Long-Term Functional Outcome of Repair of Large and Massive Chronic Tears of the Rotator Cuff

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1 This is an enhanced PDF from The Journal of Bone and Joint Surgery The PDF of the article you requested follows this cover page. Long-Term Functional Outcome of Repair of Large and Massive Chronic Tears of the Rotator Cuff ANDREW S. ROKITO, FRANCES CUOMO, MAUREEN A. GALLAGHER and JOSEPH D. ZUCKERMAN J Bone Joint Surg Am. 1999;81: This information is current as of November 30, 2010 Reprints and Permissions Publisher Information Click here to order reprints or request permission to use material from this article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA

2 Long-Term Functional Outcome of Repair of Large and Massive Chronic Tears of the Rotator Cuff * BY ANDREW S. ROKITO, M.D., FRANCES CUOMO, M.D., MAUREEN A. GALLAGHER, PH.D., AND JOSEPH D. ZUCKERMAN, M.D., NEW YORK, N.Y. Investigation performed at the Shoulder Service, Department of Orthopaedic Surgery, New York University, Hospital for Joint Diseases, New York City Abstract Background: There have been conflicting reports regarding the effect of the size of a tear of the rotator cuff on the ultimate functional outcome after repair of the rotator cuff. While some authors have reported that the size of the tear does not adversely affect the overall result of repair, others have reported that the outcome is less predictable after repair of a large tear than after repair of a small tear. The purpose of the present study was to examine the long-term functional outcome and the recovery of strength in thirty consecutive patients who had had repair of a large or massive tear of the rotator cuff. Methods: Thirty consecutive patients who had operative repair of a large or massive chronic tear of the rotator cuff had a comprehensive isokinetic assessment of the strength of the shoulder preoperatively, twelve months postoperatively, and a mean of sixty-five months (range, forty-six to ninety-three months) postoperatively. The functional outcome was assessed with the University of California at Los Angeles shoulder score. Results: All patients reported that they were satisfied with the result and had increased strength compared with preoperatively. There was a significant decrease in pain (p < 0.01) and significant improvements in function (p < 0.01) and the range of motion (p < 0.01). The mean University of California at Los Angeles shoulder score increased significantly from 12.3 points preoperatively to 31.0 points at the most recent follow-up examination (p < 0.01). The mean peak torque in flexion, abduction, and external rotation increased significantly to 80 percent (p < 0.01), 73 percent (p < 0.01), and 91 percent (p < 0.01), respectively, of that of the uninvolved shoulder by the time of the most recent follow-up examination. Conclusions: Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. The results of the present study suggest that *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. Shoulder Service, Department of Orthopaedic Surgery, New York University, Hospital for Joint Diseases, 301 East 17th Street, New York, N.Y Copyright 1999 by The Journal of Bone and Joint Surgery, Incorporated more than one year is needed for complete restoration of strength. The strength of the affected shoulders still did not equal that of the unaffected, contralateral shoulders by the time of the long-term follow-up. Operative repair of a large or massive chronic tear of the rotator cuff can be technically challenging because of retraction and inelasticity of the tendons, bursal scarring, muscle atrophy, and fatty degeneration. Intra-articular and extra-articular releases are routinely performed to mobilize the tendons so that they can be attached to the greater tuberosity. While some authors have stated that the size of the tear does not appreciably affect the overall result of the repair 1,19,32, others have reported that the outcome after repair of a large tear is less predictable than that after repair of a small tear 7,9,15,17,18,26-28,42,45,46. Isokinetic strength-testing has been found to be useful for quantifying the recovery of shoulder strength after repair of the rotator cuff 43,45. In a previous study, we found a trend between the size of the tear and the recovery of strength of the shoulder after repair 45. We also found that more than one year is needed for the recovery of strength after repair of a large or massive tear of the rotator cuff 45. The purpose of the present study was to quantify the long-term isokinetic strength of the shoulder and the functional outcome for thirty patients who had had repair of a large or massive chronic tear of the rotator cuff. Materials and Methods Thirty consecutive patients who had a reparable chronic tear of the rotator cuff that was either large (three to five centimeters) or massive (more than five centimeters) were managed operatively between June 1989 and July All of the patients provided written informed consent to verify that they understood the purpose of the investigation. The size of the tear was graded according to the system of DeOrio and Cofield 18 at the time of the operation. The criterion for inclusion in the study was a large or massive tear that could be attached to the greater tuberosity after appropriate mobilization techniques and repaired with the arm at the side. Seventeen patients had a large tear, and thirteen had a massive tear. The subscapularis tendon was intact in all patients. Patients who had a tear that could not be VOL. 81-A, NO. 7, JULY

