Original Article With Video Illustration
Arthroscopic Partial Repair of Irreparable Large to Massive
Rotator Cuff Tears
Sung-Jae Kim, M.D., Ph.D., In-Sung Lee, M.D., Seung-Hyun Kim, M.D.,
Won-Yong Lee, M.D., and Yong-Min Chun, M.D., Ph.D.
Purpose: The aim of this study was to evaluate the outcome of arthroscopic partial repair and margin
convergence of irreparable large to massive rotator cuff tears. Methods: Between January 2003 and
July 2008, 27 patients who met the inclusion criteria underwent arthroscopic partial repair and margin
convergence of irreparable large to massive rotator cuff tears. An irreparable tear was defined as a
tear with a minimum anterior-to-posterior width of 3 cm or larger, where it was not feasible to
completely cover the humeral head with the cuff at the time of surgery. Results: The mean
preoperative tear size was 42.1 ⫾ 6.2 mm. The mean size of the postoperative residual defect in the
repaired tendon along the medial margin of the greater tuberosity was 12.0 ⫾ 5.5 mm. All shoulder
scores showed improvement. The Simple Shoulder Test improved from 5.1 ⫾ 1.2 to 8.8 ⫾ 2.1 (P ⬍
.001), the Constant score from 43.6 ⫾ 7.9 to 74.1 ⫾ 10.6 (P ⬍ .001), and the University of California,
Los Angeles score from 10.5 ⫾ 3.0 to 25.9 ⫾ 5.0 (P ⬍ .001). Both Constant and University of
California, Los Angeles shoulder scores also showed an inverse correlation with defect size. We
compared muscle strength between the affected and contralateral sides and found that the strength of
the affected side was not restored to the same level as the contralateral side (P ⬍ .001). Conclusions:
Arthroscopic partial repair and margin convergence showed satisfactory short-term outcomes in
irreparable large to massive rotator cuff tears. Thus it is suggested that, even in a large to massive
tear that appears irreparable, attempting to repair it as much as possible to possibly convert it into a
functional rotator cuff tear by re-creating a balanced forced couple can be helpful in reducing pain,
as well as improving functional outcomes. Level of Evidence: Level IV, therapeutic case series.
D
espite remarkable advances in arthroscopic rotator cuff repair over the past few decades, arthroscopic repair of large to massive rotator cuff tears
From the Department of Orthopaedic Surgery, Arthroscopy and
Joint Research Institute, Yonsei University College of Medicine,
Seoul, South Korea.
The authors report that they have no conflicts of interest in the
authorship and publication of this article.
Received January 12, 2011; accepted November 16, 2011.
Address correspondence to Yong-Min Chun, M.D., Ph.D., Department of Orthopaedic Surgery, Arthroscopy and Joint Research
Institute, Yonsei University College of Medicine, CPO Box 8044,
134, Shinchon-dong, Seodaemun-gu, Seoul 120-752, South Korea.
E-mail: [email protected]
© 2012 by the Arthroscopy Association of North America
0749-8063/1133/$36.00
doi:10.1016/j.arthro.2011.11.018
Note: To access the video accompanying this report, visit the June
issue of Arthroscopy at www.arthroscopyjournal.org.
is still challenging, especially in cases of inelastic and
severely retracted torn tendons due to muscle atrophy,
fatty degeneration, and adhesion. Although mobilization of the torn tendon can be obtained through the
release of adhesion and the interval slide technique,1
poor tissue quality sometimes precludes complete reattachment of the torn tendon to its anatomic footprint
and leaves a residual defect in the cuff.
There are several treatment options for irreparable
large to massive rotator cuff tears2-10: partial repair,
simple debridement, tendon transfer, and biologic
augmentation. One should select the most appropriate
option by taking into consideration the patient’s age,
degree of comorbidities, level of activity, and physical
demand. In elderly patients with low physical demands, a simple debridement may be indicated. In
selected younger patients, tendon transfer may be feasible. The use of biologic augmentation such as tissueengineered matrix or allograft patch has shown fair to
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 6 (June), 2012: pp 761-768
761
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S-J. KIM ET AL.
poor clinical results. Partial or incomplete repair also
seems to have less favorable outcomes than complete
repair. However, Burkhart11 introduced the concept of
“functional rotator cuff tear” and the biomechanical
rationale of the “suspension bridge system.” Thus
partial rotator cuff repair attempts to re-create the
transverse force couple of the rotator cuff and provide
a stable fulcrum for the glenohumeral joint. Despite
this concept, there have been a few studies regarding
partial or incomplete arthroscopic repair of large to
massive rotator cuff tear and its results.2,3,11
The aim of our study was to evaluate the outcome of
arthroscopic partial repair of irreparable large to massive rotator cuff tears. We hypothesized that although
overall functional outcomes would improve after surgery, muscle strength would not be restored to the
same level as the contralateral shoulder.
