The timing of rotator cuff repair for the restoration of function - PDF Document

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  1. ARTICLE IN PRESS J Shoulder Elbow Surg (2010) -, 1-7 The timing of rotator cuff repair for the restoration of function Steve A. Petersen, MD*, Todd P. Murphy, MD Department of Orthopaedic Surgery, Wayne State University, Detroit, MI Introduction: This study was developed to test the hypothesis that there is a period in which a painful, traumatic rotator cuff tear, with associated weakness and the inability to abduct above shoulder level, should be repaired to allow for improvement in function. Methods: Forty-two consecutive, prospectively followed patients met the criteria for entrance into this study. Of those, 36 patients were available for a minimum 9 months follow-up (average, 31 months; range, 9e71) by office visit. Patient outcomes were measured using the UCLA End-Result and ASES scoring systems. Patient variables, including time from injury to repair, tear size, degree of preoperative fat infiltration, patient satisfaction, and improvement in pain, were evaluated for their association with surgical outcome using independent t testing. Time to repair was evaluated at 0e2 months, 2e4 months, and greater than 4 months. Results: Pain scores improved from 7 to 1.4 (P < .01) and active elevation improved from 55?to 133? (P < .01). UCLA/ASES scores improved from 8/30 to 26/79, respectively (P < .01, P < .01). All but 2 of the 36 patients were satisfied with their result. Preoperative fatty atrophy did not correlate with post- operative function. Rotator cuff tear size had no influence on patient outcome if repaired before 4 months. Massive tears repaired after 4 months had the worst outcome. Conclusion: Our results emphasize that the treatment outcome for traumatic rotator cuff tears of all sizes, with associated weakness, is not compromised up to 4 months after their injury. Level of evidence: Level III, Retrospective Case Control Study, Treatment Study. ? 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Rotator cuff repair; timing; function; open repair those who present with symptomatic rotator cuff tears.2 While the results for surgical treatment of full thickness rotator cuff tears is well 17,19,20,22,23,25,26,32,36,37,39to our knowledge there is only 1 paper in the literature which addresses timing and func- tional improvement of acute rotator cuff tears.2Bassett and Cofield2reported on a series of 37 patients to determine if there is an optimal time for repair of a rotator cuff after an acute injury. They found that surgical repair within 3 weeks of injury led to a much better functional outcome than those whose rotator cuffs were repaired after 3 weeks time. Others have suggested that patients who sustain a full thickness tear Full thickness tears of the rotator cuff are a common sourceofshoulderpainanddisability.Themajorityofrotator cuff tearing is a result of degenerative changes within the tendon. Acute, traumatic, full thickness rotator cuff tears, with immediate weakness and pain account for only 8% of documented,1,3,5,6,8,11,13,15- Institutional review board approval was not obtained for this study, as it was not a requirement, at our institution, at the time that the data was collected. All of the patients returned to the office on their own accord, after a thorough explanation of the study, to be examined. *Reprint requests: Steve A. Petersen, MD, Pavillion 2, Suite 305, 10753 Falls Road, Lutherville, MD 21093. 1058-2746/$ - see front matter ? 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2010.04.045

  2. ARTICLE IN PRESS 2 S.A. Petersen, T.P. Murphy of their rotator cuff undergo early surgical repair, with the expectation that they regain useful overhead function.13,23 There is little else in the literature that addresses timing of repair and functional improvement. It has been our experience that most patients who sustain such an injury to their shoulder initially present for treatment more than 3 weeks after their injury. While significant pain relief following rotator cuff repair is well docu- mented,1,2,4,6,7,9,11-18,21,29,30,32 regarding the timing of surgery and its expected functional improvement. The purpose of our study was to evaluate the time to repair and subsequent functional outcome in patients who sustain an acute loss of shoulder strength as the result of a painful, traumatic, full thickness rotator cuff tear. Our hypothesis is that there is a period in which a rotator cuff can be repaired after an acute loss of shoulder strength, which will allow for pain relief and improvement in function. Table degeneration I Modified Goutallier classification of fatty Grade 0- no fatty deposits Grade 1- some fatty streaks Grade 2- more muscle than fat 2A - ? 