DEFINITION

Posterosuperior tears of the rotator cuff involve the supraspinatus, infraspinatus, and occasionally the teres minor.

Some of the surgical techniques to be described here are no longer commonly used, as the majority of surgeons repair most tears using arthroscopic approaches.

These approaches, however, are still useful for treating those massive tears that may need special procedures to accomplish the repair.

 

 

ANATOMY

 

The rotator cuff is a group of four musculotendinous structures arising from the scapula: the supraspinatus, the infraspinatus, the teres minor, and the subscapularis. The first three insert on the greater tuberosity of the humerus, whereas the subscapularis inserts on the lesser tuberosity. The cuff muscles not only rotate the humerus at the glenohumeral joint but also act to keep the humeral head centered in the glenoid fossa, providing a fixed fulcrum for the arm to be elevated, primarily by the deltoid. The subacromial bursa overlies the tendons.

 

These structures, in turn, sit under the coracoacromial arch, which consists of the acromion, the coracoacromial ligament, and the outer end of the clavicle at the acromioclavicular joint.

 

The three parts of the deltoid arise from the acromion and lateral clavicle, and this muscle lies over the cuff and bursa. It acts to elevate, abduct, and extend the humerus at the shoulder joint.

 

PATHOGENESIS

 

Rotator cuff tears have a multifactorial pathogenesis.

 

Among the factors are tendon insertional degeneration (enthesopathy), shear (the inferior third of the cuff tendons being more susceptible to shear failure than the superior two-thirds), hypovascularity, impingement, and microtrauma.

 

Although impingement was felt to be the sole underlying cause of cuff disease for some time, it is now felt to be a secondary factor in that it likely comes into play once the cuff is weakened and is unable to balance the upward pull of the deltoid. This then brings the cuff into contact with the undersurface of the anteroinferior acromion and the rest of the coracoacromial arch.

 

Major injury is uncommonly a factor and usually involves an already degenerative tendon. A common major injury, which can result in a rotator cuff tear, is a primary, or a firsttime, anterior dislocation of the shoulder in a patient older than age 40 years. The older the patient, the more likely there is a cuff tear.

NATURAL HISTORY

 

The natural history of rotator cuff tears is unknown. There have been several studies in cadavers and by magnetic resonance imaging (MRI) that have confirmed that the incidence of asymptomatic cuff tears over the age of 60 years is around 33%. These subjects have been pain-free and fully functional.

 

Any study that has tried to follow asymptomatic tears prospectively over time has suffered from an unacceptably high loss of patients being followed, thereby negating any conclusions.

 

The condition of cuff tear arthropathy does not occur regularly with known cuff tears, even massive ones.

 

It has been shown that after a traumatic tear, the outcome is influenced by the time interval to repair—in other words, those repaired within the first 3 weeks do better than those repaired between 3 and 6 weeks, and those older than 6 weeks do even worse. These outcomes apply only to the uncommon traumatic tear, not to the far more common degenerative type.

 

Therefore, treatment should be based purely on the presenting symptoms of pain and functional limitation, not on the possibility that a tear may progress in size or develop into cuff tear arthropathy, because the latter possibilities cannot be predicted.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Barring the unusual history of a significant injury, such as a primary anterior glenohumeral dislocation over the age of 40 years resulting in a traumatic tear, most patients will present with a complaint of pain of indeterminate onset.

 

The pain is often worse at night and with use, especially overhead activity.

 

 

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) may provide some temporary relief, as may stretching. The pain can radiate to the lateral humerus, but not to below the elbow or into the neck and occiput.

 

There rarely will be significant motion loss (ie, motion will be unaffected) nor will the patient often notice weakness.

 

The first step in the physical examination is to examine the neck to eliminate that as a source of the pain.

 

 

P.3650

 

One should inspect the shoulder for atrophy of the supraspinatus and infraspinatus or rupture of the tendon of the long head of the biceps, which usually occurs with a large or massive tear. One should also palpate the region of the greater tuberosity and the bicipital groove for tenderness. In thin patients, it is possible to feel the cuff defect through the skin and deltoid.

 

Motion is assessed by having the patient elevate the arms actively and comparing this to passive motion and by placing the arms in 90 degrees of abduction and maximal external rotation as well as maximal external rotation with the arm at the side.

 

The inability to hold the arm in maximum active external rotation in abduction or at the side is a positive lag sign, indicating a major defect in the musculotendinous unit.

