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The Clinical and Structural Long-Term Results of Open Repair of Massive Tears of the Rotator Cuff
Matthias A. Zumstein, MD1; Bernhard Jost, MD1; Julia Hempel, MD1; Juerg Hodler, MD, MBA1; Christian Gerber, MD, FRCS1
1 Department of Orthopedics (M.A.Z., B.J., J. Hempel, and C.G.) and Division of Radiology (J. Hodler), University of Zurich, Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland. E-mail address for C. Gerber: christian.gerber@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 Department of Orthopedics and Division of Radiology, University of Zurich, Balgrist, Zürich, Switzerland

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Nov 01;90(11):2423-2431. doi: 10.2106/JBJS.G.00677
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Background: At a mean follow-up of 3.1 years, twenty-seven consecutive repairs of massive rotator cuff tears yielded good and excellent clinical results despite a retear rate of 37%. Patients with a retear had improvement over the preoperative state, but those with a structurally intact repair had a substantially better result. The purpose of this study was to reassess the same patients to determine the long-term functional and structural results.

Methods: At a mean follow-up interval of 9.9 years, twenty-three of the twenty-seven patients returned for a review and were examined clinically, radiographically, and with magnetic resonance imaging with use of a methodology identical to that used at 3.1 years.

Results: Twenty-two of the twenty-three patients remained very satisfied or satisfied with the result. The mean subjective shoulder value was 82% (compared with 80% at 3.1 years). The mean relative Constant score was 85% (compared with 83% at 3.1 years). The retear rate was 57% at 9.9 years (compared with 37% at 3.1 years; p = 0.168). Patients with an intact repair had a better result than those with a failed reconstruction with respect to the mean absolute Constant score (81 compared with 64 points, respectively; p = 0.015), mean relative Constant score (95% and 77%; p = 0.002), and mean strength of abduction (5.5 and 2.6 kg; p = 0.007). The mean retear size had increased from 882 to 1164 mm2 (p = 0.016). Supraspinatus and infraspinatus muscle fatty infiltration had increased (p = 0.004 and 0.008, respectively). Muscles with torn tendons preoperatively showed more fatty infiltration than muscles with intact tendons preoperatively, regardless of repair integrity. Shoulders with a retear had a significantly higher mean acromion index than those without retear (0.75 and 0.65, respectively; p = 0.004).

Conclusions: Open repair of massive rotator cuff tears yielded clinically durable, excellent results with high patient satisfaction at a mean of almost ten years postoperatively. Conversely, fatty muscle infiltration of the supraspinatus and infraspinatus progressed, and the retear size increased over time. The preoperative integrity of the tendon appeared to be protective against muscle deterioration. A wide lateral extension of the acromion was identified as a previously unknown risk factor for retearing.

Level of Evidence: Therapeutic 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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    Christian Gerber, MD, FRCS
    Posted on December 15, 2010
    Dr. Gerber and colleagues respond to Dr. Guishan
    Department of Orthopedics, University of Zurich, Zurich, Switzerland

    We thank Dr. Gu Guishan for his precise and correct comparison of the two papers. Nyffeler et al (1) described the distance between the glenoid (G) and the lateral aspect of the humeral head (H) as GH. We described this same distance as GT because in fact, the lateral most part of the proximal humerus is the tuberosity, so that we called the distance in the second paper (2) GT. Thus the answer to the question is yes, GH in the paper of Nyffeler et al. is identical to the distance GT in the paper of Zumstein et al. We apologize if the effort to be as precise as possible has led to confusion rather than to clarification and we retrospectively agree that using the term GH might have been easier.


    1. Nyffeler RW, Werner CM, Sukthankar A, Schmid MR, Gerber C. Association of a large lateral extension of the acromion with rotator cuff tears. J Bone Joint Surg Am. 2006;88:800-5.

    2. 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;90:2423-31.

    Gu Guishan
    Posted on December 15, 2010
    Letter to the Editor
    Jilin Province, China

    To the Editor:

    I have read the article, "The Clinical and Structural Long-term Results of Open Repair of Massive Tears of the Rotator Cuff" (2008;90:2423-31), by Zumstein et al. I have found that there is an equation which is "AI =GA/GT" in Fig 1 on page 2425 that makes me confused and is difficult to understand. In general, "GT" means the distance from the glenoid to the lateral aspect of humeral head, but according to Nyffeler's article, "Association of a Large Lateral Extension of the Acromion with Rotator Cuff Tears" (1), "GT" should be "GH".

    My question: is there any mistake in describing the concept "GH = GT"? What does "T" mean?


    1. Nyffeler RW, Werner CM, Sukthankar A, Schmid MR, Gerber C. Association of a large lateral extension of the acromion with rotator cuff tears. J Bone Joint Surg Am. 2006;88:800-5.

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