25 % fat 2B - > 25-50 % fat Grade 3- muscle ¼ fat Grade 4- less muscle than fat there is little guidance tear. Small tears were those measuring ?4 cm2, medium/large tears were those measuring 5e17 cm2, and massive tears were those that measured ?18 cm2. Preoperative magnetic resonance imaging (MRI) was utilized to determine the presence of fat infiltration of the rotator cuff musculature. To assess the influence of the chronicity of tendin- opathy on repair outcomes, rotator cuff repairs were evaluated on the degree of preoperative fatty degeneration involving the rotator cuff muscle that had the greatest involvement. The grading system developed by Goutallier et al was modified to define the effect of preoperative fat infiltration on patient outcomes, with Grade 2 subdivided into Grade 2A and 2B (Table I).16Muscle involvement of Grade 2 or less has been associated with an acute rotator cuff tear.34The global fatty degeneration index (GFDI) has been associated with rotator cuff healing after repair, and was calcu- lated for all patients with available preoperative MRI studies.17 The GDFI is the mean value of graded fatty degeneration involving the subscapularis, supraspinatus, and infraspinatus musculature. Repair integrity was associated with a GDFI less than 0.5, with recurrences in all patients with an index of greater than 2.17We compared the GFDI to the outcomes measurements for both the time to repair and tear size. Furthermore, infraspinatus atrophy has been reported to adversely affect rotator cuff healing, and patients’ outcomes were compared by the presence or absence of infraspinatus atrophy of Grade I or more on their preoperative MRI studies.16,17,26 Patient outcomes were measured using the American Shoulder and Elbow Surgeons (ASES) subjective shoulder scale,28,31the UCLA End Result Score,8improvement in active elevation, improvement in strength as measured by manual muscle testing, a visual analog scale for pain, and a patient satisfaction survey.33 Patients were asked to fill out both the pain and functional sections of the ASES subjective shoulder scale both pre- and post- operatively. Pain was evaluated using the 10-point visual analog scale from the ASES subjective shoulder scale. Patients were also asked in a questionnaire if they were satisfied with their surgery. They rated their shoulder as much better, better, same, or worse, and answered if they would have surgery again under the same circumstances. The patients were said to have a satisfactory outcome if they responded much better or better. Paired t tests were utilized to determine if there were any differences between the preoperative and postoperative ASES subjective shoulder scale values, UCLA end result scores, pain, and improvement in active elevation. Independent Student t tests were used to determine if there were significant differences between preoperative and postoperative exam findings among the various time to repair and tear size groups, and whether the patients’ demographic variables Materials and methods Institutional review board approval was not obtained for this study, as it was not a requirement at our institution at the time that the data were collected. All of the patients returned to the office on their own accord, after a thorough explanation of the study, to be examined. All patients were prospectively evaluated, with the patient data analysis performed retrospectively. Only those patients who sustained an acute, traumatic, full thickness tear of the rotator cuff, which resulted in the inability to achieve greater than 90?of active abduction of the shoulder, were included in the study. In all instances, the patients experienced a traumatic injury from a variety of mechanisms that resulted in their shoulder symptoms. This was a specific inclusion criterion for our study. All study patients had an asymptomatic, fully functional shoulder prior to injury. From 1992 to 2002, a total of 462 rotator cuff tears were performed by the senior author (SP) at the Wayne State University Shoulder Service. Forty-two consecutive patients (9%) met the criteria for inclusion into the study. Of those, 36 patients were available for a minimum 9-month follow-up visit (average, 31 months; median, 30 months; range, 9e71). To evaluate patient outcomes as a function of time to repair, patients were placed into 1 of 3 groups based on the elapsed time from their injury to the surgical repair of their rotator cuff. Group I consisted of patients who had their rotator cuff repaired within 0e8 weeks of their injury. Group II consisted of patients who had their rotator cuff repaired within 9e16 weeks of their injury. Group III consisted of patients who had their rotator cuff repaired greater than 16 weeks from their injury. There were 15 patients in Group I, 15 patients in Group II, and 6 patients in Group III. Patients were also grouped to assess their treatment outcomes as a function of rotator cuff tear size. The size of the rotator cuff tear was determined by an intraoperative measurement in each patient. Patients were placed into one of 3 groups based on the size of their rotator cuff tear. The involved area of the rotator cuff tear, as described by Galatz et al,11was used to describe the size of the impacted their outcome.