 

Internal rotation is evaluated by having the patient reach up the back to the highest point possible. Further testing for this (subscapularis function) is discussed in another chapter.

 

Strength of the external rotators is tested with the arm at the side and in maximal external rotation by having the patient resist a force directed toward the body. Strength in elevation is assessed by resisting the patient's attempt to raise the arm.

 

 

 

FIG 1 • A,B. Type III acromion, the so-called hooked acromion, on the outlet and AP views. C. Arthrogram confirming the presence of a rotator cuff tear with dye in the glenohumeral joint and the subacromial bursa simultaneously. D. T2-weighted coronal MRI showing cuff tear and its lateral to medial extent. E. T2-weighted sagittal oblique MRI showing the AP extent of the cuff defect. F. Another T2 sagittal oblique MRI showing the tear involving the teres minor but not the subscapularis. G. Axial T2 MRI of the same tear showing rupture of the teres minor with an intact subscapularis.

 

 

Provocative signs for cuff and biceps disease include the following:

 

 

Impingement sign: Forcing the fully forward elevated arm against the fixed scapula helps to localize the finding to the rotator cuff when the patient experiences pain.

 

Palm-down abduction test: By internally rotating the arm, the supraspinatus and anterior infraspinatus tendons are placed directly under the coracoacromial arch. Elevating the arm in the scapular plane when it is in internal rotation compresses these tendons against the undersurface of the acromion.

 

Biceps resistance test (Speed test): Pain during this maneuver indicates involvement of the long head of the biceps tendon.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Standard radiographs, including anteroposterior (AP) views in internal and external rotation, an axillary view,

and an outlet view, should always be taken to look for the type of acromion (FIG 1A), acromioclavicular joint changes, and narrowing of the acromial-humeral interval (FIG 1B) and to rule out other conditions.

 

 

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Additional preoperative studies include MRI, ultrasound, or arthrography.

 

 

Ultrasound is institutional-specific and operator-dependent, so its use is limited to centers with institutional expertise.

 

Arthrography once was the gold standard but now is used only under rare circumstances (ie, when an MRI cannot be done). It can show a full-thickness cuff tear (FIG 1C) but requires an intra-articular injection with fluoroscopy and radiography.

 

The most commonly used study is an MRI. It not only shows the integrity of the tendons but also provides a three-dimensional view of the cuff (FIG 1D-G). This capacity makes the MRI a versatile preoperative planning tool.

 

DIFFERENTIAL DIAGNOSIS

Cuff tendinitis without tear Incomplete rotator cuff tear Bicipital tendinitis

Calcific tendinitis Suprascapular neuropathy

 

 

NONOPERATIVE MANAGEMENT

 

If there is a history of an acute injury with immediate inability to raise the arm, the patient can be treated symptomatically and followed every 5 to 7 days for the first 2 weeks. If the ability to raise the arm does not recover, then nonoperative treatment should be abandoned and surgery undertaken.

 

The objective of treating rotator cuff disorders, in the absence of an acute injury with immediate loss of elevation, is primarily to relieve pain and secondarily to restore function or strength. Pain relief is a more predictable outcome of treatment than is restoration of function or strength. Therefore, nonoperative treatment should be directed at relieving pain.

 

Although NSAIDs can help with pain, a subacromial steroid injection is often more effective and immediate in its relief.

 

Once the pain is improved, physical therapy should be instituted.

This involves two aspects: stretching and strengthening of the rotators and elevators.

 

 

 

FIG 2 • A. Sitting position for surgery allows the surgeon to look down on the cuff and see posterosuperiorly. B.

The arm is draped free, giving extensive access to the entire shoulder.

 

SURGICAL MANAGEMENT

 

As noted earlier, in the unusual case in which there is an acute injury resulting in an immediate loss of elevation of the arm, if symptomatic treatment fails to restore the ability to raise the arm, surgical repair should be undertaken before the 3-week mark.

 

For the more common chronic attritional tear, surgery is considered if an injection, NSAIDs, and physical therapy fail to produce a level of pain relief and function that is acceptable to the patient.

 

Patients make the decision to have surgery based on whether they can live with the pain and functional limitation that they have. They need to understand that the operation can help them but can also leave them unchanged or worse.

 

Preoperative Planning

 

The radiographs and MRI should be reviewed preoperatively.

 

The radiographs will help in planning the need for and extent of acromioplasty.

