Original Research

Clinical and Radiographic Outcomes After
Arthroscopic Lamina-Specific Double-Row
Repair of Large Delaminated Rotator Cuff
Tears in Active Patients
Daisuke Mori,*† MD, Kazuha Kizaki,† MD, Noboru Funakoshi,† MD,
Fumiharu Yamashita,† MD, PhD, Yasuyuki Mizuno,† MD, Takaaki Shirai,† MD, PhD,
and Masahiko Kobayashi,† MD, PhD
Investigation performed at the Department of Orthopaedic Surgery,
Kyoto Shimogamo Hospital, Kyoto, Japan
Background: The presence of delamination and a larger rotator cuff tear (RCT) size have been associated with poorer outcomes inrotator cuff repair. Therefore, we developed a new surgical procedure, arthroscopic lamina-specific double-row fixation (ALSDR),
for the repair of large delaminated RCTs.
Purpose: To investigate the clinical outcomes, magnetic resonance imaging findings, and satisfaction with several variables after
ALSDR for large delaminated RCTs.
Study Design: Case series; Level of evidence, 4.
Methods: A total of 30 active patients (mean age, 59.1 years) undergoing ALSDR were assessed by a numeric rating scale (NRS; 010) for pain, surgery, work, and exercise as well as American Shoulder and Elbow Surgeons (ASES), Constant, and Simple
Shoulder Test (SST) scores at a mean of 65.9 months postoperatively. Rotator cuff integrity was determined by magnetic resonance imaging. The Spearman correlation coefficient (r) was used to determine the correlation between clinical and NRS scores.
Results: Five patients (16.7%) had a retear. Each of the postoperative functional and NRS scores except the NRS work score wassignificantly better in the healed shoulders than in the shoulders with a retear (P < .001). The NRS pain score showed a significant
negative correlation with ASES, Constant, and SST scores (r ¼ 0.775, 0.668, and 0.742, respectively; P < .001 for all). The
NRS surgery score had a positive correlation with Constant and SST scores (r ¼ 0.393 [P ¼ .032] and r ¼ 0.456 [P ¼ .011],
respectively). The NRS work score had a positive correlation with ASES, Constant, and SST scores (r ¼ 0.382 [P ¼ .037], r ¼ 0.386[P ¼ .035], and r ¼ 0.414 [P ¼ .023], respectively). The NRS exercise score had a positive correlation with ASES, Constant, andSST scores (r ¼ 0.567 [P ¼ .001], r ¼ 0.511 [P ¼ .004], and r ¼ 0.639 [P < .001], respectively).
Conclusion: Our results showed that there was a significant correlation between clinical and NRS scores. The results indicate that
ALSDR can provide a high degree of functionality and can be a useful alternative treatment for active patients with large delaminated RCTs.
Keywords: large rotator cuff tear; delamination; correlation; structural and clinical outcomesoutcomes. Sakaguchi et al29 reported a 50% retear rate
after conventional en masse double-row repair for large tomassive RCTs. Conversely, Sonnabend et al31,32 and MacDougal and Todhunter18 reported curetting delaminatedcomponents at the time of surgery and noted that theirpresence had no effect on the clinical outcomes of rotator
cuff repair. These differences in outcomes may be caused bysurgeon perception of tear configuration, tear location, andthickness of the inferior layer.9,10
In the repair of large-sized delaminated RCTs, which areanatomically more complex than nondelaminated RCTs, it
may be expected that maintaining rotator cuff integrity will

Delamination is a commonly observed finding at the time ofrotator cuff repair, and some clinical studies have reported
it as a negative prognostic factor in rotator cuff healing.3,5,9,10,18,19,31 However, the best operative treatment for
delaminated rotator cuff tears (RCTs) remains controversial. Sugaya et al33 described a double-row technique fordelaminated RCTs that involved the repair of each layer
separately, without reporting clinical and radiographic
The Orthopaedic Journal of Sports Medicine, 7(4), 2325967119838249
DOI: 10.1177/2325967119838249ª The Author(s) 2019

This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/
licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source arecredited. You may not alter, transform, or build upon this article without the permission of the Author(s). For article reuse guidelines, please visit SAGE’s website at
http://www.sagepub.com/journals-permissions.

12

Mori et al

be difficult compared with the repair of small- to mediumsized delaminated RCTs.9,10,19,21,34 One purpose of rotator
cuff repair is to gain pain relief and functional recovery.
However, it remains controversial whether maintaining
rotator cuff integrity is crucial, as some studies have demonstrated that postoperative rotator cuff integrity does notalways correlate with residual pain and shoulder
dysfunction.6,28 We believe that maintaining rotator cuff
integrity is necessary in active patients who have large
RCTs for muscle strength recovery to achieve desired
outcomes.11,13,25,35 Therefore, we developed a techniqueusing a combination of a double row and an additional row,which we call arthroscopic lamina-specific double-row fixation (ALSDR), for the treatment of large-sized delaminated
RCTs in active patients.22
The purpose of the present study was to evaluate theefficacy of ALSDR using clinical and structural outcomes.
In addition, we correlated our numeric rating scale (NRS)
for satisfaction with usefulness of the shoulder after theindex surgery and activity level during work and exercise
with clinical shoulder scores. We hypothesized that ALSDR
would provide a high level of functionality, allowing active
patients with large delaminated RCTs to meet desired
activity levels.