  3. ARTICLE IN PRESS Timing of rotator cuff repair 3 The average preoperative active elevation was 55? (range, 10e90?). The average postoperative active elevation was 133?(range, 55e170?) (P < .01). The average preop- erative active external rotation measured 39?(range, 0e 65?). The average postoperative active external rotation was 49?(range, 15e75?) (P < .01). The average preoperative active internal rotation was to the second lumbar vertebrae (range sacrum - thoracic vertebrae 5). The average post- operative active internal rotation was to the tenth thoracic vertebrae (range sacrum e thoracic vertebrae 5) (P < .01). None of the patients had evidence of post-traumatic shoulder arthrofibrosis involving the glenohumeral joint preoperatively. The average preoperative strength of the supraspinatus was 2.7 (range, 2e4). The average postoperative strength of the supraspinatus was 4.1 (range, 2e5). There was a significant increase in strength of the supraspinatus postoperatively(P<.01). Theaveragepreoperativestrength of the infraspinatus was 3.7 (range, 2e5). The average postoperative strength of the infraspinatus was 4.2 (range, 3e5). There was a significant increase in strength of the infraspinatus postoperatively (P < .01). Active elevation in Group I improved from 54?to 137? (P ? .01). Group II elevation improved from 52?to 142? (P < .01) and elevation in Group III improved from 66?to 100?(P < .01). A significant difference was found in the comparison of postoperative active elevation between Groups I and II to Group III (P ? .05). The ASES scores of group I improved from 28 to 82 (P ? .01). Group II scores improved from 31 to 79 (P ? 01). Group III scores improved from 24 to 65 (P ? .01). The UCLA scores for Group I improved from 6 to 30 (P ? .01). Group II improved from 9 to 30 (P ? .01). Group III scores improved from 9 to 25 (P ? .01). A significant difference (P ? .05) was found when the postoperative scores for Groups I and II were compared to Group III (Table III). All patients experienced improvement in active eleva- tion, ASES score and UCLA score after rotator cuff repair, regardless of the size of their tear. Active elevation improved from 68?to 145?for those with small tears. Those with medium/large tears had improvement from 52? to 141?. Those with massive tears improved from 53?to 120?, though massive tears had less active elevation than medium/large tears (P ? .05). The UCLA scores for small and medium/large tears both improved from 9 to 29 (P ? .01), and for massive tears improvement from 7 to 27 (P ? .01) was noted. The ASES scores for small tears improved from 22 to 79 (P ? .01), medium/large tears improved from 27 to 75 (P ? .01) and massive tears improved from 30 to 73 (P ? .01). Significant postoperative differences in both UCLA and ASES scores were not found among the different tear sizes (Table III). The preoperative MRI studies of 34 patients were available for review. Twenty-four patients had evidence of preoperative fatty atrophy of Grade 2A or less and 10 Demographic variables evaluated included gender, tobacco use, workman’s compensation, and tearing of the dominant shoulder. All calculated P values were considered significant if less than .05. Standard statistical software (SPSS Inc., Chicago, Illinois) was used to analyze the data. Surgical technique and postoperative rehabilitation All rotator cuff tears were repaired with an open deltoid splitting approach, utilizing braided nonabsorbable suture and repairing the tendon to the greater tuberosity through prepared trans-osseous tunnels. All procedures included an anterior acromioplasty.30A standard postoperative rehabilitation program was utilized for study patients. In the immediate postoperative period, passive range of motion exercises were begun within a tension free range that was determined intraoperatively. The patients were advanced to full passive range of motion at 6-8 weeks postoperatively and to full active-assisted range of motion at 10-12 weeks. A strength- ening program for the periscapular and rotator cuff musculature was started at 10-16 weeks, depending on the rotator cuff tear size and integrity of the repair. Patients with large to massive tears were immediately protected in an abduction pillow for 4 weeks, with passive motion above the level of the brace determined at surgery. After removal of the pillow, a sling was worn for another 2 months. All other patients were protected in a sling for 2 months. Results