 

The MRI will show which tendons are torn and the degree to which they are torn or retracted. It will also show the presence or absence of fatty infiltration of the muscles.

 

Positioning

 

The patient is positioned in a sitting position, even more upright than the so-called beach-chair position (FIG 2A). The arm is draped free to allow uninhibited mobility of the extremity (FIG 2B).

 

This allows the surgeon to look down on the cuff from above, therefore, being able to see posterosuperiorly as well as superiorly and anteriorly. It also permits better access to the posterior part of the infraspinatus and the teres minor.

Approach

 

There are basically three approaches to cuff repair:

 

 

 

The all-arthroscopic approach (discussed in another chapter) Arthroscopic decompression and mini-open repair of the cuff

 

Open repair of the cuff: includes direct repair, grafting, and tendon transfers

 

 

P.3652

 

 

TECHNIQUES

• Arthroscopic Subacromial Decompression and Mini-Open Cuff Repair

  The standard posterior viewing portal is established, and the glenohumeral joint is evaluated. The defect in the cuff is viewed from the articular side, and the long head of the biceps is assessed.

  Any débridement or other intra-articular procedures deemed necessary can be carried out at this time.

  The arthroscope is then redirected into the subacromial space and enough bursa resected to allow adequate visualization of the cuff tear, the anterior inferior surface of the acromion, and the coracoacromial ligament. If deemed appropriate (as discussed later), the ligament is released and the anterior and anterolateral margins of the acromion are defined.

  A burr is used to perform an acromioplasty to the same degree that is done in the open technique. This is an important point. Although the means of accomplishing the decompression differ, the ultimate result is the same: an adequate decompression.

  Through a small lateral portal, a suture punch is used to pass several traction sutures through the leading edge of the torn tendons. Using these sutures as handles to control and apply traction to the cuff, a small elevator is introduced through the same lateral portal and used to free the surrounding adhesions on both surfaces of the cuff. The degree of mobility achieved can be assessed by applying traction through the previously placed sutures.

  Once enough mobility of the cuff has been restored, an incision is made at the anterolateral corner of the acromion for about 1.5 to 2 cm (TECH FIG 1). The deltoid is split in the same line as the skin, and additional subdeltoid freeing is done. Narrow retractors are placed under the acromion and anteriorly to expose the tear.

  The procedure at this point is the same as described in the next section.

   

   

   

  TECH FIG 1 • Skin incision for the mini-open repair technique.

• Open Repair of the Cuff

Incision and Dissection

 

With the patient in the sitting position as described earlier and the arm draped free, an incision is made beginning superiorly at the posterior aspect of the acromioclavicular joint, continuing over the top of the joint, and ending at a point at the lateral tip of the coracoid (TECH FIG 2A).

 

After mobilization of the skin flaps, the deltotrapezial aponeurosis and the superior acromioclavicular ligament are incised into the acromioclavicular joint.

 

The deltoid muscle is split in line with its fibers only as far distally as the tip of the coracoid.

 

 

 

TECH FIG 2 • A. Skin incision for the standard anterosuperior approach. B. Subperiosteal dissection of deltoid origin from superior aspect of the lateral clavicle, acromioclavicular joint, and anterior acromion, without cutting across the deltoid origin. (continued)

 

 

P.3653

 

 

 

TECH FIG 2 • (continued) C. Completed elevation of the anterior deltoid origin. D. The completed dissection. (A: From Neviaser R, Neviaser AS. Open repair of massive rotator cuff tears: tissue mobilization techniques. In: Zuckerman J, ed. Advanced Reconstruction: Shoulder. Chicago: American Academy of Orthopaedic Surgery, 2007:177-184.)

 

 

Using a sharp knife blade, the deltoid origin is dissected subperiosteally from the lateral clavicle for about 1 cm. It is also dissected from the anterior, superior, and undersurface of the acromion out to the anterolateral corner of the acromion (TECH FIG 2B-D).

 

No incision is made across the tendon of origin of the deltoid on the acromion; that is, the deltoid is not detached from the acromion.

Clavicular Resection and Acromioplasty

 

The coracoacromial ligament is identified and isolated. If, in the judgment of the surgeon, the cuff can be securely repaired, the ligament is released from its attachment on the acromion. If the repair is tenuous, the ligament is not released, or if it is, it is dissected from the undersurface of the acromion to achieve maximal length and repaired back to the acromion through drill holes in the acromion at the end of the procedure.