METHODS
Patient Selection
The study protocol was approved by our institutional
review board, and informed consent for inclusion in the
study was preoperatively obtained from all patients. Data
were prospectively collected in our database and retrospectively reviewed. The initial study sample consisted of
63 consecutive patients with delaminated RCTs who
underwent arthroscopic separate double-layer doublerow fixation for small- to medium-sized (1-3 cm) RCTs
(31 patients) or arthroscopic lamina-specific double-row
fixation (ALSDR) for large-sized (3-5 cm) RCTs (32patients) by a single surgeon (D.M.) between June 2007
and November 2011.
The diagnosis of RCTs was based on magnetic resonanceimaging (MRI). The final evaluation, however, was performed at the time of arthroscopic surgery. We defineddelamination as a horizontal tear occurring between thelayers of the rotator cuff and the presence of 2 distinct
layers during the arthroscopic assessment. The indications
for ALSDR were as follows: (1) the inferior layer (deeplayer/articular side) in a delaminated RCT was retracted
medially to the glenoid and could be advanced to the medial
footprint of the greater tuberosity with a tendon grasper
after tendon mobilization, (2) the superior layer (bursal

The Orthopaedic Journal of Sports Medicineside) was able to be advanced laterally to the edge of thegreater tuberosity, and (3) a 3- to 5-cm tear size. We used
this to define large delaminated RCTs.22 We performed separate double-layer double-row fixation for small to medium
delaminated RCTs.33
The inclusion criteria for this study were (1) an RCT withpain and functional disability refractory to conservative
treatment for at least 6 months, (2) active patients with thehope of possible complete recovery of function and muscle
strength and premorbid activity levels after the index surgery (see below), (3) an intact teres minor tendon, (4) availability of MRI to evaluate the integrity of the rotator cuff
tendons before surgery and at 12 months and final followup after surgery, (5) a minimum follow-up period of 24months after surgery, and (6) relatively higher education
with a high level of literacy (ie, some high school, highschool graduate, college graduate), as lower education levelhas been associated with poorer functional outcomes inrotator cuff surgery.14 The exclusion criteria were (1) smallto medium-sized RCTs, (2) irreparable RCTs diagnosed
during surgery as rotator cuff tendons that are so damaged
as to be unable to mobilize the tendon to the insertion, (3) abursal layer that was more retracted than the articularlayer (n ¼ 0), (4) grade 3 or 4 fatty infiltration in the affectedrotator cuff muscle on MRI according to the classification of
Goutallier et al,8 (5) the development of symptoms after a
motor vehicle accident because patients did not receive
long-term follow-up (those with workers’ compensation
were included in this study), (6) a history of surgery, and(7) full-thickness subscapularis tendon tears. Of the 32
patients who underwent ALSDR, 1 who met the inclusion
criteria was lost to follow-up, and 1 had sedentary activity.
The remaining 30 shoulders in 30 active patients who
underwent ALSDR were included in the study. None of thepatients had a history of diabetes.

Patient Assessment
Activity Level. Activity level was defined using the criteria of Galatz et al7 and Kim et al.14 Overall activity levels
were rated as sedentary, light, moderate, or strenuous. The
patient was considered to be sedentary when he or she did
not participate in sports, and general lifting was limited to
15 lb (6.8 kg). Light activity was defined as participation inlight recreational sports, such as golf, light gardening,water aerobics, walking, and stretching, or the ability tolift 25 to 30 lb (11.3-13.6 kg). Activity was considered moderate if the patient regularly participated in moderatestress recreational sports such as racket sports excluding
tennis, gardening, jogging, light swimming, recreationalgolf, and landscaping or could lift 50 to 75 lb (22.7-34.0kg) on a regular basis. Strenuous activity meant that the*Address correspondence to Daisuke Mori, MD, Department of Orthopaedic Surgery, Kyoto Shimogamo Hospital, 17 Shimogamo Higashimorigamaecho, Sakyo-ku, Kyoto, 606-0866, Japan (email: altair.0421@gmail.com).
†
Department of Orthopaedic Surgery, Kyoto Shimogamo Hospital, Kyoto, Japan.
The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosuresagainst the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility
relating thereto.
Ethical approval for this study was obtained from Kyoto Shimogamo Hospital (No. 2012-002).

The Orthopaedic Journal of Sports Medicine

Outcomes for Large Delaminated Rotator Cuff Tears

3

Figure 1. (A) Illustrations of arthroscopic lamina-specific double-row fixation. 1, Sutures of the medial-row anchor are placed
through the inferior and superficial layers in a mattress fashion. 2, A lamina-specific lateral-row anchor is inserted between the
typical medial and lateral rows. A suture limb of the lamina-specific lateral-row anchor is placed just through the inferior layer in a
simple suture fashion. 3, Sutures of the lamina-specific lateral-row anchor are tied. A suture limb of the lateral-row anchor is placed
through the superficial layer. 4, Knot tying for the lateral row of simple sutures is performed, and repair is then completed by knot
tying for the medial row in a mattress fashion. (B-D) Arthroscopic images of the right shoulder as viewed from the posterolateral
portal. Images B, C, and D correspond to illustrations 2, 3, and 4, respectively. (B) The red circle indicates sutures of the medial-row
anchor, and the yellow circle indicates sutures of the lamina-specific lateral-row anchor. (C) The inferior layer is fixed on thefootprint. (D) Repair is completed. IL, inferior layer; SL, superficial layer.
patient regularly participated in contact sports oroverhead-throwing sports at a competitive level, such as
tennis, baseball, lap swimming, running, and weight lifting, or could lift >75 to 100 lb (34.0-45.4 kg) on a regularbasis. Activity level was defined on the basis of the moststrenuous work or leisure activities that the patient performed on a regular basis.
Outcome Assessment. Outcome scores were used toassess patients on the day before surgery, at 12 and 24
months postoperatively, and at a final functional evaluation performed a minimum of 24 months postoperatively.
Measures used included the Constant score and the American Shoulder and Elbow Surgeons (ASES) score. The Simple Shoulder Test (SST) was used at final follow-up.
Objective outcome measures, including range of motion
and muscle strength, were performed by the treating surgeon (D.M.) and a clinical assistant who was not involvedin the study to verify the results and avoid errors in theassessments. A goniometer was used to measure active
shoulder range of motion to the point of pain, including
forward flexion, external rotation with the arm at the side,and internal rotation at the back. To aid in statisticalanalysis, for internal rotation, we converted the vertebral
level reached to a numeric value: levels T1-T12 converted to
1-12, levels L1-L5 to 13-17, the sacrum to 18, and the buttock
to 19. An Isobex dynamometer (Cursor AG) was used toquantitatively assess isometric muscle strength in both theaffected and the unaffected upper extremities. Abduction
strength was tested with the arm abducted to 90 in thescapular plane with the elbow extended and the forearm
pronated. The measurement was made 3 times, and themean of these values was used for analysis to calculate theConstant score.
Pain, Satisfaction, and Activity Level Scoring. An
11-point (0-10) NRS was used to assess pain at strenuous
activity, at rest, and while sleeping. Of the 3 domains, thehighest pain level was chosen for the clinical assessment.
In addition, an NRS for satisfaction with usefulness ofthe shoulder after the index surgery (NRS surgery) was
utilized. Similarly, patient activity level was assessedwith the use of an 11-point NRS in each of 2 domains: (1)activity at work and (2) activity during sports/recreation(NRS work and NRS exercise, respectively) (Appendix
Table A1).