There were 22 males and 14 females included in this study. Six patients were smokers. The injury was work associated in 12 patients. Twenty-nine patients sustained the injury to their dominant shoulder. Fourteen patients had undergone some form of physical therapy prior to initial presentation, and 9 patients had received an intra-articular cortisone injection prior to presentation. The mean age at time of surgery was 57 years (range, 21e74). The mean time from injury to the first office visit was 9 weeks (range, 1e19). The mean elapsed time from date of injury to surgical repair was 11 weeks (range, 2e24 weeks; median, 13). There were 8 massive tears, 6 medium/large tears, and 1 small tear in Group I, with an average age of 58 years. Four massive, 8 medium/large, and 3 small tears comprised Group II, with an average age of 53 years. Three massive, 2 medium/large, and 1 small tear were in Group III, with an average age of 61 years (Table II). All patients in the study had marked pain relief following their rotator cuff repair. The mean visual analog scores improved from 7 to 1.4 (P ? .01) and significantly improved in all groups regardless of the time to repair or the rotator cuff tear size. Thirty-four of the 36 patients were satisfied with their results and regarded their shoulders as much better or better. Both dissatisfied patients had massive tears repaired after 4 months. Thirty-three of the 36 patients would have had their surgery again under the same circumstances.

  4. ARTICLE IN PRESS 4 S.A. Petersen, T.P. Murphy Table II Patient data Case No. Age Tear size (cm2) No. tendons torn Time to repair (weeks) Elevation pre- post GDFI Atrophy Satisfied SS IS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 52 63 45 21 64 61 57 60 63 51 71 50 56 65 74 47 44 64 69 43 53 66 72 54 58 64 53 50 55 58 37 45 70 72 52 56 35 24 24 35 24 35 21 28 42 28 35 28 27 28 9 9 9 12 12 16 9 9 6 8 6 7 6 13.5 3 3 2 3 5 0.5 48 9 2 2 2 3 2 2 2 2 2 3 2 2 2 3 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 2 1 2 1 2 1 8 5 8 9 90 20 80 90 80 20 20 40 90 20 70 15 30 90 90 60 30 90 10 70 10 90 60 20 30 65 60 40 85 90 90 30 30 80 45 60 130 120 145 110 115 115 140 85 165 130 145 150 130 60 150 130 160 130 100 130 130 150 155 150 150 170 150 110 170 125 165 165 110 130 55 155 2 1.33 1.33 1 1.33 1.66 3 2.33 2 2.33 1 1.33 1.66 2.66 1 1.33 1 0.66 0.66 0.66 1.33 0.33 0.33 1 1.33 0.33 0 0 1 0.66 0.66 0.33 0.66 1.66 NA NA 3 3 2a 2a 2a 2a 4 2b 3 4 2a 2b 2a 4 2a 2a 1 2a 2a 2a 2a 1 2a 2a 2a 0 0 0 2b 0 2a 0 2a 2a NA NA 2a 1 2a 0 2a 1 1 1 3 1 1 2a 3 2a 1 1 1 1 1 0 0 0 1 1 0 1 0 0 1 0 0 0 0 1 NA NA Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 21 16 8 6 16 4 8 14 8 18 7 5 10 4 9 24 11 8 2 4 13 11 9 9 15 16 13 4 22 21 24 10 GDFI, global fatty degeneration index; SS, supraspinatus; IS, infraspinatus. patients had evidence Grade 2B or greater atrophy involving the rotator cuff musculature. The average age of those with preoperative fatty atrophy ?2A and those ?2B was 57 years (Table II). Eleven patients displayed no evidence of infraspinatus atrophy and 23 patients had Grade 1 or greater infraspinatus atrophy. The average age was 50 years for those with the presence of preoperative infra- spinatus atrophy, and 60 years for those without preopera- tive infraspinatus atrophy (Table II). There was not a significant difference in the mean postoperative active elevation between those that had ?2A preoperative fatty atrophy (137?) and those with ?2B preoperative fatty atrophy (128?). Likewise, there was not a statistical difference in the postoperative UCLA scores or ASES scores between those that had ? Grade 2A preoperative atrophy (28/75) and those with ? Grade 2B atrophy (28/80) (Table IV). Subscapularis atrophy was graded and was used in the calculation of the GFDI for all patients. There were 3 patients with subscapularis tears, as noted in Table II. One of the patients was 21 years old and had no atrophy; the other 2 patients had grade 4 atrophy of their subscapularis. The rest of the patients had Grade 0 atrophy of their sub- scapularis and this was used in the calculation. There was a trend toward an increased GFDI as the time to repair increases from Group I to Group III (P ¼ .15). The GFDI of Group I patients was 1.15, Group II patients averaged 1.1, and Group III patients averaged 1.41. There was a signifi- cant increase (P < .01) in the GFDI between massive tears (1.78) and both small (.82) and medium/large tears (.71).