METHODS
Study Population and Demographics
Between January 2003 and July 2008, 37 patients
underwent arthroscopic partial repair and margin convergence of irreparable large to massive rotator cuff
tears and their medical reports including radiologic
findings were reviewed retrospectively. An irreparable
tear was defined as a tear with a minimum anteriorto-posterior width of 3 cm or larger, where it was not
feasible to completely cover the humeral head with the
cuff at the time of surgery. Of the patients in the initial
study population, 27 met the inclusion criteria. The
inclusion criteria were (1) irreparable large to massive
rotator cuff tear (ⱖ3 cm in diameter) accompanied by
pain and functional disability refractory to conservative treatment; (2) arthroscopic partial rotator cuff
repair (failed attempt to completely cover the humeral
head with the cuff, leaving the defect in the repaired
rotator cuff); and (3) available for a minimum 2-year
follow-up after surgery. Ten patients were excluded
according to the exclusion criteria, which were (1) a
subscapularis tear requiring repair; (2) near complete
fatty replacement of the supraspinatus, infraspinatus,
and teres minor tendon; (3) prior surgery on the affected shoulder; (4) moderate to severe rotator cuff
arthropathy (Hamada classification III, IV, or V)12; (5)
existing shoulder pain on the contralateral side; and
(6) Workers’ Compensation claim. The mean patient
age at the time of the operation was 62.3 years (range,
54 to 72 years), and the mean follow-up period was
41.3 months (range, 36 to 52 months). Approval for
this study was obtained from our institutional review
board, and informed consent was obtained from all
patients.
Surgical Procedure and Postoperative
Rehabilitation
Under general anesthesia, all patients underwent
arthroscopic rotator cuff repair in the lateral decubitus
position with 10 lb of longitudinal traction. Typically,
the senior author used 4 routine portals: posterior,
lateral, posterolateral, and anterior portal. If necessary,
additional portals were created to obtain an optimal insertion angle of the anchors, as well as to appropriately
release adhesion. By use of the posterolateral or lateral
portal as a viewing portal, the status and mobility of the
retracted torn tendon were evaluated (Video 1, available
at www.arthroscopyjournal.org). After release of adhesions and mobilization of the tendon, it still could not
be completely advanced to the greater tuberosity. The
surgeon tried to repair it as well as possible and
converge the margins to help restore the transverse
force couple and reduce the size of the tear (Fig 1). A
single-row repair was performed with insertion of the
suture anchors within the footprint of the greater tuberosity or less than 1 cm medial to the junction
between the articular cartilage and greater tuberosity.
After the partial repair and margin convergence had
been performed, the residual defect was measured
along the junction between the articular cartilage and
greater tuberosity. Arthroscopic acromioplasty was
performed limited to the impingement site, with preservation of the coracoacromial ligament as much as
possible (Fig 2).
With regard to coexisting lesions of the long head of
the biceps or SLAP lesions, unless the SLAP lesion
had severe degeneration in the superior labrum or long
head of the biceps, arthroscopic SLAP repair was
performed with suture anchors. In the case of a lesion
of the long head of the biceps, if the lesion involved
more than one-fourth of the tendon or was subluxated
or dislocated, tenotomy was performed in patients
aged older than 60 years and tenodesis in patients aged
younger than 60 years. If the biceps lesion involved
less than one-fourth of the tendon, a simple debridement was performed.