4

Mori et al

The Orthopaedic Journal of Sports Medicine

TABLE 1Baseline Demographics and Characteristicsa

Sex, n (%)
Male
FemaleAge, yFollow-up period, mo
Affected side, n (%)
Right
Left
Dominant side affected, n (%)
Workers’ compensation, n (%)
Smoking, n (%)
Partial subscapularis tear, n (%)
Biceps tenodesis, n (%)
Tear size, cm
Medial to lateral
Anterior to posterior
No. of anchors
Greater tuberosity
Humeral head
Fatty degenerationd
Subscapularis
Supraspinatus
Infraspinatus

Total Cohort (N ¼ 30)

Intact (n ¼ 25)

Retear (n ¼ 5)

26 (86.7)
4 (13.3)
59.1 ± 7.5 (43-72)
65.9 ± 11.1 (32-88)

23 (92.0)
2 (8.0)59.2 ± 7.9 (43-72)
66.7 ± 11.5 (32-88)

3 (60.0)
2 (40.0)
58.4 ± 5.3 (51-64)
66.2 ± 8.6 (52-71)

18 (60.0)
12 (40.0)
21 (83.3)
4 (13.3)
1 (3.3)7 (23.3)
3 (10.0)

15 (60.0)
10 (60.0)
17 (68.0)
3 (12.0)0 (0.0)6 (24.0)
2 (8.0)3 (40.0)
2 (40.0)
4 (80.0)
1 (20.0)
1 (20.0)
1 (20.0)
1 (20.0)>.999b.538b.167b>.999b.433b

3.5 ± 0.5 (3-5)
2.9 ± 0.5 (2-4)

3.5 ± 0.5 (3-5)
2.8 ± 0.5 (2-4)

3.4 ± 0.4 (3-4)
2.9 ± 0.5 (2-4)

.680c
.821c

5.5 ± 0.5 (5-6)
5.9 ± 1.0 (5-9)

5.5 ± 0.5 (5-6)
5.9 ± 0.9 (5-9)

5.2 ± 0.4 (5-6)
5.8 ± 1.3 (5-8)

.203c
.870c

0.9 ± 0.6 (0-2)
2.1 ± 0.3 (2-3)
1.8 ± 0.4 (1-2)

1.0 ± 0.5 (0-2)
2.1 ± 0.3 (2-3)
1.8 ± 0.4 (1-2)

0.6 ± 0.9 (0-2)
2.0 ± 0.0 (2-2)
2.0 ± 0.0 (2-2)

.184c
.432c
.289c

P Value
.119b

.824c
.420c
>.999bData are reported as mean ± SD (range) unless otherwise indicated.
Fisher exact test.
c
Unpaired t test.
dAccording to the classification of Goutallier et al.8ab

MRI Examination
MRI was performed with a 1.5-T closed-type scanner(EXCELART Vantage powered by Atlas or VISART/EX;
Toshiba). Oblique coronal, oblique sagittal, and axial T2weighted scans were acquired for structural and qualitative assessments of the rotator cuff tendons, and repair
integrity was evaluated. The slice thickness was 4 mm, andthe interslice gap was 0.5 mm in the former scanner and 0.8
mm in the latter scanner. Repair integrity was evaluatedusing the classification of Sugaya et al,33 in which types III
to V are considered a retear. The MRI scans showing tendon healing were evaluated by 3 observers including thetreating surgeon (D.M., K.K., N.F.). The intraclass correlation coefficient revealed good intraobserver reliability(0.771 [95% CI, 0.628-0.874]).17 The final assessment wasdetermined by the majority rating. However, in cases of adiscrepancy among the 3 observers, the assessment was
discussed to reach a consensus.

Surgical Procedure
Patients were placed in the beach-chair position under general anesthesia. The operative technique of ALSDR has
been described in detail previously (Figure 1).22 The operative indication of ALSDR was as follows: The treating surgeon evaluated delamination by pulling the torn superior
and inferior layers laterally to the footprint using a tendon

grasper with a 7-mm bite. If the edge of the inferior layer
could be grasped and pulled laterally to the footprint withthe grasper, we regarded this inferior layer as thick andtough tissue. We performed ALSDR for delaminated RCTs
with such inferior layers. If the inferior layer tissue wastorn and fragile at the time of the evaluation, standard
double-row fixation (separate double-layer double-row fixation) was performed.
The ALSDR was performed using an additional row(lamina-specific lateral row) of suture anchors placed
between the typical medial and lateral rows of sutureanchors. Medial-row sutures were passed through the inferior (articular side) and superior (bursal side) layers in amattress fashion. Next, lamina-specific lateral-row simple
sutures were passed through the inferior layer. Last,
lateral-row simple sutures were passed through the superior layer.

Postoperative Rehabilitation
Shoulders were immobilized postoperatively for 6 weeks
using a sling immobilizer or an abduction pillow. In all
patients, relaxation of the shoulder girdle muscles wasstarted on the first postoperative day with a physical therapist. After 2 weeks, patients were instructed to commenceisometric exercises and active-assisted exercises. After 6
weeks, patients started strengthening exercises of the rotator cuff and the scapular stabilizers. Patients were allowed

The Orthopaedic Journal of Sports Medicine

Outcomes for Large Delaminated Rotator Cuff Tears

5

Figure 2. (A) Postoperative radiograph. (B) Repair integrity shown on postoperative oblique coronal T2-weighted magnetic resonance imaging (MRI) of the right shoulder. Sugaya type II tendon showing sufficient thickness with partial high intensity as in an
intact shoulder. (C) Repair integrity shown on postoperative oblique coronal T2-weighted MRI of the right shoulder. Sugaya type V
tendon showing the presence of discontinuity as in a shoulder with a retear.