 

This is necessary to prevent anterosuperior escape of the humerus, which occurs when the cuff is deficient and there is no coracoacromial arch to contain the humeral head, which is being pulled upward by the unopposed deltoid.

 

Using a reciprocating saw, the lateral 7 to 8 mm of the lateral end of the clavicle is removed without damaging the periosteum or posterior capsule. The portion removed is trapezoidal in shape, with the larger base being posterior, to prevent contact of the clavicle with the acromion posteriorly.

 

The clavicular resection allows the acromion and scapula to be rotated posteriorly more easily and gives

greater access to the posterior cuff.

 

Using the same instrument, an acromioplasty is performed by removing the anteroinferior surface of the acromion from the medial articular margin out to the anterolateral corner. The anterior edge is not recessed beyond its normal anatomy, and it is not the removal of the full thickness of the acromion, creating a type I acromion (TECH FIG 3). The portion removed is a triangular piece, with its base being the anterior edge.

 

The entire subacromial space is freed bluntly of adhesions between the bursa and the undersurface of the deltoid. Retractors are placed into the subacromial space under the acromion to avoid tension on the deltoid.

 

 

 

TECH FIG 3 • Type I acromion on outlet view.

 

 

P.3654

Tear Repair

 

The bursa is incised, undermined, and reflected. The tear in the cuff can now be seen. The friable, avascular edges are trimmed with a sharp knife. This resection is minimal—only until healthy tendon is seen (TECH FIG 4A), not to bleeding tendon. This usually requires the removal of only a few millimeters.

 

No. 1 nonabsorbable traction sutures are placed in the edges of the freshened cuff. Applying traction through these sutures, blunt mobilization is done using an elevator, dissecting scissors, or the surgeon's finger.

 

This step of mobilization is critical, and as the musculotendinous unit becomes free, additional sutures are placed successively medially until the apex of the tear is identified (TECH FIG 4B).

 

If the cuff edge cannot be brought sufficiently far to reach its original insertion, interval releases are done by incising between the supraspinatus and the subscapularis and between the infraspinatus and the teres minor. This restores the differential gliding between these adjacent tendons.

 

 

 

TECH FIG 4 • A. Intraoperative photograph showing freshened edges of tear. Healthy tendon is seen but not bleeding edges. Note cancellous trough at the anatomic neck and the greater tuberosity. B. Triangular tear with apex medially. C. Drawing of sutures passed through bone tunnels in the trough and greater tuberosity, pulling the edge of the cuff into the trough. Anchors can be used instead. D. Completed L-shaped repair. (D: From Neviaser R, Neviaser AS. Open repair of massive rotator cuff tears: tissue mobilization techniques. In: Zuckerman J, ed. Advanced Reconstruction: Shoulder. Chicago: American Academy of Orthopaedic Surgery, 2007:177-184.)

 

 

When the leading edge of the cuff can be brought to its insertion on the greater tuberosity, a shallow trough is made in the anatomic neck at the greater tuberosity (TECH FIG 4A).

 

Drill holes are made in the trough and the lateral side of the tuberosity and connected with a punch. Locking horizontal mattress sutures or modified Mason-Allen sutures are placed in the cuff and passed through the bone tunnels created by connecting the drill holes (TECH FIG 4C). Suture anchors can also be used in the trough and the tuberosity in a double-row fashion instead of the bone tunnels.

 

With the arm in some internal rotation and slight abduction, the sutures are tied securely to bring the free edge of the cuff into the trough.

 

 

This leaves a longitudinal split, which is sutured side to side, not only closing the split but also helping to relieve tension on the cuff advanced into the trough (TECH FIG 4D).

 

• Biceps Graft

  P.3655

   

  If the cuff cannot be brought to the greater tuberosity and there is a residual defect of modest size, an interpositional graft of the tendon of the long head of the biceps can be used. The critical requirement to use this or any graft is that the musculotendinous motor must be functional, not fixed and immobile. If

  there is no springy give when traction is applied to the tendon, no graft should be done.

   

  First, the tendon of the long head is tenodesed to the transverse humeral ligament in the bicipital groove using three figure-8 nonabsorbable no. 1 sutures. The tendon is transected just above the most proximal suture and then released from its origin at the supraglenoid tubercle.