After the operation, the shoulder was kept in an
abduction brace for 6 weeks. Every 4 hours, the patient was encouraged to remove the brace and to
perform pendulum exercises, starting the day after
surgery. Self-assisted passive range-of-motion exercise as tolerated was begun at 4 to 5 weeks postoper-
REPAIR OF LARGE TO MASSIVE ROTATOR CUFF TEAR
FIGURE 1. (A, B) Margin convergence technique in a U-shaped
tear. Sometimes, a dog-ear deformity formed at the top of the sideto-side sutures. (C, D) Margin
convergence technique in a Vshaped tear.
A
B
C
D
atively according to pain subsidence, and self-assisted
active range-of-motion exercise began at 6 to 8 weeks
postoperatively. Isotonic strengthening exercises by
use of an elastic band were begun at 3 to 4 months
postoperatively.
Assessment
As for radiologic evaluation, magnetic resonance
imaging was reviewed in addition to the plain radiographs, such as standing shoulder anteroposterior
view in neutral, axial view, and supraspinatus outlet
view. To evaluate the superior migration of the humeral head, the acromiohumeral distance was measured preoperatively and postoperatively by an inde-
763
pendent observer. The observer measured the distance
twice, and the mean of these 2 values was used.
Muscle atrophy and fatty degeneration were evaluated
on the most lateral oblique sagittal T1-weighted magnetic resonance images in which the scapular spine
was seen in contact with the scapular body (the socalled Y-shaped view).13,14 A 5-stage system was used
to evaluate the amount of fatty degeneration in the
cuff muscle: stage 0 indicates a completely normal
muscle without any fatty streaks; in stage 1 the muscle
contains some fatty streaks; in stage 2 fatty infiltration
is increased but there is still more muscle than fat;
stage 3 contains as much fat as muscle; and stage 4
contains more fat than muscle (Fig 3).
764
S-J. KIM ET AL.
zero) for the UCLA score and on a scale of 0 to 25 (25,
normal; 20, good; 15, fair; 10, poor; 5, trace; and 0,
zero) for the Constant score.
Statistical Analysis
To compare preoperative and postoperative outcomes, a paired t test was implemented. A simple
linear regression analysis was performed to investigate the correlation between residual defect size in
the repaired cuff and muscle strength, as well as the
overall shoulder score and fatty infiltration of the
supraspinatus and infraspinatus. A level of significance of P ⬍ .05 was used with a 95% confidence
interval.
FIGURE 2. Arthroscopic acromioplasty with preservation of coracoacromial ligament as much as possible. View from lateral portal.
The arrow indicates the coracoacromial ligament.
RESULTS
Arthroscopic Findings
As for functional evaluation, the Simple Shoulder
Test, the University of California, Los Angeles
(UCLA) shoulder score, and the Constant shoulder
score were used preoperatively and postoperatively.
With regard to the manual measurement of muscle
strength, in the UCLA shoulder score, isometric 90°
forward flexion was measured bilaterally with the
elbow extended and the forearm in a neutral position
and was compared with the strength of the normal
contralateral side. If the strength of the affected arm
was the same as that of the normal contralateral side,
it was graded as normal. If the affected arm was
weaker than the contralateral side, it was graded as
good. If the patient could barely raise the arm or was
unable to resist the examiner’s downward pull at all, it
was graded as fair. An independent observer measured
arm strength twice, and the mean of these values was
used. In the Constant score, isometric 90° abduction
strength was measured twice in the scapular plane
with the elbow extended and the forearm pronated in
the same manner; the mean of these 2 values was
used. We acknowledge that in the Constant score,
abduction strength was measured using a spring balance and expressed in pounds. In addition, this absolute strength value varies according to age and sex. It
is possible to normalize and correct according to age
and sex, as was reported by Katolik et al.15 However,
we chose the strength of the contralateral side as the
normal standard of comparison with the affected side.
The strength of active forward elevation or abduction
was measured manually and graded on a scale of 0 to
5 (5, normal; 4, good; 3, fair; 2, poor; 1, trace; and 0,
A U-shaped tear was found in 19 of 27 patients
(70%), and a V-shaped tear was found in the remaining 8 (30%). The mean tear size was 42.1 ⫾ 6.2 mm
(range, 35 to 54 mm). After arthroscopic partial rotator cuff repair with suture anchors, the mean size of
the residual defect along the medial margin of the
greater tuberosity was 12.0 ⫾ 7.0 mm (range, 5 to 32
mm) and the mean decrease in tear size after repair
was 30.4 ⫾ 9.4 mm (range, 24 to 40 mm). The mean
number of anchors used was 3.0 (range, 1 to 5), and in
all but 4 patients, the surgeon placed side-to-side
sutures for margin convergence. However, the number
of side-to-side sutures per patient varied.