TABLE 2Functional Outcomesa

ASES score
Preoperative
Postoperative
Change (95% CI)
P valueConstant score
Preoperative
Postoperative
Change (95% CI)
P valueConstant strength score
Preoperative
Postoperative
Change (95% CI)
P value
SST
Postoperative
NRS painPreoperative
Postoperative
Change (95% CI)
P value

Total Cohort (N ¼ 30)

Intact (n ¼ 25)

Retear (n ¼ 5)

P Value

42.8 ± 10.9 (11.7 to 59.9)
93.6 ± 11.0 (60.0 to 100.0)
50.8 ± 13.9 (45.6 to 55.9)<.001c43.6 ± 10.7 (11.7 to 59.9)
97.9 ± 3.5 (85.0 to 100.0)
54.3 ± 10.7 (49.9 to 58.7)<.001c38.7 ± 12.4 (26.7 to 56.7)
71.7 ± 9.1 (60.0 to 81.7)
33.0 ± 15.3 (14.0 to 51.9)
.008c

.368b
<.001b.001b45.5 ± 9.1 (20.0 to 58.0)
86.2 ± 10.5 (60.0 to 100.0)
40.7 ± 11.6 (36.4 to 45.1)<.001c46.6 ± 7.6 (25.0 to 58.0)
90.1 ± 5.8 (81.0 to 100.0)
43.5 ± 9.1 (39.8 to 47.3)<.001c40.0 ± 14.7 (20.0 to 58.0)
66.8 ± 5.8 (60.0 to 73.0)
26.8 ± 13.5 (10.0 to 43.6)
.011c

.146b
<.001b.002b7.5 ± 2.5 (2.0 to 11.0)
16.8 ± 6.2 (5.0 to 25.0)
9.3 ± 6.1 (7.1 to 11.6)<.001c7.8 ± 2.3 (2.0 to 11.0)
18.4 ± 5.4 (8.0 to 25.0)
10.6 ± 5.8 (8.2 to 13.0)<.001c6.2 ± 3.4 (2.0 to 11.0)
9.2 ± 3.4 (5.0 to 14.0)
3.0 ± 2.1 (0.4 to 5.6)
.034c

.209b
.001b
.008b

11.4 ± 1.1 (8.0 to 12.0)

11.8 ± 0.5 (10.0 to 12.0)

9.4 ± 1.1 (8.0 to 11.0)<.001b

6.5 ± 1.2 (4.0 to 9.0)
0.7 ± 1.4 (0.0 to 5.0)
–5.8 ± 1.6 (–6.6 to –5.2)<.001c6.4 ± 1.2 (4.0 to 9.0)
0.1 ± 0.4 (0.0 to 2.0)
–6.2 ± 1.2 (–6.6 to –5.8)<.001c7.0 ± 1.2 (5.0 to 8.0)
3.6 ± 0.9 (4.0 to 9.0)
–3.4 ± 1.3 (–5.1 to –1.7)<.001c.294b<.001b<.001ba
Data are reported as mean ± SD (range) unless otherwise indicated. ASES, American Shoulder and Elbow Surgeons; NRS, numeric rating
scale; SST, Simple Shoulder Test.
b
Unpaired t test (intact vs retear).
c
Paired t test (preoperative vs postoperative).

to return to sports and heavy labor after 6 months depending on each person’s functional recovery.

Assessing ALSDR Efficacy
The expected healing rate after arthroscopic rotator cuff
repair has yet to be defined.1 Moreover, we did not know
how many shoulders were needed for assessing ALSDR

efficacy. Hence, we created the following process. First,
we looked for differences in the retear rate between ourgroups and previous studies with inclusion and exclusion
criteria similar to ours. A study by Sakaguchi et al 29
reported the retear rate as 50% after en masse repair for
18 shoulders with large or massive delaminated RCTs. In
addition, Barber at al2 performed arthroscopic dermal
matrix augmentation for patients with arthroscopically6Mori et al

The Orthopaedic Journal of Sports Medicine

Figure 3. Scatter plot showing the correlation between the (A) American Shoulder and Elbow Surgeons (ASES), (B) Constant,(C) Constant strength, and (D) Simple Shoulder Test (SST) scores and the numeric rating scale pain score. r, Spearman correlation
coefficient.
repairable large RCTs that were 3 to 5 cm in size and foundmore intact repair sites, as detected by MRI, in suchpatients compared with the control group (rotator cuff
repair without augmentation). In that study, Barber at
al2 hypothesized that reducing the retear rate by half would
be clinically meaningful when comparing the augmented
and nonaugmented groups. Based on their work, wehypothesized that reducing the retear rate in our groups
to less than half the retear rate of 50% reported by Sakaguchi et al29 was clinically meaningful.
Second, we know that this technique has higher medical
costs, such as requiring more suture anchors and a longer
operative time, compared with other operative techniques,
such as conventional en masse repair or separate doublelayer double-row fixation. The principle of ALSDR is tomaintain rotator cuff integrity, resulting in the restorationof shoulder function and individual premorbid activity
levels. Therefore, we created the following 2 criteria toassess the efficacy of ALSDR for large delaminated RCTs.
First, we looked for clinical differences in patients with andwithout a retear after ALSDR by using the ASES and Constant scores, the Constant strength score, and the SST.

Second, we correlated the above clinical outcome scoreswith the aforementioned NRS scores for pain, index surgery success, and activity level.