  5. ARTICLE IN PRESS Timing of rotator cuff repair 5 Table III Outcomes for all groups and tear sizes Average active elevation Average ASES score Average UCLA score Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Group I Group II Group III Small Medium/large Massive 54 52 66 68 52 53 137 142 100 145 141 120 28 31 24 22 27 30 82 79 65 79 75 73 6 9 9 9 9 7 30 30 25 29 29 27 Table IV Outcomes measures dependent on preoperative fatty atrophy Average preoperative active elevation Average postoperative active elevation Avereage ASES scores Average UCLA scores Preoperative Postoperative Preoperative Postoperative ?2A ?2B 58 50 137 128 28 28 75 80 9 7 28 28 There was a statistical difference in the mean post- operative improvement in active external rotation of those patients with preoperative infraspinatus atrophy (10? improvement) and those without preoperative infraspinatus atrophy (no improvement) (P < .01); however, the post- operative UCLA and ASES scores were not significantly different (Table V). Gender, tobacco use, workman’s compensation and tearing of the dominant shoulder did not influence the patients’ outcomes in our study. All patients in this study had a previously asymptomatic shoulderpriortoinjuryandhadsustainedanacute,traumatic, full-thicknessrotatorcufftearthatresultedinimmediatepain andtheinabilitytoraisetheirarm.Whileearlysurgicalrepair hasbeenadvocatedinthesepatients,3, 13thereisonly1study that has investigated the time to repair.2Utilizing improve- ment in active elevation as their outcome measure, they concluded that those patients who had their rotator cuff tears repaired within 3 weeks of their injury had a much better functional outcome than those who were operated on after 3 weeks time. Other studies have observed better functional resultswithearlyrepair3;yet,nootherstudyhasinvestigated further the timing of repair and its effect on shoulder function. We found that the average postoperative active elevation of all tear sizes significantly improved if repair took place within 4 months of their injury. Furthermore, we found that the postoperative ASES and UCLA scores of all tear sizes improved if repair takes place within four months of injury. Postoperative active elevation of massive rotator cuff tears was less than those of smaller tears and the function of massive tears repaired after 4 months time was worse than those repaired prior to 4 months. We did not find a differ- ence in outcome measures when comparing small and medium/large tears. Interestingly, active external rotation only improved in those patients with preoperative infra- spinatus atrophy. This is contrary to the observation of others and might optimistically be the result of a healed repair.17 The adverse effect of fatty degeneration of rotator cuff musculature on the prognosis of rotator cuff surgery has been studied.10,16,17,37Thomazeau et al37reported that preoperative atrophy of the supraspinatus was the main predictive factor for a postoperative retear of the rotator cuff. Goutallier et al16also found a significant association Discussion Regardless of the timing of surgery or the size of the rotator cuff tear, surgical repair was successful in reducing pain in our series of patients, consistent with other studies that have investigated rotator cuff repairs.1-3,5,8,11,13,15- 17,19,20,22,23,25,26,32,36,37,39Functional improvement was evi- dencedinallstudypatientsthathadarotatorcuffrepairwithin 4 months following injury. There is support in the literature for the nonoperative management of rotator cuff tears.4,14,21,24,38,39Bokor et al4 reported that patients presenting for nonoperative treatment within 3 months of their injury had satisfactory outcomes. Successful nonoperative management has been associated with the presence of satisfactory motion and strength at the initiation of treatment.24,39Unfortunately, Itoi and Tabata24 have demonstrated that the outcome of nonoperative management deteriorates over time, and Goldberg et al14 concluded that the overall response of shoulder function to nonoperative intervention was poor. None of the patients in this study that had a preoperative trial of physical therapy had appreciable improvement in their shoulder pain or function.