A coexisting SLAP type II lesion was found in 5
patients (19%). Four of these underwent arthroscopic
SLAP repair with a suture anchor, with the exception
of one patient who had concomitant severe tendinitis
involving greater than 25% of the tendon. Coexisting
severe tendinitis of the long head of the biceps was
present in 6 patients (22%); arthroscopic biceps tenodesis was performed in 1 patient with a suture anchor,
and tenotomy was performed in 2 patients. Two patients underwent arthroscopic debridement for the biceps lesion. In the remaining 1 patient, the long head
of the biceps was already ruptured (Table 1). In all
cases, arthroscopic acromioplasty was performed limited to the impingement site while preserving the
coracoacromial ligament as much as possible.
Functional and Radiologic Assessment
All 3 of the shoulder scores showed significant
improvement over the preoperative scores at the most
REPAIR OF LARGE TO MASSIVE ROTATOR CUFF TEAR
FIGURE 3.
Different stages of fatty degeneration: (A) stage 0, (B) stage 1, (C) stage 2, (D) stage 3, and (E) stage 4.
recent follow-up: the Simple Shoulder Test improved
from 5.1 ⫾ 1.2 to 8.8 ⫾ 2.1 (P ⬍ .001), the Constant
shoulder score from 43.6 ⫾ 7.9 to 74.1 ⫾ 10.6 (P ⬍
.001), and the UCLA shoulder score from 10.5 ⫾ 3.0 to
25.9 ⫾ 5.0 (P ⬍ .001) (Tables 2 and 3). In the simple
TABLE 1.
765
Concomitant Lesions and Related Procedures
Coexisting Lesion
SLAP lesion: 5 (19%)
Long head of biceps lesion: 6 (22%)
Concomitant
Procedure
Repair using anchor: 4
Tenotomy: 1
Debridement: 2
Tenotomy: 2
Tenodesis: 1
Already ruptured: 1
linear correlation analysis between the residual defect
size in the repaired cuff and muscle strength (active
forward elevation), there was an inverse correlation (␤ ⫽
⫺0.720, P ⬍ .001). Both the Constant and UCLA shoulder scores showed an inverse correlation with the defect
size (␤ ⫽ ⫺0.751 [P ⬍ .001] for Constant shoulder
score and ␤ ⫽ ⫺0.780 [P ⬍ .001] for UCLA shoulder
score) and showed an inverse correlation with stage of
fatty infiltration (␤ ⫽ ⫺0.558 [P ⫽ .003] for supraspinatus and ␤ ⫽ ⫺0.668 [P ⬍ .001] for infraspinatus for
Constant shoulder score and ␤ ⫽ ⫺0.534 [P ⫽ .004] for
supraspinatus and ␤ ⫽ ⫺0.524 [P ⫽ .005] for infraspinatus for UCLA shoulder score). In addition, the residual
defect size showed a correlation with stage of fatty
infiltration in the supraspinatus (␤ ⫽ 0.564, P ⫽ .002)
and infraspinatus (␤ ⫽ 0.507, P ⫽ .007).
766
TABLE 2.
S-J. KIM ET AL.
Preoperative and Postoperative Constant
Shoulder Score
Preoperative
Pain (0-15)
Activities of daily living
(0-10)
Range of motion (0-50)
Strength (manual muscle
testing) (0-25)
Total (0-100)
Postoperative P Value
2.6 ⫾ 2.5
9.6 ⫾ 2.4
⬍.0001
3.0 ⫾ 1.8
25.0 ⫾ 4.5
8.0 ⫾ 1.4
39.2 ⫾ 5.4
⬍.0001
⬍.0001
13.0 ⫾ 2.5
43.6 ⫾ 7.9
17.2 ⫾ 2.9
74.1 ⫾ 10.6
⬍.0001
⬍.0001
NOTE. The values are given as the mean ⫾ standard deviation.