Statistical Analysis
As previously mentioned, the sample sizes were calculatedwith a significant difference set at a retear rate less than
25% in our groups compared with the study by Sakaguchi
et al29 using a binomial test. A sample size of 30 patientswas required for the present study to achieve a statisticalpower of 80% at a type I error level of .05. A paired t test wasused to compare the preoperative and postoperative clinicalscores, range of motion, and NRS pain score. The baseline
patient characteristics and clinical scores between the
intact and retear groups were compared using the Fisher
exact test and unpaired t test. In addition, we used theSpearman correlation coefficient (r) to determine the correlation between clinical scores, such as ASES, Constant,
Constant strength, and SST scores, and NRS scores for
pain, surgery, work, and exercise. The level of significancefor statistical tests was set at P ¼ .05, and 95% CIs were

The Orthopaedic Journal of Sports Medicine

Outcomes for Large Delaminated Rotator Cuff Tears

7

Figure 4. Scatter plot showing the correlation between the (A) American Shoulder and Elbow Surgeons (ASES), (B) Constant,(C) Constant strength, and (D) Simple Shoulder Test (SST) scores and the numeric rating scale surgery score. Ope, satisfaction forthe operated shoulder. r, Spearman correlation coefficient.
calculated. All statistical analyses were performed using
SAS version 9.2 (SAS Institute).

RESULTS
Preoperative Patient Demographics
Detailed information for the 30 patients is shown in Table 1
and Appendix Table A2.

Structural Outcomes
Postoperative MRI at final follow-up showed 5 tendons with
Sugaya type I (16.7%), 20 tendons with Sugaya type II(66.6%), and 5 tendons with Sugaya type V (16.7%). The
retear rate was 16.7% (Figure 2 and Appendix Table A3).

86.2 ± 10.5), and Constant strength score (from 7.5 ± 2.5
to 16.8 ± 6.2) (P < .001 for all). The mean NRS pain scoresignificantly improved from 6.5 ± 1.2 preoperatively to
0.7 ± 1.4 at final follow-up (P < .001) (Table 2 and Appendix
Table A3).

Range of Motion
Mean shoulder range of motion significantly improved frompreoperatively to final follow-up for active forward flexion(from 127.2 ± 25.2 to 164.5 ± 7.9 ), external rotation at
the side (from 32.8 ± 14.8 to 52.5 ± 11.4 ), and internalrotation at the back (from 15.7 ± 2.7 to 12.1 ± 1.9 ) (P <.001 for all) (Appendix Table A4).

Comparison of Shoulders Withand Without Retears

Total Functional Outcomes and NRS Pain
The mean outcome scores significantly improved from preoperatively to final follow-up for the ASES (from 42.8 ± 10.9
to 93.6 ± 11.0), Constant score (from 45.5 ± 9.1 toEach of the postoperative functional and NRS scores except
the NRS work score was significantly better in the healed
shoulders (ASES: 97.9 ± 3.5; Constant: 90.1 ± 5.8; Constantstrength: 18.4 ± 5.4; SST: 11.8 ± 0.5; NRS pain: 0.1 ± 0.4;8Mori et al

The Orthopaedic Journal of Sports Medicine

Figure 5. Scatter plot showing the correlation between the (A) American Shoulder and Elbow Surgeons (ASES), (B) Constant,(C) Constant strength, and (D) Simple Shoulder Test (SST) scores and the numeric rating scale work score. r, Spearman correlation
coefficient.
NRS surgery: 9.2 ± 1.1; NRS exercise: 8.3 ± 2.1) than in theshoulders with a retear (ASES: 71.7 ± 9.1 [P < .001]; Constant: 66.8 ± 5.8 [P < .001]; Constant strength: 9.2 ± 3.4[P ¼ .001]; SST: 9.4 ± 1.1 [P < .001]; NRS pain: 3.6 ± 0.9[P < .001]; NRS surgery: 6.2 ± 2.3 [P < .001]; NRS exercise:
2.8 ± 0.4 [P < .001]) at final follow-up. There was no significant difference between the shoulders with and without
retears for the NRS work score (8.2 ± 2.0 vs 6.6 ± 2.6, respectively; P ¼ .136).

Correlation Between Multiple Clinical Scoresand NRS Scores
The NRS pain score showed a significant negative correlation with ASES, Constant, Constant strength, and SSTscores (r ¼ 0.775, 0.668, 0.436, and 0.742, respectively; P ¼ .016 for Constant strength score and P < .001
for the remaining 3 scores). The NRS surgery score showeda significant positive correlation with Constant and SSTscores (r ¼ 0.393 [P ¼ .032] and r ¼ 0.456 [P ¼ .011],
respectively). The NRS work score showed a significant
positive correlation with ASES, Constant, and SST scores(r ¼ 0.382 [P ¼ .037], r ¼ 0.386 [P ¼ .035], and r ¼ 0.414[P ¼ .023], respectively). The NRS exercise score showeda significant positive correlation with ASES, Constant,
Constant strength, and SST scores (r ¼ 0.567 [P ¼ .001],
r ¼ 0.511 [P ¼ .004], r ¼ 0.511 [P ¼ .004], and r ¼ 0.639[P < .001], respectively) (Figures 3-6).

Complications
No patients had neural injuries, wound infections, or
suture anchor problems at the final visit. In 1 patient, we
experienced difficulty with the anchor during knot tying of
middle-row sutures because of the anchor pulling out. However, we reinserted a larger anchor at the time of surgery.

DISCUSSION
The uniqueness of this study is that, to find the valueof performing ALSDR on active patients with large delaminated RCTs, we investigated not only the improvement in clinical scores and the retear rate but also theThe Orthopaedic Journal of Sports Medicine

Outcomes for Large Delaminated Rotator Cuff Tears

9

Figure 6. Scatter plot showing the correlation between the (A) American Shoulder and Elbow Surgeons (ASES), (B) Constant,(C) Constant strength, and (D) Simple Shoulder Test (SST) scores and the numeric rating scale exercise score. r, Spearman
correlation coefficient.

correlation between clinical scores and NRS scores forpain and activity level (surgery, work, and exercise). The
most important finding of this study was the high healing rate and good improvement in outcome scores inpatients with this difficult tear pattern. Note that there
was only 1 patient (3.3%) who was a smoker, whichmight have played a role in the high healing rate that
we found (83.3%). Additionally, the present study demonstrated 2 findings: (1) patients with healed rotator cuff
tendons had significantly higher clinical scores thanpatients with retears at final follow-up, and (2) multiple
outcome scores (ASES, Constant, Constant strength, andSST) significantly correlated with NRS pain, surgery,
work, and exercise scores. These findings support our
hypothesis that ALSDR can provide good functional
results in active patients with large delaminated RCTs.
Some previous studies have reported that rotator cuff
tendon healing at the repair site correlated with clinicalimprovement, particularly in the recovery of muscle
strength, although structural failure (rotator cuff tendon
retear) did not always imply clinical failure.3,6,12,14,25,28