3 992 A. S. ROKITO, FRANCES CUOMO, M. A. GALLAGHER, AND J. D. ZUCKERMAN repaired, who had had a previous procedure involving the shoulder, or who had symptoms in the contralateral shoulder were excluded from the study. The study group consisted of twenty-one men and nine women with a mean age of fifty-seven years (range, thirty-nine to seventy-eight years). The tear was on the dominant side in twenty-three patients. All patients had substantial pain and functional limitation, with regard to work and activities of daily living, that had lasted for more than six months and that were unresponsive to nonoperative treatment. Nonoperative treatment consisted of a period of relative rest, modification of activity, nonsteroidal anti-inflammatory medication, and a home-exercise program that emphasized range-ofmotion exercises and strengthening of the shoulder. Cortisone injections were not used for any patient. The clinical diagnosis of a torn rotator cuff was confirmed with arthrography or magnetic resonance imaging. Preoperative Assessment The University of California at Los Angeles shoulder score 20 was used to assess the patients both before and after the operation. In order to eliminate bias, this test was administered by one of us (A. S. R.) who had not been involved in the operative procedures and who was blinded to the operative findings. This system assigns a maximum of 10 points each for pain and function and 5 points each for range of motion, strength of forward elevation, and overall patient satisfaction, for a total possible score of 35 points. The strength of the shoulder was graded from 0 to 5, according to standard manual muscle-testing with the arm in maximum elevation. No patient was satisfied with the results of the nonoperative treatment before the operation. Isokinetic Strength Isokinetic strength-testing was done within seven days preoperatively, twelve months postoperatively, and at the time of the most recent long-term follow-up examination. Testing was performed with a modified dynamometer (Biodex, Shirley, New York), with use of a standardized protocol, by one of us (M. A. G.) who was blinded to the operative findings. The instrument was interfaced with an NEC-386 computer (Biodex) and a software package that supplies values for parameters related to torque and displacement. The software allows for normalization of the maximum gravity effect caused by the weight of the arm. The shoulders were tested at 60 degrees per second in three axes of motion: flexion-extension and abduction-adduction with the patient sitting and external-internal rotation with the patient standing. The axis of rotation for flexion-extension was set at the acromion and was positioned to align with the pivot point of the input arm of the dynamometer. The range-of-motion stops were set at 0 and 120 degrees. The elbow was maintained in full extension, with the forearm in neutral rotation. The axis of rotation for abduction-adduction of the shoulder approximated the axis of the acromioclavicular joint and was aligned perpendicular to the coronal plane. The range-of-motion stops were set at 0 and 120 degrees. External-internal rotation was tested with the shoulder in neutral, the elbow in 90 degrees of flexion, and the forearm in neutral rotation. The limb was supported by an elbow pad. The range-of-motion stops were set at 30 degrees of internal rotation and 45 degrees of external rotation. Stabilization straps were secured and foot-markers were placed during all testing to ensure a standardized and reproducible protocol. Three trials were performed at submaximum effort in each axis to acquaint the patient with the testing conditions. These trials were followed by a five-minute rest period. Three trials at maximum effort were then performed in each axis. A five-minute rest period was allowed between each testing sequence. Scores for peak torque were recorded for the three repetitions in each axis of motion. The contralateral shoulder was tested in an identical manner. The mean and standard deviation for the three repetitions were then determined for each axis for each shoulder. Values for peak torque as a percentage of that of the uninvolved, contralateral shoulder were calculated. Operative Technique The standardized operative procedure was performed by two of us (F. C. and J. D. Z.). First, a superior incision