An isometric 90° abduction strength was measured bilaterally in
the scapular plane with the elbow extended and the forearm pronated and was compared with the contralateral side. The strength
was graded on a scale of 0 to 25 (25, normal; 20, good; 15, fair; 10,
poor; 5, trace; and 0, zero).
In terms of comparing muscle strength (active forward flexion and 90° abduction in the scapular plane
by manual test) between the affected and contralateral
sides, mean muscle strength was 3.4 ⫾ 0.6 on the
affected side (␬ value for intraobserver reliability,
0.971) and 4.6 ⫾ 0.5 on the contralateral side (␬ value
for intraobserver reliability, 0.961) (0 to 5 scale,
where 5 indicates normal; 4, good; 3, fair; 2, poor; 1,
trace; and 0, zero) in forward flexion (P ⬍ .001).
Mean muscle strength in 90° of abduction was 17.2 ⫾
2.9 on the affected side (␬ value for intraobserver
reliability, 0.939) and 23.1 ⫾ 2.5 on the contralateral
side (␬ value for intraobserver reliability, 0.917) (0 to
25 scale, where 25 indicates normal; 20, good; 15,
fair; 10, poor; 5, trace; and 0, zero) (P ⬍ .001). Some
patients with a fair motor grade (4 of 13 patients)
swung their arm up or bent their elbow first when
raising their arm, to decrease the length of the lever
arm.
The mean acromiohumeral distance before surgery
was 6.5 ⫾ 1.5 mm (range, 3 to 9.5 mm) (␬ value for
intraobserver reliability, 0.980), and this decreased to
5.9 ⫾ 1.8 mm (range, 2 to 9.5 mm) (␬ value for
intraobserver reliability, 0.989) at the most recent
follow-up. This difference of 0.7 ⫾ 0.6 mm was
statistically significant (P ⬍ .001). According to the
stage system for muscle fatty infiltration on the
oblique sagittal image, the mean stage was 3.2 (range,
2 to 4) for the supraspinatus and 2.7 (range, 2 to 4) for
the infraspinatus.
DISCUSSION
The treatment of massive rotator cuff tear has been
a challenging problem. Although most massive rotator
cuff tears are reparable and some favorable outcomes
have been documented,16-20 severe retraction and poor
tendon quality combined with fatty infiltration and
muscle atrophy have occasionally precluded complete
repair of the torn tendon to its native footprint. However, it has been documented that through the concept
of margin convergence, the repaired tendon could not
only re-create the transverse force couple of the rotator cuff but also reduce the overall tension of the
repaired tendon on the bone by distributing it to the
anterior and posterior tear leaves.11,21 Thus surgeons
began to recognize that re-establishment of a stable
fulcrum is more important than complete closure of
the defect.22 In addition, several studies have verified
favorable clinical outcomes despite partial or incomplete repair.3,11,22
Early on, Burkhart et al.23 proposed a “suspension
bridge” in the rotator cuff and emphasized the role of
the rotator cable. This concept could be applied to
margin convergence, in repairing massive rotator cuff
tears and reducing tensile strain on repaired tendon
and re-creating the rotator cuff cable and balanced
force couple.21 Recently, Halder et al.24 performed an
in vitro biomechanical study that supported this concept and showed that muscle forces could be effectively transmitted through the rotator cuff cable even
with small- or medium-sized tears. They proposed that
even in irreparable rotator cuff tears, side-to-side repair may be worthwhile to restore the muscle pretension and integrity of the rotator cable. Similar to
these previous reports, our study indicates that with
reduced residual defects in the cuff, there was functional improvement and a relatively strong inverse
correlation between the residual defect size and post-
TABLE 3.
Preoperative and Postoperative UCLA
Shoulder Score
Preoperative Postoperative P Value
Pain (0-10)
Function (0-10)
Satisfaction (0 or 5)
Active forward flexion
(0-5) (range of motion)
Strength (manual muscle
testing) (0-5)
Total (0-35)
2.0 ⫾ 1.2
3.3 ⫾ 1.5
0
7.0 ⫾ 1.7
7.6 ⫾ 1.2
4.1 ⫾ 2.0
⬍.0001
⬍.0001
⬍.0001
2.6 ⫾ 0.7
3.8 ⫾ 0.7
⬍.0001
2.6 ⫾ 0.5
10.5 ⫾ 3.0
3.4 ⫾ 0.6
25.9 ⫾ 5.0
⬍.0001
⬍.0001
NOTE. The values are given as mean ⫾ standard deviation. An
isometric 90° forward flexion was measured bilaterally with the
elbow extended and the forearm in neutral position and was compared with the strength of the contralateral side. The strength was
graded on a scale of 0 to 5 (5, normal; 4, good; 3, fair; 2, poor; 1,
trace; and 0, zero).