Indeed, in this study, shoulders with intact rotator cuff
tendons had significantly higher Constant and Constantstrength scores than the improved scores in shoulders
with a retear (rotator cuff tendon failure). However, theConstant score is a self- and examiner-based tool.16 For
the ASES and SST, healed shoulders also had significantly higher scores than unhealed shoulders. However,these 2 outcome measures are based solely on patient
self-assessment, which is a subjective tool. Hence, weused the Constant score as an objective assessment andthe ASES and SST as subjective assessments to assess
the efficacy of ALSDR. Therefore, in our active patients,
greater pain relief and muscle strength restoration wereassociated with greater patient satisfaction with theirclinical results and individual activity level recovery.
For active patients with RCTs, an anatomically intact
repair site may be necessary for satisfaction and functional
recovery because these patients usually engage in more
physically active recovery.6,12,23,35 Several previous studies
have shown a correlation between retears and satisfaction
with surgery or between retears and unsuccessful outcomes

10

Mori et al

after rotator cuff repair. Kim et al14 demonstrated thatpatients with a full-thickness rotator cuff retear had significantly lower subjective shoulder function compared withthose without a retear, especially for younger patients.
Namdari et al25 described an association between a laborintensive occupation and outcomes after structural failureof rotator cuff repair. These studies support the use of
ALSDR to ensure structural integrity for a satisfactory outcome in physically active patients.
Several authors have carried out a histological assessment of delaminated RCTs.18,19,32 Clark and Harryman4
demonstrated that rotator cuff tendons are composed of 5
layers, with layers 2 and 3 containing the fibers of thesupraspinatus and infraspinatus tendons and layer 5 being
the true joint capsule of the shoulder. Matsuki et al19 and
MacDougal and Todhunter18 stated that delamination
appears to be a separation of layers 2 and 3 (as describedby Clark and Harryman4) in rotator cuff tendons, while
Sonnabend et al32 reported that a synovium-like lining wasoften present in delaminated layers. In contrast to these
opinions, we regard the thick inferior layer as a complex
structure including at least layer 5 (capsule), which stabilizes the glenohumeral joint.20 A recent study by Nimura
et al26 showed that the attachment of the shoulder joint
articular capsule occupied a substantial area of thegreater tuberosity. The articular side of the rotator cuff
insertion is under greater stress during shoulder movements.30,36 These reports support the rationale for using
ALSDR.20,26,30,36
Park et al27 reported a retear rate for en masse suture
bridge repair of large to massive delaminated RCTs of 19%(4/21 shoulders), which was comparable with our retear
rate (16.7%) in patients with similarly sized tears. In otherwords, ALSDR may not significantly reduce the retear ratecompared with en masse suture bridge repair. Indeed,
there were no significant differences between intact
shoulders and shoulders with a retear in terms of baselinevariables such as tear size, number of suture anchors, andfatty degeneration in each rotator cuff muscle (see Table 2).
ALSDR is a combination of separate double-row repair withsuturing of the superior and inferior layers in a mattressfashion, which may avoid tendon mismatch and ensure
articular-side fixation.22 However, there is a disadvantage
to ALSDR in that the knots for articular-side lamina repair
have to be buried within the repaired tendons, which maylead to an inflammatory foreign-body response and negatively produce strangulation and necrosis of the repaired
tendon, possibly resulting in poor tendon healing.11 Kim
et al15 compared en masse repair and separate doublelayer double-row fixation for the treatment of delaminated
RCTs, finding lower pain scores in patients undergoing separate double-layer double-row fixation. Nakamizo andHorie24 compared en masse repair and double-layer suture
bridge repair for the treatment of delaminated RCTs, finding better range of motion in patients undergoing doublelayer suture bridge repair. However, these studies did notinvestigate the reason for such differences in theirresults.15,24 We also could not clarify the cause of retears
based on our results. Therefore, further trials with areduced number of anchors should be considered.11

The Orthopaedic Journal of Sports Medicine

This study has several limitations. First, the data were
prospectively collected but retrospectively reviewed. Second,
the mean follow-up period was in the short-term to midterm
range. Third, although the objective outcome measures wereassessed by the treating surgeon and a clinical assistant not
involved in the study for verification and to avoid assessment errors, the possibility of observer bias remains. The
structural outcomes assessment included the same weakness, despite good intraobserver reliability in the 3 observers. Fourth, we did not have a control group to compare
ALSDR with other conventionally used techniques, such asen masse suture bridge repair or separate double-layer
double-row fixation for large delaminated RCTs. However,based on the data from the present study, we believe that, toassess a new shoulder treatment method in clinical practice,a combination of reliable and previously tested shoulder outcome instruments and subjective patient assessments of satisfaction with the treatment and recovery of quality of life
during work and/or sports is helpful.

CONCLUSION
Our results showed that there was a significant correlation
between clinical and NRS scores. The results indicate that
ALSDR can provide high functionality, allowing active
patients with large delaminated RCTs the ability to meetdesired activity levels.

