair, as in a shoulder with a supraspinatus tear.

The structural results of rotator cuff repairs have been analyzed only rarely^14,21,34,38. In the current study, the integrity of the repairs and the presence of retears were determined with magnetic resonance imaging; however, this modality is demanding as well as labor-intensive, and it may become even more difficult to use due to legal and monetary constraints. Several authors^14,21,38 have documented the structural quality of their repairs and have shown that patients who have a successful repair do better than those who have a failed repair. The findings in the present study reemphasize that fact and document a markedly significant superiority in the results of patients with a successful repair compared with those of patients who did not have a successful repair. The fact that no new retears were observed after two years in the twelve patients who had already had complete documentation at one to two years is consistent with the experimental finding that retears occur very early¹⁷ and also with the clinical finding that the results of rotator cuff repair are durable^4,8. We believe that the significantly shorter preoperative duration of the symptoms in the shoulders that could not be successfully repaired was most likely due to a traumatic extension of a large preexisting tear, leading to very poor function and often to pseudoparalysis. Whether immediate repair or preoperative rehabilitation is preferable after such a traumatic event is currently not known. Despite the findings in this study, it is our experience that a long-standing pseudoparalysis can almost never be reversed with operative cuff repair, whereas the regaining of useful overhead function after an acute loss of overhead elevation is a reasonable expectation; therefore, we continue to recommend early repair if pseudoparalysis has suddenly developed.

In our entire series, abduction strength improved compared with the preoperative value, but not significantly. However, when the successfully repaired shoulders were evaluated separately, abduction strength was found to have increased very significantly (from 1.55 to 4.4 kilograms). These findings are consistent with the observation of Thomazeau et al. that an intact cuff is mandatory if abduction strength of more than four kilograms is to be achieved³⁸.

Fatty degeneration and atrophy occur in association with chronic rotator cuff tears in both animals⁵ and humans^18,28,38. Clinical experience suggests that advanced muscular atrophy may not be reversible and that weakness after rotator cuff repair is a certainty²⁵. The present study shows that, at least within two years, muscular atrophy is at least stopped and may be reversed in successfully repaired supraspinatus musculotendinous units whereas atrophy increases after an unsuccessful repair. This finding is in agreement with the data of Thomazeau et al., who also reported a reversal of supraspinatus atrophy in half of the successfully repaired cuffs but in none that had a failed repair³⁸. In the other muscles that were studied, however, atrophy tended to increase, especially after a failed repair. Due to the large variation in the size and musculature of patients, it may be necessary to study larger patient populations to clarify the apparent reversibility of supraspinatus atrophy and the absence of reversibility in the other two muscles, since in our study only the supraspinatus tendon was preoperatively torn in all patients.

Fatty degeneration is not reversible as assessed with our methodology. It increased in the supraspinatus more rapidly when a tendon repair failed than when it did not. An increase in fatty degeneration was seen predominantly in the musculotendinous units that were noted to be torn intraoperatively and therefore were repaired, suggesting that operative repair may damage the musculotendinous units and thereby result in progression of fatty degeneration. We have always palpated the supraspinatus and infraspinatus and have never found any clinical evidence of neurological damage, which potentially can be caused by the extensive mobilization of the cuff⁴³. However, we cannot exclude the possibility that the tension created by the repair causes damage due to fatty degeneration. In light of the potential effects of postoperative tension, it seems logical to try to minimize tension by optimal protection of the repair^5,23 in order to avoid iatrogenic damage to the musculotendinous unit.

References

Introduction | Materials and Methods | Results | Discussion | References

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Sher, J. S.; Uribe, J. W.; Posada, A.; Murphy, B. J.; and Zlatkin, M. B.: Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg, 77-A: 10-15, Jan. 1995.

Takagishi, N.: Conservative treatment of the ruptures of the rotator cuff. J. Japanese Orthop. Assn., 52: 781-787, 1978.

Thomazeau, H.; Boukobza, E.; Morcet, N.; Chaperon, J.; and Langlais, F.: Prediction of rotator cuff repair results by magnetic resonance imaging. Clin. Orthop., 344: 275-283, 1997.

Walch, G.; Marè¢¨al, E.; Maupas, J.; and Liotard, J. P.: Traitement chirurgical des ruptures de la coiffe des rotateurs. Facteurs de pronostic. Rev. chir. orthop., 78: 379-388, 1992.

Wallace, W. A., and Wiley, A. M.: The long-term results of conservative management of full-thickness tears of the rotator cuff. In Proceedings of the British Orthopaedic Association. J Bone Joint Surg, 68-B(1): 162, 1986.