REPAIR OF LARGE TO MASSIVE ROTATOR CUFF TEAR
operative functional shoulder score. Duralde and Bair3
reported in their series regarding partial repair of
massive rotator cuff tear that 67% of patients showed
good to excellent results with satisfactory pain relief
and increased active elevation and 92% of patients
were satisfied with the results of surgery. In their
series the mean size of the residual defect in the
repaired cuff was 1.7 cm (range, 0.5 to 3 cm).
Burkhart11 also reported outstanding outcomes with
partial repair of irreparable rotator cuff tears: All
patients were satisfied with their results, except for 1,
and their mean residual defect was 2.9 cm2 in size.
Our study also showed satisfactory outcome with a
mean residual defect size of 12 mm, with 81% of
patients satisfied with their improvement. Although all
of the previously mentioned studies left a residual
defect and the outcomes may be inferior to those of
complete repair, these partial or incomplete repairs of
irreparable large to massive rotator cuff tears may be
worthwhile, given the level of preoperative pain and
functional disability.
However, we do not deny the effectiveness or
promising outcomes of complete closure of the rotator
cuff tear and do not insist that partial repair is superior
to complete repair, which is beyond the scope of this
study.
The acromiohumeral distance was decreased from
6.5 ⫾ 1.5 mm to 5.9 ⫾ 1.8 mm, and this was statistically significant, even though it does not seem to be
clinically significant. Other reports showed similar
outcomes in change of the acromiohumeral distance3-5: Duralde and Bair3 indicated no significant
difference after partial repair. Liem et al.4 and Boileau
et al.5 reported a 1-mm decrease or greater in acromiohumeral distance after arthroscopic debridement
or biceps tenotomy/tenodesis.
This study had several limitations. First, like previous similar studies, this study indicated a relatively
short-term result, and we do not expect that this satisfactory outcome will last for the long-term. We
suppose, because there are negative prognostic factors
in treating massive rotator cuff tears,22 that there will
be a possibility of the outcome deteriorating over
time. Thus we are not sure that arthroscopic partial or
incomplete rotator cuff repair will guarantee satisfactory midterm or long-term outcomes. Second, this
study did not have a control group to determine
whether this treatment option would be better than
other options, such as arthroscopic debridement, in
addressing irreparable large to massive rotator cuff
tear repair. Third, we did not perform follow-up magnetic resonance imaging to assess the changes in fatty
767
infiltration, muscle atrophy, and structural integrity. If
these scans had been done, this study would have been
weightier. Fourth, the strength of 90° of abduction in
the Constant score was measured manually and compared with the contralateral side. This could make the
outcomes appear better than they actually were.
CONCLUSIONS
Arthroscopic partial repair showed satisfactory
short-term outcomes in irreparable large to massive
rotator cuff tears if the patients did not have severe
muscle atrophy and fatty infiltration in all supraspinatus, infraspinatus, or teres minor. This study suggests
that in large to massive rotator cuff tears that appear
irreparable, a partial repair may provide improvement
in pain and functional outcomes; however, additional
work is necessary.
Acknowledgment: The authors are grateful to Dong-Su
Jang (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, South
Korea) and Young-Jun Cho for their help with the figures.
REFERENCES
1. Lo IK, Burkhart SS. Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double
interval slides: Technique and preliminary results. Arthroscopy
2004;20:22-33.
2. Berth A, Neumann W, Awiszus F, Pap G. Massive rotator cuff
tears: Functional outcome after debridement or arthroscopic
partial repair. J Orthop Traumatol 2010;11:13-20.
3. Duralde XA, Bair B. Massive rotator cuff tears: The result of
partial rotator cuff repair. J Shoulder Elbow Surg 2005;14:121127.
4. Liem D, Lengers N, Dedy N, Poetzl W, Steinbeck J, Marquardt B. Arthroscopic debridement of massive irreparable
rotator cuff tears. Arthroscopy 2008;24:743-748.
5. Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C, Trojani
C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator
cuff tears. J Bone Joint Surg Am 2007;89:747-757.
6. Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer
for the treatment of irreparable rotator cuff tears. J Bone Joint
Surg Am 2006;88:113-120.
7. Klinger HM, Steckel H, Ernstberger T, Baums MH. Arthroscopic debridement of massive rotator cuff tears: Negative
prognostic factors. Arch Orthop Trauma Surg 2005;125:261266.
8. Iannotti JP, Codsi MJ, Kwon YW, Derwin K, Ciccone J,
Brems JJ. Porcine small intestine submucosa augmentation of
surgical repair of chronic two-tendon rotator cuff tears. A
randomized, controlled trial. J Bone Joint Surg Am 2006;
88:1238-1244.
9. Moore DR, Cain EL, Schwartz ML, Clancy WG Jr. Allograft
reconstruction for massive, irreparable rotator cuff tears. Am J
Sports Med 2006;34:392-396.
10. Nho SJ, Delos D, Yadav H, et al. Biomechanical and biologic
768
11.
12.
13.
14.
15.
16.
17.
S-J. KIM ET AL.
augmentation for the treatment of massive rotator cuff tears.
Am J Sports Med 2010;38:619-629.
Burkhart SS. Reconciling the paradox of rotator cuff repair
versus debridement: A unified biomechanical rationale for the
treatment of rotator cuff tears. Arthroscopy 1994;10:4-19.
Hamada K, Fukuda H, Mikasa M, Kobayashi Y. Roentgenographic findings in massive rotator cuff tears. A long-term
observation. Clin Orthop Relat Res 1990:92-96.
Mellado JM, Calmet J, Olona M, et al. Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty
degeneration, and muscle atrophy correlated with intraoperative
and clinical findings. AJR Am J Roentgenol 2005;184:1456-1463.
Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty
degeneration of the muscles of the rotator cuff: Assessment by
computed tomography versus magnetic resonance imaging. J
Shoulder Elbow Surg 1999;8:599-605.
Katolik LI, Romeo AA, Cole BJ, Verma NN, Hayden JK,
Bach BR. Normalization of the Constant score. J Shoulder
Elbow Surg 2005;14:279-285.
Burkhart SS, Barth JR, Richards DP, Zlatkin MB, Larsen M.
Arthroscopic repair of massive rotator cuff tears with stage 3
and 4 fatty degeneration. Arthroscopy 2007;23:347-354.
Moser M, Jablonski MV, Horodyski M, Wright TW. Functional outcome of surgically treated massive rotator cuff tears:
A comparison of complete repair, partial repair, and debridement. Orthopedics 2007;30:479-482.
18. Zumstein MA, Jost B, Hempel J, Hodler J, Gerber C. The
clinical and structural long-term results of open repair of
massive tears of the rotator cuff. J Bone Joint Surg Am 2008;
90:2423-2431.
19. Papadopoulos P, Karataglis D, Boutsiadis A, Fotiadou A,
Christoforidis J, Christodoulou A. Functional outcome and
structural integrity following mini-open repair of large and
massive rotator cuff tears: A 3-5 year follow-up study. J
Shoulder Elbow Surg 2011;20:131-137.
20. Hanusch BC, Goodchild L, Finn P, Rangan A. Large and
massive tears of the rotator cuff: Functional outcome and
integrity of the repair after a mini-open procedure. J Bone
Joint Surg Br 2009;91:201-205.
21. Burkhart SS, Athanasiou KA, Wirth MA. Margin convergence: A method of reducing strain in massive rotator cuff
tears. Arthroscopy 1996;12:335-338.
22. Bedi A, Dines J, Warren RF, Dines DM. Massive tears of the
rotator cuff. J Bone Joint Surg Am 2010;92:1894-1908.
23. Burkhart SS, Esch JC, Jolson RS. The rotator crescent and
rotator cable: An anatomic description of the shoulder. Arthroscopy 1993;9:611-616.
24. Halder AM, O’Driscoll SW, Heers G, et al. Biomechanical
comparison of effects of supraspinatus tendon detachments,
tendon defects, and muscle retractions. J Bone Joint Surg Am
2002;84:780-785.
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