was made in Langer s lines over the top of the acromion and was continued to just lateral to the coracoid process. Subcutaneous flaps were then raised in all directions, followed by detachment of the anterior part of the deltoid from the acromion and resection of the coracoacromial ligament. The deltoid was split in line with its fibers to the level of the greater tuberosity. Care was taken to ensure that this split was not extended more than five centimeters so as to avoid injury of the axillary nerve. By rotating the humerus, it was possible to gain access to all aspects of the tear without the need for a more posterior split of the deltoid. An anterior-inferior acromioplasty was performed, followed by resection of any spurs on the undersurface of the acromioclavicular joint. The lateral end of the clavicle was not resected because the acromioclavicular joint was thought to be asymptomatic in all patients. After a partial bursectomy, the tear was measured in centimeters from anterior to posterior at its maximum diameter with the arm at the side. The rotator cuff was then repaired with a combination of tendon-totendon and tendon-to-bone techniques. After the traction sutures were placed, the mobility of the tendons was assessed. In some patients, the tendon tissue was of good quality and could be repaired readily without the need for extensive mobilization. In other patients, the quality of the tissue was poor with substantial scarring THE JOURNAL OF BONE AND JOINT SURGERY

4 LONG-TERM FUNCTIONAL OUTCOME OF REPAIR OF LARGE AND MASSIVE CHRONIC TEARS 993 and extensive mobilization was needed to repair the defect. All defects could be closed after appropriate mobilization techniques had been performed. Mobilization of the cuff began with blunt dissection of extra-articular and intra-articular adhesions. When necessary, the coracohumeral ligament was divided close to its insertion on the base of the coracoid process. If additional length was needed, an intra-articular release of the superior aspect of the capsule and the rotator cuff from the superior aspect of the labrum was performed with a combination of sharp and blunt dissection. If additional mobilization was needed at this point, the rotator interval was released sharply to the base of the coracoid. The rotator cuff tendons in all patients were mobilized sufficiently to permit a transosseous repair to a bleeding cancellous bed prepared in the greater tuberosity with the arm at the side. The arm was then moved through a gentle range of motion to test the repair and to determine a safe range of motion for rehabilitation. The deltoid was then repaired to the acromion through drill-holes. Postoperative Care A standardized postoperative rehabilitation protocol was carried out by occupational therapists for all patients. An arm sling was used for the first six weeks postoperatively. An abduction brace was not used. Passive range-of-motion exercises within the predetermined safe range of motion were initiated on the first postoperative day. Active range-of-motion exercises were begun when the healing of the rotator cuff was thought to be secure, usually six to eight weeks postoperatively. Isometric and isotonic cuff-strengthening exercises were added when at least 80 percent of the active range of motion had returned, usually at approximately twelve weeks postoperatively. Postoperative Assessment All thirty patients were reevaluated with isokinetic strength-testing and the University of California at Los Angeles shoulder score 20 at twelve months postoperatively and again at a mean of sixty-five months (range, forty-six to ninety-three months) postoperatively. Statistical Analysis The significance of the differences, between the preoperative and postoperative evaluations, in strength for each axis of motion and the clinical findings according to the University of California at Los Angeles shoulder score 20 was determined with a Student t test. A p value of less than 0.05 was considered significant. Results The mean preoperative University of California at Los Angeles shoulder score 20 was 12.3 points (range, 6 to 20 points). This value increased significantly to a mean of 28.3 points (range, 13 to 35 points) (p < 0.01) TABLE I UNIVERSITY OF CALIFORNIA AT LOS ANGELES SHOULDER SCORES 20 * Preop. Score (points) Most Recent Score (points) Pain 3.0 (1-6) 8.5 (6-10) Function 2.5 (1-6) 8.4 (2-10) Active forward 3.5 (0-5) 4.6 (2-5) elevation Strength of 3.3 (2-5) 4.5 (1-5) forward elevation Satisfaction 0 5 Total 12.3 (6-20) 31.0 (16-35) *The values are given as the mean, with the range in parentheses. All improvements were significant at p < All patients were satisfied and had improvement at the most recent evaluation. The maximum possible score for a normal shoulder is 35 points. at one year postoperatively and to a mean of 31.0 points (range, 16 to 35 points) (p < 0.01) at the most recent follow-up examination (Table I). According to the shoulder score, sixteen