  6. ARTICLE IN PRESS 6 S.A. Petersen, T.P. Murphy Table V Outcomes measures dependent on preoperative infraspinatus atrophy Average preoperative external rotation Average postoperative external rotation Avereage ASES scores Average UCLA scores Preoperative Postoperative Preoperative Postoperative No infraspinatus atrophy Infraspinatus atrophy 46 45 29 74 9 28 34 44 28 78 8 28 a variable in their study. Jost et al25,26found that despite arotatorcuffdefectafterrepair,patientshadimprovementin painandfunctionwhencomparedtotheirpreoperativestatus and that this clinical improvement did not deteriorate over time. Preinjurytendonpathologywaslikelypresentinourstudy participants, and its effect on resulting rotator cuff injury cannot be determined. In a histological analysis of 891 spontaneously ruptured tendons, Kannus and Jozsa reported thatallspecimensdemonstrateddegenerativechangeswithin the tendons that preceded rupture.27Sher et al found the prevalence of rotator cuff tears to be 34% in their study of 96 asymptomatic individuals.35It is likely that many of our patients had long standing, asymptomatic pathology of their rotatorcuffandsubsequentlysustainedanacuteextensionof that pathology which led to their symptoms. We acknowl- edge that it can be difficult to diagnose a rotator cuff tear as acute without knowing the pre-existing condition of the tendon. We attempted to address this question by reviewing thepreoperativeMRIexamsofthosewhichwereavailableto us and quantifying the degree of fatty infiltration present in the rotator cuff musculature prior to repair. There are weaknesses of this study. We did not attain follow-up imaging to assess tendon integrity; all of our patients did not have preoperative MRI studies that could accurately assess muscle atrophy; statistical analysis was performed on a limited patient population; and there is always potential for bias introduced in a retrospective study. Furthermore, we cannot effectively assess the integrity of our patient’s rotator cuff prior to injury. The strengths of this study allow its comparison to previously published studies. One surgeon performed all of the rotator cuff repairs allowing for a consistent technique; data were prospectively collected; MRI data were analyzed to assess rotator cuff atrophy as an outcome measurement; and the number of patients included in our study was comparable in size to a similar study.2 between a recurrent tear and pre-surgical fatty degenera- tion. They further observed, in a separate study,17that infraspinatus fatty degeneration can occur in large ante- rosuperior rotator cuff tears even if the infraspinatus is not torn and that infraspinatus degeneration had a highly negative influence on the outcome of supraspinatus repairs. By subdividing Goutallier’s classification for the anal- ysis of fatty degeneration of the most affected rotator cuff muscle, we attempted to further assess tear chronicity as a function of fatty infiltration. Fatty infiltration of the rotator cuff musculature impairs the physiologic properties of the muscle and is likely irreversible.9,12,27Meyer et al29 demonstrated that the muscular changes following tendon tear were asymmetric and likely due to architectural changes within the muscle rather than from uniform muscle disease. As the tendon retracts and the pennation angle of the muscle fibers increases, the muscle fiber length decreases and the fiber gap increases, allowing fat cells to infiltrate the gap. Coleman et al7found, in a sheep model, that tendons repaired 6 weeks after section displayed better functional recovery as compared to those repaired 18 weeks after section. Safran et al34noted a 32% loss of muscle volume in the first 6 weeks after detaching canine infra- spinatus tendons. Those repaired 18 weeks after section were considered irreparable. We used this data to evaluate the acuity of rotator cuff tearing