ACKNOWLEDGMENT
The authors thank Hajime Yamakage, MD, for statisticalanalyses.
REFERENCES
1. Arce G, Bak K, Bain G, et al. Management of disorders of the rotator
cuff: proceedings of the ISAKOS Upper Extremity Committee consensus meeting. Arthroscopy. 2013;29(11):1840-1850.
2. Barber FA, Burns JP, Deutsch A, Labbé MR, Litchfield RB. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012;28(1):8-15.
3. Boileau P, Brassart N, Watkinson DJ, Hatzidakis AM, Krishnan SG.
Arthroscopic repair of full-thickness tears of the supraspinatus: does
the tendon really heal? J Bone Joint Surg Am. 2005;87:1229-1240.
4. Clark JM, Harryman DT. Tendons, ligaments and capsule of the rotator cuff: gross and microscopic anatomy. J Bone Joint Surg Am. 1992;
74:713-725.
5. Flurin PH, Landreau P, Gregory T, et al. Arthroscopic repair of fullthickness cuff tears: a multicentric retrospective study of 576 caseswith anatomical assessment [in French]. Rev Chir Orthop Reparatrice
Appar Mot. 2005;91(suppl 8):31-42.
6. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The
outcome and repair integrity of completely arthroscopically repairedlarge and massive rotator cuff tears. J Bone Joint Surg Am. 2004;
86(2):219-224.
7. Galatz LM, Griggs S, Cameron BD, Iannotti JP. Prospective longitudinal analysis of postoperative shoulder function: a ten-year follow-up
study of full-thickness rotator cuff tears. J Bone Joint Surg Am. 2001;
83(7):1052-1056.
8. Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S.
Influence of cuff muscle fatty degeneration on anatomic andThe Orthopaedic Journal of Sports Medicine

functional outcomes after simple suture of full-thickness tears. J
Shoulder Elbow Surg. 2003;12(6):550-554.
9. Gwak HC, Kim CW, Kim JH, Choo HJ, Sagong SY, Shin J. Delaminated rotator cuff tear: extension of delamination and cuff integrity
after arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2015;24(5):719-726.
10. Han Y, Shin JH, Seok CW, Lee CH, Kim SH. Is posterior delaminationin arthroscopic rotator cuff repair hidden to the posterior viewing
portal? Arthroscopy. 2013;29:1740-1747.
11. Hepp P, Engel T, Osterhoff G, Marquass B, Josten C. Knotless anatomic double-layer double-row rotator cuff repair: a novel techniquere-establishing footprint and shape of full-thickness tears. Arch
Orthop Trauma Surg. 2009;129(8):1031-1036.
12. Jost B, Pfirrmann CW, Gerber C. Clinical outcome after structural
failure of rotator cuff repairs. J Bone Joint Surg Am. 2000;82(3):304-314.
13. Karas V, Hussey K, Romeo AR, Verma N, Cole BJ, Mather RC 3rd.
Comparison of subjective and objective outcomes after rotator cuff
repair. Arthroscopy. 2013;29(11):1755-1761.
14. Kim HM, Caldwell JM, Buza JA, et al. Factors affecting satisfaction
and shoulder function in patients with a recurrent rotator cuff tear.
J Bone Joint Surg Am. 2014;96(2):106-112.
15. Kim YS, Lee HJ, Jin HK, Kim SE, Lee JW. Conventional en masse
repair versus separate double-layer double-row repair for the treatment of delaminated rotator cuff tears. Am J Sports Med. 2016;44(5):1146-1152.
16. Kirkley A, Griffin S, Dainty K. Scoring systems for the functional
assessment of the shoulder. Arthroscopy. 2003;19(10):1109-1120.
17. Krippendorff K. Content Analysis: An Introduction to Its Methodology.
2nd ed. Thousand Oaks, California: SAGE; 2004.
18. MacDougal GA, Todhunter CR. Delamination tearing of the rotator
cuff: prospective analysis of the influence of delamination tearing on
the outcome of arthroscopically assisted mini open rotator cuff repair.
J Shoulder Elbow Surg. 2010;19:1063-1069.
19. Matsuki K, Murate R, Ochiai N, Ogino S, Fujita K, Ishige N. Delamination observed in full-thickness rotator cuff tears [in Japanese].
Katakansetsu. 2005;29:603-606.
20. Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior
capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med.
2012;40(10):2248-2255.
21. Mochizuki T, Nimura A, Miyamoto T, Koga H, Akita K, Muneta T.
Repair of rotator cuff tear with delamination: independent repairs of
the infraspinatus and articular capsule. Arthrosc Tech. 2016;5(5):e1129-e1134.

Outcomes for Large Delaminated Rotator Cuff Tears

11

22. Mori D, Funakoshi N, Yamashita F. Arthroscopic lamina-specificdouble-row fixation for large delaminated rotator cuff tears. Arthrosc
Tech. 2014;3(6):e667-e671.
23. Nakajima D, Yamamoto A, Kobayashi T, et al. The effects of rotator
cuff tears, including shoulder without pains on activities of daily livingin the general population. J Orthop Sci. 2012;17(2):136-140.
24. Nakamizo H, Horie R. Comparison of en masse versus dual-layer
suture bridge procedures for delaminated rotator cuff tears. Arthroscopy. 2018;34(12):3150-3156.
25. Namdari S, Donegan RP, Chamberlain AM, Galatz LM, Yamaguchi K,
Keener JD. Factors affecting outcome after structural failure of
repaired rotator cuff tears. J Bone Joint Surg Am. 2014;96(2):99-105.
26. Nimura A, Kato A, Yamaguchi K, et al. The superior capusule of theshoulder joint complements the insertion of the rotator cuff. J Shoulder Elbow Surg. 2012;21(7):867-872.
27. Park JY, Lhee SH, Oh KS, Moon SG, Hwang JT. Clinical and ultrasonographic outcomes of arthroscopic suture bridge repair for massive
rotator cuff tear. Arthroscopy. 2013;29(2):280-289.
28. Russell RD, Knight JR, Mulligan E, Khazzam M. Structural integrity
after rotator cuff repair does not correlate with patient function andpain: a meta-analysis. J Bone Joint Surg Am. 2014;96(4):265-271.
29. Sakaguchi K, Ito Y, Naka Y, et al. MRI evaluation of double row rotator
cuff tears for delamination type repairs [in Japanese]. Katakansetsu.
2008;32(3):627-630.
30. Sano H, Wakabayashi I, Itoi E. Stress distribution in the supraspinatus
tendon with partial-thickness tears: an analysis using twodimensional finite element model. J Shoulder Elbow Surg. 2006;15:
100-105.
31. Sonnabend DH, Watson EM. Structural factors affecting the outcomeof rotator cuff tears. J Shoulder Elbow Surg. 2002;11:212-218.
32. Sonnabend DH, Yu Y, Howlett CR, Harper GD, Walsh WR. Laminatedtears of the human rotator cuff: a histologic and immunochemical
study. J Shoulder Elbow Surg. 2001;10(2):109-115.
33. Sugaya H, Maeda K, Matsuki K, Moriishi J. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair:single-row versus dual-row fixation. Arthroscopy. 2005;21(11):1307-1316.
34. Tanaka T, Mochizuki T, Nimura A, et al. Location and thickness ofdelaminated rotator cuff tears: cross-sectional analysis with surgery
record review. J Shoulder Elbow Surg Open Access. 2018;2(1):84-90.
35. Virk MS, Levy DM, Kuhns BD, et al. Patient preference before andafter arthroscopic rotator cuff repair: which is more important, pain
relief or strength return? Am J Orthop. 2017;46(4):e244-e250.
36. Wakabayashi I, Itoi E, Sano H, et al. Mechanical environment of thesupraspinatus tendon: a two-dimensional finite element model analysis. J Shoulder Elbow Surg. 2003;12(6):612-617.