patients (53 percent) had an excellent result (a score of 34 or 35 points), seven (23 percent) had a good result (a score of 29 to 33 points), and seven (23 percent) had a poor result (a score of less than 29 points) at the time of the most recent follow-up. Pain: The mean score for pain improved significantly from 3.0 points (range, 1 to 6 points) preoperatively to 8.5 points (range, 6 to 10 points) at the most recent follow-up evaluation (p < 0.01) (Table I). Sixteen (53 percent) of the thirty patients had no pain, and fourteen (47 percent) had either slight, occasional pain or pain only while performing strenuous or particular activities. Function: The mean score for function increased significantly from 2.5 points (range, 1 to 6 points) preoperatively to 8.4 points (range, 2 to 10 points) at the most recent follow-up evaluation (p < 0.01) (Table I). At the time of the most recent follow-up, seventeen patients (57 percent) were able to perform all of their normal activities without limitation, eleven (37 percent) had only slight or moderate restriction of activity, and two (7 percent) were able to perform only light activities. Active forward elevation: The mean score for active forward elevation improved significantly from 3.5 points (range, 0 to 5 points) preoperatively to 4.6 points (range, 2 to 5 points) at the most recent follow-up evaluation (p < 0.01) (Table I). Twenty-three patients (77 percent) had 150 degrees or more of active forward elevation (measured with the patient sitting), four (13 percent) had 120 to 150 degrees, one (3 percent) had 90 to 120 degrees, and two (7 percent) had 45 to 90 degrees at the most recent follow-up evaluation. Strength of forward elevation: Strength of forward elevation, as determined with manual muscle-testing, VOL. 81-A, NO. 7, JULY 1999

5 994 A. S. ROKITO, FRANCES CUOMO, M. A. GALLAGHER, AND J. D. ZUCKERMAN TABLE II PEAK TORQUE VALUES* Preop. 1 Year Postop. Most Recent Follow-up Flexion Peak torque (N-m) 19.5 ( ) 26.3 ( ) 29.4 ( ) Percent of uninvolved side 52 (17-82) 70 (13-91) 80 (13-100) Abduction Peak torque (N-m) 13.0 ( ) 26.2 ( ) 23.3 ( ) Percent of uninvolved side 43 (9-66) 86 (15-90) 73 (15-100) External rotation Peak torque (N-m) 12.6 ( ) 18.3 ( ) 19.1 ( ) Percent of uninvolved side 57 (15-76) 87 (22-96) 91 (22-100) *The values are given as the mean, with the range in parentheses. improved significantly from a mean of 3.3 points (range, 2 to 5 points) preoperatively to a mean of 4.5 points (range, 1 to 5 points) at the most recent follow-up evaluation (p < 0.01) (Table I). Twenty-one patients (70 percent) had grade-5 strength, seven (23 percent) had grade-4 strength, one (3 percent) had grade-2 strength, and one had grade-1 strength at the most recent followup evaluation. Satisfaction: At the most recent follow-up evaluation, all thirty patients reported that they were satisfied and that the condition of the shoulder had improved. Isokinetic strength: The mean peak torque in flexion, abduction, and external rotation increased significantly during the study period (Table II). The mean peak torque in flexion increased from 19.5 newton-meters (range, 5.3 to 40.6 newton-meters) and 52 percent (range, 17 to 82 percent) of that on the contralateral side preoperatively to 26.3 newton-meters (range, 4.7 to 44.5 newton-meters) and 70 percent (range, 13 to 91 percent) of that on the contralateral side at one year postoperatively and to 29.4 newton-meters (range, 7.3 to 53.3 newton-meters) and 80 percent (range, 13 to 100 percent) of that on the contralateral side at the most recent follow-up evaluation (p < 0.01). The mean peak torque in abduction increased from a mean of 13.0 newtonmeters (range, 4.1 to 32.2 newton-meters) and 43 percent (range, 9 to 66 percent) of that on the contralateral side to 26.2 newton-meters (range, 4.0 to 46.3 newtonmeters) and 86 percent (range, 15 to 90 percent) of that on the contralateral side at one year postoperatively, but then it decreased to 23.3 newton-meters (range, 6.6 to 51.6 newton-meters) and 73 percent (range, 15 to 100 percent) of that on the contralateral side at the most recent follow-up evaluation. This was still an overall significant improvement (p < 0.01). The mean peak torque in external rotation increased progressively from 12.6 newton-meters (range, 4.2 to 19.3 newton-meters) and 57 percent (range, 15 to 76 percent) of that on the contralateral side preoperatively to 18.3 newtonmeters (range, 4.7 to 25.8 newton-meters) and 87 percent (range, 22 to 96 percent) of that on the contralateral side at one year postoperatively and to 19.1 newtonmeters (range, 4.7 to 30.4 newton-meters) and 91 percent (range, 22 to 100 percent) of that on the contralateral side at the most recent follow-up evaluation (p < 0.01). Complications There were no intraoperative or postoperative complications. Although a recurrent tear was suspected clinically in three patients who had a persistent limitation of active forward elevation