in our patients. Patients with 2A atrophy could be considered as having a recent rotator cuff tear. However, we did not find that preoperative supraspinatus or infraspinatus fatty atrophy influenced patient outcomes to a significant degree. We did note an increase in the GFDI as time to repair increased and as tear size increased, suggesting that retears were likely present in this group of patients.17 Unfortunately, postoperative imaging was not preformed to assess the integrity of the rotator cuff repairs, and we are unable to draw conclusions on the effectiveness of timing and tear size on the integrity of rotator cuff repair. The importance of the functional integrity of the rotator cuff after repair is well accepted.19,25,26Harryman et al19 found that those patients that did not have a full thickness, recurrent defect after rotator cuff repair had significantly better functional outcomes than those patients who did. When comparing preoperative tear size with postoperative outcomes, they found that tear size did not correlate with the patient’s postoperative function, pain, and overall satisfac- tion; however, the time from injury to repair was not Conclusion In conclusion, the operative repair of an acute, traumatic rotator cuff tear with associated weakness function is predictably improved if the repair occurs within 4 months after injury. Massive rotator cuff tears have

  7. ARTICLE IN PRESS Timing of rotator cuff repair 7 17. Goutallier D, Postel J, Gleyze P, Leguilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg 2003;12:550-4. doi:10.1016/s1058-2746(03)00211-8 18. Harryman DT II, Hettrich BS, Smith KL, Campbell B, Sidles JA, MatsenFAIII.Aprospectivemultipracticeinvestigationofpatientswith full-thickness rotator cuff tears. J Bone Joint Surg 2003;85-A:690-6. 19. Harryman DT II, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA III. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg 1991;73-A:982-9. 20. Hawkins RH, Dunlop R. Nonoperative treatment of rotator cuff tears. CORR 1995;321:178-88. 21. Hawkins RJ, Misamore GW, Hobieka PE. Surgery for full-thickness rotator-cuff tears. J Bone Joint Surg 1985;67-A:1349-55. 22. Iannotti JP. Full-thickness rotator cuff tears: Factors affecting surgical outcome. JAAOS 1994;2:87-95. 23. Iannotti JP, Bernot MP, Kuhlman JR, Kelley MJ, Williams GR. Postoperative assessment of shoulder function: a prospective study of full thickness rotator cuff tears. J Shoulder Elbow Surg 1996;5:449-57. 24. Itoi E, Tabata S. Conservative treatment of rotator cuff tears. CORR 1992;275:165-73. 25. Jost B, Pfirrmann CW, Gerber C. Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg 2000;82-A:304-14. 26. Jost B, Zumstein M, Pfirrmann CW, Gerber C. Long-term outcome after structural failure of rotator cuff repairs. J Bone Joint Surg 2006; 88-A:472-9. doi:10.2106/JBJS.E.00003 27. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. J Bone Joint Surg 1991;73-A:1507-25. 28. Kocher MS, Horan MP, Briggs KK, Richardson TR, O’Holloeran J, Hawkins RJ. Reliability, validity, and responsiveness of The American Shoulderand ElbowSurgeonsSubjective Shoulder Scale inpatientswith shoulder instability, rotator cuff disease, and glenohumeral arthritis. J Bone Joint Surg 2005;87-A:2006-11. doi:10.2106/JBJS.C.01624 29. Meyer DC, Pirkl C, Pfirrmann CW, Zanetti M, Gerber C. Asymmetric atrophy of the supraspinatus muscle following tendon tear. J Orthop Res 2005;23:254-8. doi:10.1016/jorthres.2004.06.010 30. Neer CS II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg 1972;54:41-50. 31. Richards RR, An K, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994;3:347-52. 32. Romeo AA, Hang DW, Bach BR Jr, Shott S. Repair of full thickness rotator cuff tears. Gender, age, and other factors affecting outcome. CORR 1999;367:243-55. 