   

   

   

  TECH FIG 5 • A. Filleted intra-articular portion of the tendon of the long head of the biceps. B. Biceps graft in place. (A: From Neviaser RJ. Tears of the rotator cuff. Orthop Clin North Am 1980;11:295-306; B: From Neviaser JS. Ruptures of the rotator cuff of the shoulder: new concepts in the diagnosis and treatment of chronic ruptures. Arch Surg 1971;102:483-485.)

   

   

  This segment of tendon is filleted (TECH FIG 5A) and placed into the cuff defect. It is trimmed to fit the defect and contoured to accommodate it.

   

  It is sutured side to side to the cuff and to a trough in the anatomic neck at the greater tuberosity, as described earlier (TECH FIG 5B).

• Freeze-dried Cadaver Rotator Cuff Graft

   

  If the residual defect is too large for a biceps graft to cover, a larger graft is needed. The best choice is a freeze-dried graft of human rotator cuff. As with every graft, the musculotendinous motor (ie, the native rotator cuff) must be a functional unit, as noted earlier.

   

  After the described mobilization techniques have reduced the size of the defect as much as possible, the graft is reconstituted in sterile saline for 30 minutes so that it becomes soft and pliable (TECH FIG 6A).

   

   

   

  TECH FIG 6 • A. Reconstituted freeze-dried cadaver rotator cuff graft. B. Reconstituted freeze-dried cadaver rotator cuff graft sutures in place. (A: From Neviaser JS, Neviaser RJ, Neviaser TJ. The repair of chronic massive ruptures of the rotator cuff by use of a freeze-dried rotator cuff. J Bone Joint Surg Am 1978;60A:681-684; B: From Neviaser R, Neviaser AS. Open repair of massive rotator cuff tears: tissue mobilization techniques. In: Zuckerman J, ed. Advanced Reconstruction: Shoulder. Chicago: American Academy of Orthopaedic Surgery, 2007:177-184.)

   

   

  It is then trimmed and contoured to accommodate the free edge of the native cuff and then sutured to it with nonabsorbable no. 1 sutures.

   

  It is also trimmed to reach a trough in the anatomic neck adjacent to the greater tuberosity and secured in the same fashion as the direct repair through drill holes in the bone or by anchors, as previously described (TECH FIG 6B).

   

  P.3656

• Local Tendon Transfers

   

  When the cuff cannot be closed by direct repair and the proximal native cuff is not mobile, the subscapularis and teres minor can be used as local tendon transfers.

   

  The interval between the subscapularis and the anterior capsule is identified near the musculotendinous junction and traced laterally toward the insertion on the lesser tuberosity.

   

  The tendon is separated from the capsule and released from the insertion. A traction suture is placed in the tendon, and the subscapularis is mobilized so that it can be shifted superiorly.

   

  The subscapularis is then transferred superiorly (TECH FIG 7A) to close the residual defect. Its superior border is sutured to the intact portion of the cuff, its distal end to the greater tuberosity, and its inferior border to the superior edge of the undisturbed anterior capsule (TECH FIG 7B,C).

   

  If the subscapularis alone does not provide adequate closure of the tear, the teres minor can also be transferred from posterior to superior. The interval between the tendon of the teres minor and the posterior capsule is developed (TECH FIG 7D), starting medially at the musculotendinous junction and freed laterally to its insertion on the greater tuberosity. It is detached from the tuberosity.

   

   

   

  TECH FIG 7 • A. Detached subscapularis mobilized and moved superiorly. B. Subscapularis transferred and sutured to residual cuff, the greater tuberosity, and the superior border of the undisturbed anterior capsule. C. Subscapularis transferred and sutured. D. Interval between the teres minor and posterior capsule developed. (continued)

   

   

  The muscle-tendon unit is mobilized bluntly and transferred superiorly to meet the transposed subscapularis (TECH FIG 7E).

   

  The two tendons are sutured together to form a new broad tendon, which is inserted into a trough at the greater tuberosity, as described earlier.

   

  The inferior borders of the respective tendons are sutured to the superior edges of the undisturbed capsules (teres minor to the posterior capsule and the subscapularis to the anterior capsule) (TECH FIG 7F,G).

   

  If none of these techniques allows the cuff to be reconstructed satisfactorily, a latissimus dorsi transfer is undertaken; this is described elsewhere.