Weiner, D. S., and Macnab, I.: Superior migration of the humeral head. A radiological aid in the diagnosis of tears of the rotator cuff. J Bone Joint Surg, 52-B(3): 524-527, 1970.

Zanetti, M.; Gerber, C.; and Hodler, J.: Quantitative assessment of the muscles of the rotator cuff with magnetic resonance imaging. Invest. Radiol., 33: 163-170, 1998.

Zanotti, R. M.; Carpenter, J. E.; Blasier, R. B.; Greenfield, M. L.; Adler, R. S.; and Bromberg, M. B.: The low incidence of suprascapular nerve injury after primary repair of massive rotator cuff tears. J. Shoulder and Elbow Surg., 6: 258-264, 1997.

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: TABLE IClinical Parameters in Relation to Which Rotator Cuff Tendons Were Torn Preoperatively

	Tear of Supraspinatus and Infraspinatus (N = 17)	Tear of Supraspinatus and Subscapularis (N = 10)
Preop.*	Postop.*	P Value	Preop.*	Postop.*	P Value
Constant score
Absolute¹⁰ (points)	40	73.8	0.291	48.3	74.5	0.0011
Relative†⁹ (percent)	60.6	89.3	0.123	58.3	90.5	0.0019
Pain‡(points)	7.6	14.4	0.034	3.8	12.7	0.0001
Activities of daily living§ (points)	5.8	9.3	0.0084	4.9	9.8	0.0003
Functional use of arm# (points)	6.4	8.6	0.144	7.1	9.5	0.036
Active motion
Flexion (degrees)	83	143	0.048	121	147	0.005
Abduction (degrees)	74	148	0.018	105	149	0.0043
External rotation (degrees)	41	29.3	0.74	58	52	0.54
Internal rotation§ (points)	6.8	8.6	0.122	5.6	7.6	0.05
Strength in abduction** (kg)	0.8	3.3	0.1002	3.1	3.9	0.039

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: TABLE IClinical Parameters in Relation to Which Rotator Cuff Tendons Were Torn Preoperatively

	Tear of Supraspinatus and Infraspinatus (N = 17)	Tear of Supraspinatus and Subscapularis (N = 10)
Preop.*	Postop.*	P Value	Preop.*	Postop.*	P Value
Constant score
Absolute¹⁰ (points)	40	73.8	0.291	48.3	74.5	0.0011
Relative†⁹ (percent)	60.6	89.3	0.123	58.3	90.5	0.0019
Pain‡(points)	7.6	14.4	0.034	3.8	12.7	0.0001
Activities of daily living§ (points)	5.8	9.3	0.0084	4.9	9.8	0.0003
Functional use of arm# (points)	6.4	8.6	0.144	7.1	9.5	0.036
Active motion
Flexion (degrees)	83	143	0.048	121	147	0.005
Abduction (degrees)	74	148	0.018	105	149	0.0043
External rotation (degrees)	41	29.3	0.74	58	52	0.54
Internal rotation§ (points)	6.8	8.6	0.122	5.6	7.6	0.05
Strength in abduction** (kg)	0.8	3.3	0.1002	3.1	3.9	0.039

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: TABLE IIClinical Parameters in Relation to Whether the Tear Involved Two or Three Tendons

	Tear Involving Two Tendons (N = 17)			Tear Involving Three Tendons (N = 10)
Preop.*	Postop.*	P Value	Preop.*	Postop.*	P Value
Constant score
Absolute¹⁰ (points)	47.6	74.2	0.0002	27	64.3	0.0034
Relative†⁹ (percent)	59.1	90	0.0133	31.8	76.4	0.0024
Pain‡(points)	5.2	13.4	0.0001	6.8	12.1	0.0077
Activities of daily living§ (points)	5.2	9.6	0.0001	3.4	8.8	0.001
Functional use of arm# (points)	6.9	9.1	0.0043	4.8	8.2	0.0263
Active motion
Flexion (degrees)	107	145	0.0008	66	136	0.0019
Abduction (degrees)	94	149	0.002	59	117	0.0097
External rotation (degrees)	52	43	0.59	46	38	0.625
Internal rotation§ (points)	6	8	0.01	5.8	6.4	0.42
Strength in abduction** (kg)	2.3	3.6	0.011	0.2	2.6	0.42

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: TABLE IIClinical Parameters in Relation to Whether the Tear Involved Two or Three Tendons