and poor strength, no imaging studies were done to confirm the diagnosis. No patient chose to have additional operative treatment. Discussion Many authors have reported on the efficacy of acromioplasty and repair of the rotator cuff in reducing pain in the shoulder and in restoring function, with overall good or excellent results documented in most studies 2,8,9,13,15,16,20,22,29,35,36,39,41,42,49. Fewer studies, however, have critically examined the ultimate functional outcome of repair of the rotator cuff 8,27,28,30,47, and this has been the subject of increased attention 20,28,30,45. In particular, relatively few reports have examined the functional outcome of repair of large and massive tears of the rotator cuff 6,8,10,12,18,21,24,29,34,39,41,44,48. Several techniques have been proposed to either repair or reconstruct large defects in the tendons. Reconstructive procedures (including local tendon transposition with the superior portion of the subscapularis 14 ; incorporation of the biceps tendon 33 ; implantation of fascia 3,4, allograft tissue 37, or synthetic material 40 ; and extrinsic tendon transfer with use of the latissimus dorsi 25 ) have been proposed as potential treatment options and have had varying degrees of success. Other investigators have recommended attaching the shortened rotator cuff more medially onto the articular surface of the humeral head 31. While tendon débridement and subacromial decompression, either by open or arthroscopic means 10,11,21,24,44, has been shown to decrease pain and to improve function, the results often do not compare favorably with those in studies in which the tears were repaired 34,39. Recognizing the importance of anterior and posterior stability of the glenohumeral joint in patients who have THE JOURNAL OF BONE AND JOINT SURGERY

6 LONG-TERM FUNCTIONAL OUTCOME OF REPAIR OF LARGE AND MASSIVE CHRONIC TEARS 995 a massive tear of the rotator cuff, Burkhart et al. 12 recently recommended partial repair. In general, however, when appropriate mobilization techniques are used, most large and massive tears of the rotator cuff can be repaired completely, rather than partially, with better results 8,34,39. Several investigators have stated that the size of the tear preoperatively has no substantial influence on the overall results of operative treatment 1,19,32. More recently, however, a strong association between the size of the tear and the functional outcome has been identified. Bassett and Cofield 2 found that strength on abduction and external rotation after repair of small and mediumsize tears was consistently better than that after repair of larger tears. Hawkins et al. 29 found a direct relationship (although not a significant one) between the size of the tear and strength as determined with postoperative manual muscle-testing. In a long-term follow-up study of 105 rotator-cuff repairs, Harryman et al. 28, using ultrasound, found a much higher prevalence of recurrent defects in the cuff in the patients who had had a larger tear. Those authors found that the integrity of the repair was the most important factor affecting the functional result. In a previous report on forty-two patients who had repair of the rotator cuff 45, we found a trend between the size of the tear and the recovery of strength. The twenty-four patients with a small or medium tear had almost complete recovery of strength during the first postoperative year, whereas a longer period of rehabilitation was needed for the eighteen patients with a large or massive tear. Iannotti et al. 30, in a prospective study of forty patients who had repair of the rotator cuff, found a significant association between functional outcome and the size of the tear at the time of the operation (p 0.002). Several authors have recommended tendon débridement and decompression for the treatment of irreparable lesions of the rotator cuff. Rockwood et al. 44 reported a good or excellent result for forty-four (83 percent) of fifty-three patients who had open débridement and decompression. Gartsman 24 reported that twenty-six (79 percent) of thirty-three patients in his series believed that the condition of the shoulder had improved after operative débridement and subacromial decompression. Although there was a significant decrease in pain (p = 0.001) and a significant improvement in the range of motion (p = 0.038), strength was decreased. Overall, the results of débridement and decompression are inferior to those of decompression and repair of a torn rotator cuff 34,39. It is difficult to compare the results of decompression and repair of large and massive tears of the rotator cuff in the present study with those of decompression and débridement alone for massive tears. It should be emphasized that in most studies the latter group consisted of patients who had a massive, irreparable tear, whereas in the present study all of the tears could be mobilized and repaired. The results of the present study compare favorably