   

  P.3657

   

   

   

  TECH FIG 7 • (continued) E. Detached, mobilized subscapularis and teres minor being transferred superiorly. F. Transferred subscapularis and teres minor sutured together to a trough in the greater tuberosity and to the undisturbed anterior and posterior capsules, respectively. G. The transferred subscapularis and teres minor sutures in place. (D and G: From Neviaser RJ, Neviaser TJ. Transfer of the subscapularis and teres minor for massive defects of the rotator cuff. In: Bayley I, Kessel L, eds. Shoulder Surgery. Heidelberg: Springer-Verlag, 1982:60-69.)

• Closure

 

The closure is the same for all procedures.

 

Because the deltoid has not been detached from its origin, it is allowed to fall back to its normal anatomic position or brought back by the surgeon. Simple sutures with the knots buried under the deltoid are placed to repair the side-to-side split, being sure to pass the suture through the external muscle fascia, the muscle itself, and the internal muscle fascia.

 

If the deltotrapezial aponeurosis and superior acromioclavicular ligament have been incised, they are repaired side to side with figure-8 sutures.

 

The skin is closed with a subcuticular 3-0 nylon suture and Steri-Strips. A sterile dressing is applied, and the extremity is immobilized in an immobilizer with the elbow forward of the midline of the body and the shoulder in internal rotation.

Postoperative

deltoid detachment

• This can be avoided by subperiosteally elevating the origin and not incising

across it.

Axillary nerve

injury with deltoid split

• This can be avoided by not splitting the deltoid beyond the tip of the

coracoid. Exposure is achieved by superior access, not distally.

Excessive

tendon resection

• Friable, poor-quality tendon should be trimmed only to healthy fibers, not to

bleeding tendon.

Postoperative

repair failure

• Tendons should be repaired to bone under only normal resting tension. If

  this is not possible, the described grafts or tendon transfers should be used.

• The early postoperative rehabilitation program is used to regain motion; strengthening is avoided until at least 3 weeks.

PEARLS AND PITFALLS

 

 

 

 

POSTOPERATIVE CARE

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Within 24 to 72 hours of the surgery, the dressing is changed. The patient is instructed in passive-only forward elevation and external rotation at the side while lying supine. The operative arm must be completely relaxed with no muscle activity at all, and the arm is elevated to at least 90 degrees forward and external rotation to neutral only.

 

Over the next 4 to 6 weeks, the amount of passive forward elevation is slowly increased, as is the external rotation at the side, but the latter should not go beyond 10 to 15 degrees of external rotation at most.

 

The extremity is kept in the immobilizer at all other times during this period. At 4 to 6 weeks postoperatively, depending on the security of the repair and the technique used, formal active and assisted exercises are permitted, along with continued passive stretching. Strengthening, weights, or resistive exercises are avoided until at least 3 months.

 

OUTCOMES

Repairs of small and medium-sized tears have a high rate of success in relieving pain and recovering motion and function while remaining structurally intact, regardless of whether repaired by arthroscopic, mini-open, or open techniques.

Repairs of large and massive tears also have resulted in good pain relief and functional recovery but have a much lower incidence of remaining intact structurally.

 

 

COMPLICATIONS

 

Deltoid origin detachment

Cuff repair dehiscence Anterosuperior instability or escape Infection

Loss of motion

Cuff tear arthropathy

 

 

SUGGESTED READINGS

1. Cofield RH. Subscapularis muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet 1982;154:667-672.

    

    

2. Karas SE, Giacello TL. Subscapularis transfer for reconstruction of massive tears of the rotator cuff. J Bone Joint Surg Am 1996;78A:239-245.

    

    

3. Neviaser JS. Ruptures of the rotator cuff: new concepts in the diagnosis and operative treatment for chronic tears. Arch Surg 1971;102:483-485.

    

    

4. Neviaser JS, Neviaser RJ, Neviaser TJ. The repair of chronic massive ruptures of the rotator cuff by use of a freeze-dried rotator cuff. J Bone Joint Surg Am 1978;60A:681-684.

    

    

5. Neviaser RJ, Neviaser TJ. Major ruptures of the rotator cuff. In: Watson M, ed. Practical Shoulder Surgery. London: Grune & Stratton, 1985:171-224.

    

    

6. Neviaser RJ, Neviaser TJ. Transfer of the subscapularis and teres minor for massive defects of the rotator cuff. In: Bayley I, Kessel L, eds. Shoulder Surgery. Heidelberg: Springer-Verlag, 1982:60-69.