	Tear Involving Two Tendons (N = 17)			Tear Involving Three Tendons (N = 10)
Preop.*	Postop.*	P Value	Preop.*	Postop.*	P Value
Constant score
Absolute¹⁰ (points)	47.6	74.2	0.0002	27	64.3	0.0034
Relative†⁹ (percent)	59.1	90	0.0133	31.8	76.4	0.0024
Pain‡(points)	5.2	13.4	0.0001	6.8	12.1	0.0077
Activities of daily living§ (points)	5.2	9.6	0.0001	3.4	8.8	0.001
Functional use of arm# (points)	6.9	9.1	0.0043	4.8	8.2	0.0263
Active motion
Flexion (degrees)	107	145	0.0008	66	136	0.0019
Abduction (degrees)	94	149	0.002	59	117	0.0097
External rotation (degrees)	52	43	0.59	46	38	0.625
Internal rotation§ (points)	6	8	0.01	5.8	6.4	0.42
Strength in abduction** (kg)	2.3	3.6	0.011	0.2	2.6	0.42

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: TABLE IIIComparison of the Findings on Two Follow-up Examinations*

*The values are given as the average, for twelve patients.†The values indicate the cross-sectional area of the muscle.

	Intact Repair			Retear			Total
First Exam.	Second Exam.	P Value	First Exam.	Second Exam.	P Value	First Exam.	Second Exam.	P Value
Duration of follow-up (mos.)	16.5	39.8		16.5	39.6		16.5	39.7
Subjective shoulder value (percent)	90	90.8	0.87	76.6	65.8	0.57	83.3	78.3	0.73
Relative Constant score⁹ (percent)	95.6	95.5	0.87	63.1	69.6	0.52	79.4	82.6	0.69
Fatty degeneration^18,19 (stage)
Supraspinatus	1.66	1.33	0.52	2.5	2.8	0.57	2.08	2.1	0.97
Infraspinatus	1.6	1.5	0.63	2.5	2.0	0.37	2.08	1.75	0.32
Subscapularis	0.53	0.5	0.06	1.33	1.16	0.93	1.13	0.83	0.15
Atrophy†(mm²)
Supraspinatus	405	411	0.87	257	227	0.57	331	319	0.54
Infraspinatus	1033	1160	0.68	1028	913	0.68	1031	1036	0.72
Subscapularis	1228	1033	0.52	1192	949	0.17	1210	991	0.15

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: TABLE IIIComparison of the Findings on Two Follow-up Examinations*

*The values are given as the average, for twelve patients.†The values indicate the cross-sectional area of the muscle.

	Intact Repair			Retear			Total
First Exam.	Second Exam.	P Value	First Exam.	Second Exam.	P Value	First Exam.	Second Exam.	P Value
Duration of follow-up (mos.)	16.5	39.8		16.5	39.6		16.5	39.7
Subjective shoulder value (percent)	90	90.8	0.87	76.6	65.8	0.57	83.3	78.3	0.73
Relative Constant score⁹ (percent)	95.6	95.5	0.87	63.1	69.6	0.52	79.4	82.6	0.69
Fatty degeneration^18,19 (stage)
Supraspinatus	1.66	1.33	0.52	2.5	2.8	0.57	2.08	2.1	0.97
Infraspinatus	1.6	1.5	0.63	2.5	2.0	0.37	2.08	1.75	0.32
Subscapularis	0.53	0.5	0.06	1.33	1.16	0.93	1.13	0.83	0.15
Atrophy†(mm²)
Supraspinatus	405	411	0.87	257	227	0.57	331	319	0.54
Infraspinatus	1033	1160	0.68	1028	913	0.68	1031	1036	0.72
Subscapularis	1228	1033	0.52	1192	949	0.17	1210	991	0.15

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: TABLE IVIntegrity of the Rotator Cuff as Seen on Magnetic Resonance Imaging*

*The values are given as the number of patients.

	Supraspinatus and Infraspinatus	Supraspinatus and Subscapularis	All Three Tendons
Preop. tear	7	10	10
Postop.
Intact	4	8	5
Retear
<1.5 cm	0	0	1
1.5-3.0 cm	2	1	2
3.1-5.0 cm	1	1	2
5.0 cm	0	0	0

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: TABLE IVIntegrity of the Rotator Cuff as Seen on Magnetic Resonance Imaging*

*The values are given as the number of patients.

