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Clinical and Structural Outcomes of Nonoperative Management of Massive Rotator Cuff Tears
P.O. Zingg, MD1; B. Jost, MD1; A. Sukthankar, MD1; M. Buhler, MD1; C.W.A. Pfirrmann, MD1; C. Gerber, MD1
1 Departments of Orthopaedics (P.O.Z., B.J., A.S., M.B., and C.G.) and Radiology (C.W.A.P.), University of Zurich, Balgrist, Forch-strasse 340, CH-8008 Zurich, Switzerland. E-mail address for B. Jost: bernhard.jost@balgrist.ch
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Departments of Orthopaedics and Radiology, University of Zurich, Balgrist, Zurich, Switzerland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Sep 01;89(9):1928-1934. doi: 10.2106/JBJS.F.01073
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Background: The natural history of massive rotator cuff tears is not well known. The purpose of this study was to determine the clinical and structural mid-term outcomes in a series of nonoperatively managed massive rotator cuff tears.

Methods: Nineteen consecutive patients (twelve men and seven women; average age, sixty-four years) with a massive rotator cuff tear, documented by magnetic resonance imaging, were identified retrospectively. There were six complete tears of two rotator cuff tendons and thirteen complete tears of three rotator cuff tendons. All patients were managed exclusively with nonoperative means. Nonoperative management was chosen when a patient had low functional demands and relatively few symptoms and/or if he or she refused to have surgery. For the purpose of this study, patients were examined clinically and with standard radiographs and magnetic resonance imaging.

Results: After a mean duration of follow-up of forty-eight months, the mean relative Constant score was 83% and the mean subjective shoulder value was 68%. The score for pain averaged 11.5 points on a 0 to 15-point visual analogue scale in which 15 points represented no pain. The active range of motion did not change over time. Forward flexion and abduction averaged 136°; external rotation, 39°; and internal rotation, 66°. Glenohumeral osteoarthritis progressed (p = 0.014), the acromiohumeral distance decreased (p = 0.005), the size of the tendon tear increased (p = 0.003), and fatty infiltration increased by approximately one stage in all three muscles (p = 0.001). Patients with a three-tendon tear showed more progression of osteoarthritis (p = 0.01) than did patients with a two-tendon tear. Four of the eight rotator cuff tears that were graded as reparable at the time of the diagnosis became irreparable at the time of final follow-up.

Conclusions: Patients with a nonoperatively managed, moderately symptomatic massive rotator cuff tear can maintain satisfactory shoulder function for at least four years despite significant progression of degenerative structural joint changes. There is a risk of a reparable tear progressing to an irreparable tear within four years.

Level of Evidence: Prognostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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