33. Romeo AA, Mazzocca A, Hang DW, Shott S, Bach BR. Shoulder scoring scales for the evaluation of rotator cuff repair. CORR 2004; 427:107-14. doi:10.1097/01.blo.0000142624.dd 34. Safran O, Derwin KA, Powell K, Iannotti JP. Changes in rotator cuff muscle volume, fat content, and passive mechanics after chronic detachment in a canine model. J Bone Joint Surg 2006;87-A:2662-70. doi:10.2106/JBJS.D.02421 35. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg 1995;77-A:10-5. 36. Thomazeau H, Boukobza E, Morcet N, Chaperon J, Langlais F. Prediction of rotator cuff repair results by magnetic resonance imaging. CORR 1997;344:275-83. 37. Watson EM, Sonnabend DH. Outcome of rotator cuff repair. J Shoulder Elbow Surg 2002;11:201-11. doi:10.1067/msc.2002. 122271 38. Wirth MA, Basamania C, Rockwood CA Jr. Nonoperative manage- ment of full thickness tears of the rotator cuff. Orthop Clin N Am 1997;28:59-67. 39. WolfgangGL.Surgicalrepairsoftearsoftherotatorcuffoftheshoulder. Factors influencing the result. J Bone Joint Surg 1974;56-A:14-26. poorer functional outcome than smaller tears; however, significant pain relief can be attained with operative repair regardless of the size of the tear. The extent of preoperative fat infiltration did not appreciably affect the functional outcome of our patients following repair. Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not receivedanyfinancialpaymentsorotherbenefitsfromany commercial entity related to the subject of this article. References 1. Adamson GL, Tibone JE. Ten year assessment of primary rotator cuff repairs. J Shoulder Elbow Surg 1993;2:57-63. 2. Bassett RW, Cofield RH. Acute tears of the rotator cuff. The timing of surgical repair. Clin Orthop 1983;175:18-24. 3. Bigliani LU, Cordasco FA, McIlveen SV, Musso ES. Operative repairs of massive rotator cuff tears: long-term results. J Shoulder Elbow Surg 1992;1:120-30. 4. Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop 1993;294:103-10. 5. Cofield RH. Current concept review. Rotator cuff disease of the shoulder. J Bone Joint Surg 1985;67-A:974-9. 6. Cofield RH, Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup DM, Rowland CM. Surgical repair of chronic rotator cuff tears: A prospective long-term study. J Bone Joint Surg 2001;83-A:71-7. 7. Coleman SH, Fealy S, Ehteshami JR, MacGillvry JD, Altchek DW, Warren RF, et al. Chronic rotator cuff injury and repair model in sheep. J Bone Joint Surg 2003;85-A:2391-402. 8. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End result study of factors influencing reconstruction. J Bone Joint Surg 1986;68- A:1136-44. 9. Fabis J, Bogucki A, Mazanowska-Gajdowicz J. Function of the rabbit supraspinatus muscle after large detachment of its tendon: 6-week, 3- month and 6-month observation. J Shoulder Elbow Surg 2000;9:211-6. 10. Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degen- eration of the muscles of the rotator cuff: Assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 1999;8:599-605. 11. Galatz LM, Griggs S, Cameron BD, Ianotti JP. Prospective longitu- dinal analysis of postoperative shoulder function. J Bone Joint Surg 2001;83-A:1052-6. 12. Gerber C, Fuchs B, Holder J. The results of massive tears of the rotator cuff. J Bone Joint Surg 2000;82-A:505-15. 13. Gerber C, Meyer DC, Schneeberger VonRecheberg B. Effect of tendon release and delayed repair of the structure of the muscles of the rotator cuff: An experimental study in sheep. J Bone Joint Surg 2004;86-A:1973-82. 14. Goldberg BA, Nowinski DO, Matsen FA III. Outcome of nonoperative managementoffull-thicknessrotatorcufftears.CORR2001;382:99-107. 15. Gore DR, Murray MP, Sepic MS, Gardner GM. Shoulder muscle strength and range of motion following surgical repair of full-thickness rotator-cuff tears. J Bone Joint Surg 1986;68-A:266-72. 16. Goutallier D, Postel J, Bernageau J, Lavau L, Voisin M. Fatty muscle degeneration in cuff ruptures: Pre- and postoperative evaluation by CT scan. CORR 1994;304:78-83. AG, Hopperer H,