	Supraspinatus and Infraspinatus	Supraspinatus and Subscapularis	All Three Tendons
Preop. tear	7	10	10
Postop.
Intact	4	8	5
Retear
<1.5 cm	0	0	1
1.5-3.0 cm	2	1	2
3.1-5.0 cm	1	1	2
5.0 cm	0	0	0

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: TABLE VClinical Results as a Function of the Integrity of the Rotator Cuff

*The values are given as the average.†According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop. Two-Tendon Tear			Preop. Three-Tendon Tear
Intact Repair*(N = 12)	Retear*(N = 5)	P Value†	Intact Repair*(N = 5)	Retear*(N = 5)	P Value†
Subjective shoulder value (percent)	84.2	74	0.08	91	56	0.022
Constant score
Absolute¹⁰ (points)	76.9	67.8	0.37	77.2	51.4	0.0088
Relative⁹ (percent)	94.4	79.4	0.126	91	61.8	0.016
Pain (points)	13.1	14.2	0.67	14.2	10	0.094
Flexion (degrees)	149.5	135	0.75	158	113	0.012
Strength in abduction (kg)	4.3	2.0	0.05	4.4	0.7	0.011

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: TABLE VClinical Results as a Function of the Integrity of the Rotator Cuff

*The values are given as the average.†According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop. Two-Tendon Tear			Preop. Three-Tendon Tear
Intact Repair*(N = 12)	Retear*(N = 5)	P Value†	Intact Repair*(N = 5)	Retear*(N = 5)	P Value†
Subjective shoulder value (percent)	84.2	74	0.08	91	56	0.022
Constant score
Absolute¹⁰ (points)	76.9	67.8	0.37	77.2	51.4	0.0088
Relative⁹ (percent)	94.4	79.4	0.126	91	61.8	0.016
Pain (points)	13.1	14.2	0.67	14.2	10	0.094
Flexion (degrees)	149.5	135	0.75	158	113	0.012
Strength in abduction (kg)	4.3	2.0	0.05	4.4	0.7	0.011

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: TABLE VIPostoperative Muscle Atrophy as a Function of the Preoperative and Postoperative Integrity of the Tendons

	Preop. Cross-Sectional Area(mm²)	Postop. Cross-Sectional Area (mm²)			P Value for Difference Between Preop. and Postop. Values in Entire Series*
Intact Preop.	Torn Preop.	Entire Series
Supraspinatus†
Entire series	382	-	374	-	0.841
Intact repair	-	-	435	-	-
Failure	382	-	247	-	0.1002
P value for difference between intact repair and failure*	-	-	0.008	-	-
Subscapularis
Entire series	1516	1913	1416	1516	0.1949
Intact repair	1913	2135	1240	1496	0.1109
Failure	1416	1692	1107	1705	0.1893
P value for difference between intact repair and failure*	0.2963	-	0.655	0.83	-
Infraspinatus
Entire series	919	1193	1044	1163	0.0662
Intact repair	843	1168	1316	1219	0.0549
Failure	1046	1307	909	1092	0.698
P value for difference between intact repair and failure*	0.584	0.34	0.071	0.547	-

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: TABLE VIPostoperative Muscle Atrophy as a Function of the Preoperative and Postoperative Integrity of the Tendons

	Preop. Cross-Sectional Area(mm²)	Postop. Cross-Sectional Area (mm²)			P Value for Difference Between Preop. and Postop. Values in Entire Series*
Intact Preop.	Torn Preop.	Entire Series
Supraspinatus†
Entire series	382	-	374	-	0.841
Intact repair	-	-	435	-	-
Failure	382	-	247	-	0.1002
P value for difference between intact repair and failure*	-	-	0.008	-	-
Subscapularis
Entire series	1516	1913	1416	1516	0.1949
Intact repair	1913	2135	1240	1496	0.1109
Failure	1416	1692	1107	1705	0.1893
P value for difference between intact repair and failure*	0.2963	-	0.655	0.83	-
Infraspinatus
Entire series	919	1193	1044	1163	0.0662
Intact repair	843	1168	1316	1219	0.0549
Failure	1046	1307	909	1092	0.698
P value for difference between intact repair and failure*	0.584	0.34	0.071	0.547	-

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: TABLE VIIFatty Muscle Degeneration as a Function of the Preoperative and Postoperative Integrity of the Tendons

*According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop. Stage^18,19	Postop. Stage^18,19				P Value for Difference Between Preop. and Postop. Stage in Entire Series*
Intact Preop.	Torn Preop.	P Value for Difference Between Intact and Torn Preop.*	Entire Series
Supraspinatus
Entire series	1.50	-	2.04		2.037	0.062
Intact repair	-	-	1.79		1.79
Failure	1.50	-	2.63		2.63	0.0062
P value for difference between intact repair and failure*			0.017		0.017
Subscapularis
Entire series	1.14	0.83	2.07	0.0084	1.79	0.052
Intact repair	1.125	0.83	2.03	0.007	1.71	0.477
Failure	1.143	-	2.25		2.25	0.0495
P value for difference between intact repair and failure*	0.957		0.68		0.337
Infraspinatus
Entire series	1.735	1.70	2.47	0.027	2.093	0.1229
Intact repair	1.375	1.70	2.46	0.033	2.06	0.056
Failure	2.056	-	2.5		2.5	0.41
P value for difference between intact repair and failure*	0.1124		0.999		0.517

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: TABLE VIIFatty Muscle Degeneration as a Function of the Preoperative and Postoperative Integrity of the Tendons

*According to the Mann-Whitney U test, with the level of significance set at p < 0.05.