with those of Bigliani et al. 8. Those authors reported the long-term results of operative repair of a massive tear of the rotator cuff in sixty-one patients. Fifty-two (85 percent) of the patients had a satisfactory result, and fifty-six (92 percent) had satisfactory relief of pain. The mean improvement in the range of motion was 76 degrees in forward elevation and 30 degrees in external rotation. In the present study, twenty-three patients (77 percent) had a good or excellent result. There was a significant reduction in pain and significant improvements in function, range of motion, strength, and overall satisfaction of the patient. These results are also comparable with those of Ellman et al. 20, who evaluated patients with a much wider spectrum of tears. According to the University of California at Los Angeles shoulder score 20, forty-two (84 percent) of their fifty patients had a good or excellent result. Careful selection of the patient is critical when the type of treatment is being chosen for a suspected large defect of the rotator cuff. Often, the size and reparability of a tear can be predicted on the basis of the preoperative history, physical examination, and imaging studies. When a patient reports an insidious onset of pain and loss of function, has substantial atrophy of the infraspinatus and supraspinatus muscles, and has a substantial loss of active motion and is unable to maintain a position of external rotation with the arm at the side, a sizable tear of the rotator cuff should be suspected. Furthermore, patients who have marked superior migration of the humeral head, as seen on plain anteroposterior radiographs, and atrophy and fatty replacement of the spinatus muscles, as seen on magnetic resonance imaging studies, do not have a reparable tear. Operative treatment is usually avoided for these patients unless there is substantial pain and poor function with associated arthritis, in which case hemiarthroplasty with preservation of the coracoacromial ligament can be considered. Gerber 25 reported good results with transfer of the latissimus dorsi for patients who did not have arthritis and who had preservation of a passive range of motion. The present study group was a relatively homogeneous population of older individuals who had a chronic tear of the rotator cuff. No patient had substantial concomitant disease of the cervical spine or the acromioclavicular joint. Thus, these conditions were not suspected of playing an important role in the most recent functional outcome. Furthermore, no patient was involved in a Workers Compensation claim or another form of litigation that could have influenced the subjective result. Nevertheless, a study of this kind has a number of limitations. It is difficult to differentiate true weakness from pain-related weakness with isokinetic strengthtesting. This is an important consideration, as pain has been shown to adversely affect strength of the shoulder 5. Furthermore, such testing represents only strength on VOL. 81-A, NO. 7, JULY 1999

7 996 A. S. ROKITO, FRANCES CUOMO, M. A. GALLAGHER, AND J. D. ZUCKERMAN maximum effort, not endurance, which may be more important in terms of functional recovery. Finally, no imaging studies were performed at the most recent follow-up examination, and thus the integrity of the rotator cuff and its effect on the postoperative outcome were not accurately determined. This is especially important with regard to the treatment of large or massive chronic tears of the rotator cuff, which have been shown to have a high prevalence of recurrence 28. Another important point relates to treatment of the coracoacromial ligament. Some authors 23,38 have advocated preservation of the coracoacromial ligament in patients who have an irreparable tear of the rotator cuff, as resection leads to a loss of integrity of the coracoacromial arch and superior migration of the humeral head with a subsequent decrease in function of the shoulder. As the ligament was resected in all of the patients in the present study, it is possible that this could have adversely affected the overall results, especially in the patients in whom a recurrent defect of the cuff may have developed. In summary, it is possible to obtain a satisfactory long-term outcome after repair of a large or massive chronic tear of the rotator cuff. A substantial decrease in pain as well as improved function, range of motion, and strength can be achieved. More than a year is needed for maximum recovery of strength after repair of a large or massive chronic tear of the rotator cuff, and the strength does not return to the level on the unaffected, contralateral side. References 1. Bakalim, G., and Pasila, M.: Surgical treatment of rupture of the rotator cuff tendon. Acta Orthop. Scandinavica, 46: , Bassett, R. W., and Cofield, R. H.: Acute tears of the rotator cuff. The timing of surgical repair. Clin. Orthop., 175: 18-24, Bateman, J. 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