	Preop. Stage^18,19	Postop. Stage^18,19				P Value for Difference Between Preop. and Postop. Stage in Entire Series*
Intact Preop.	Torn Preop.	P Value for Difference Between Intact and Torn Preop.*	Entire Series
Supraspinatus
Entire series	1.50	-	2.04		2.037	0.062
Intact repair	-	-	1.79		1.79
Failure	1.50	-	2.63		2.63	0.0062
P value for difference between intact repair and failure*			0.017		0.017
Subscapularis
Entire series	1.14	0.83	2.07	0.0084	1.79	0.052
Intact repair	1.125	0.83	2.03	0.007	1.71	0.477
Failure	1.143	-	2.25		2.25	0.0495
P value for difference between intact repair and failure*	0.957		0.68		0.337
Infraspinatus
Entire series	1.735	1.70	2.47	0.027	2.093	0.1229
Intact repair	1.375	1.70	2.46	0.033	2.06	0.056
Failure	2.056	-	2.5		2.5	0.41
P value for difference between intact repair and failure*	0.1124		0.999		0.517

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: TABLE VIIIAnalysis of Failures

	Preop.			Postop.			P Value for Difference Between Preop. and Postop. Values†
Failure*	Intact Repair*	P Value†	Failure*	Intact Repair*	P Value†	Failure	Intact Repair
Age (yrs.)	56.8	56.2	0.51
Durat. of symptoms preop. (mos.)	11	28.1	0.021
Durat. of follow-up (mos.)				36.9	37.1	0.404
Constant score
Absolute¹⁰ (points)	34.6	43.8	0.35	59.6	77	0.0112	0.0099	0.0001
Relative⁹ (percent)	40.1	54.1	0.26	70.6	93.4	0.0077	0.037	0.0001
Pain (points)	4.4	6.3	0.34	12.1	13.4	0.64	0.0087	0.0004
Activities of daily living (points)	4.5	4.28	0.758	8.4	9.8	0.075	0.0045	0.0001
Functional use of arm (points)	5.3	6.6	0.261	7.6	9.47	0.108	0.109	0.001
Flexion (degrees)	80	98.9	0.246	124	152.1	0.0038	0.012	0.0001
Abduction (degrees)	72.6	86.8	0.53	119	147.4	0.157	0.032	0.0001
External rotation (degrees)	45.6	52.1	0.707	32.5	45.8	0.16	0.53	0.47
Internal rotation (points)	5.3	6.28	0.339	7.2	7.5	0.911	0.056	0.122

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: TABLE VIIIAnalysis of Failures

	Preop.			Postop.			P Value for Difference Between Preop. and Postop. Values†
Failure*	Intact Repair*	P Value†	Failure*	Intact Repair*	P Value†	Failure	Intact Repair
Age (yrs.)	56.8	56.2	0.51
Durat. of symptoms preop. (mos.)	11	28.1	0.021
Durat. of follow-up (mos.)				36.9	37.1	0.404
Constant score
Absolute¹⁰ (points)	34.6	43.8	0.35	59.6	77	0.0112	0.0099	0.0001
Relative⁹ (percent)	40.1	54.1	0.26	70.6	93.4	0.0077	0.037	0.0001
Pain (points)	4.4	6.3	0.34	12.1	13.4	0.64	0.0087	0.0004
Activities of daily living (points)	4.5	4.28	0.758	8.4	9.8	0.075	0.0045	0.0001
Functional use of arm (points)	5.3	6.6	0.261	7.6	9.47	0.108	0.109	0.001
Flexion (degrees)	80	98.9	0.246	124	152.1	0.0038	0.012	0.0001
Abduction (degrees)	72.6	86.8	0.53	119	147.4	0.157	0.032	0.0001
External rotation (degrees)	45.6	52.1	0.707	32.5	45.8	0.16	0.53	0.47
Internal rotation (points)	5.3	6.28	0.339	7.2	7.5	0.911	0.056	0.122