12Mori et al

The Orthopaedic Journal of Sports Medicine

APPENDIXTABLE A1
11-Point Numeric Rating Scales

The Orthopaedic Journal of Sports Medicine

Outcomes for Large Delaminated Rotator Cuff Tears

13

TABLE A2
Demographics
Patient No.

Sex

Age at Surgery, ySide

Follow-up, mo

Occupation

Sport

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
Mean ± SD

Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
FemaleFemale
Male
Male
Male
Female
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Female
Male

50
54
61
55
64
62
62
59
57
71
66
58
64
68
51
58
46
61
72
53
72
52
68
55
43
62
52
66
53
58
59.1 ± 7.5

Right
Right
Right
Left
Right
Right
Right
Right
Left
Right
Left
Right
Right
Right
Left
Left
Right
Right
Right
Left
Right
Right
Left
Left
Right
Left
Left
Left
Right
Left

61
73
71
83
73
58
61
73
74
64
65
60
56
63
52
61
71
71
68
88
72
78
65
61
68
85
54
54
63
32
65.9 ± 11.1

FarmerFarmerFarmerManual worker
Landscaping
Carpenter
Waste collector
Pharmacy clerk
Manual worker
Landscaping
Carpenter
Carpenter
Housewife
HousewifeLandscaping
Waste collector
Manual worker
Cook
Landscaping
Truck driver
Farmer
Therapist
Carrier
Forklift driver
Carpenter
Manual worker
Manual worker
Carpenter
FarmerCook

Recreational golf
Jogging
Recreational golf
Running
Weight lifting
Light swimming
Weight lifting
Jogging
TennisTennis
Weight lifting
TennisClassical dance
Tennis
Weight lifting
Jogging
Recreational golf
Recreational golf
Jogging
Swimming
Recreational golf
Weight lifting
Mountain biking
Weight lifting
Weight lifting
Recreational golf
Recreational baseball
Recreational golf
Swimming
Swimming

TABLE A3
Rotator Cuff Integrity and Functional Outcomesa
Patient
No.

Rotator
NRS Pain
ASES Score
Constant Score
Constant Strength Score
SST
Cuff
Integrityb Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Postoperative

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Type II
Type II
Type V
Type II
Type II
Type II
Type II
Type II
Type II
Type II
Type II
Type I
Type V
Type II
Type V
Type I
Type II
Type V
Type II
Type II

7.0
7.0
5.0
8.0
7.0
7.0
7.0
7.0
7.0
4.0
6.0
5.0
7.0
6.0
7.0
8.0
6.0
8.0
5.0
7.0

0.0
0.0
3.0
0.0
0.0
1.0
0.0
0.0
0.0
0.0
0.0
0.0
5.0
0.0
3.0
2.0
0.0
4.0
0.0
0.0

33.3
43.3
56.7
44.5
53.3
31.7
33.3
35.0
44.3
59.9
38.3
54.9
45.0
49.9
36.7
41.7
56.6
28.3
56.7
45.0

96.7
96.7
73.3
100.0
98.3
90.0
100.0
96.7
100.0
100.0
100.0
100.0
65.0
100.0
81.7
85.0
98.3
60.0
94.9
100.0

25.0
48.0
58.0
51.0
42.0
41.0
35.0
47.0
52.0
58.0
42.0
51.0
49.0
55.0
41.0
48.0
52.0
20.0
50.0
48.0

91.0
96.0
72.0
91.0
91.0
82.0
91.0
96.0
98.0
81.0
88.0
96.0
62.0
83.0
67.0
88.0
96.0
60.0
85.0
100.0

5.0
8.0
11.0
8.0
8.0
5.0
5.0
8.0
8.0
11.0
5.0
8.0
5.0
8.0
5.0
8.0
5.0
2.0
11.0
11.0

20.0
25.0
14.0
20.0
17.0
20.0
20.0
25.0
25.0
8.0
17.0
25.0
5.0
8.0
8.0
20.0
20.0
8.0
11.0
20.0

10.0
12.0
9.0
12.0
12.0
11.0
11.0
12.0
12.0
12.0
12.0
12.0
8.0
12.0
11.0
12.0
12.0
9.0
10.0
12.0

(continued)

14Mori et al

The Orthopaedic Journal of Sports Medicine

TABLE A3 (continued)
Patient
No.
21
22
23
24
25
26
27
28
29
30
Mean ± SD

NRS Pain
ASES Score
Constant Score
Constant Strength Score
SST
Rotator
Cuff
Integrityb Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Postoperative
Type I
Type II
Type II
Type V
Type I
Type I
Type II
Type II
Type II
Type II

6.0
5.0
6.0
8.0
6.0
9.0
5.0
8.0
5.0
5.0
6.5 ± 1.2

0.0
0.0
0.0
3.0
0.0
0.0
0.0
0.0
0.0
0.0
0.7 ± 1.4

43.3
46.7
51.7
27.7
43.3
11.7
51.6
28.3
48.3
43.3
42.8 ± 10.9

98.3
100.0
100.0
78.3
98.3
100.0
100.0
96.7
98.3
100.0
93.6 ± 11.0

39.0
56.0
49.0
32.0
51.0
38.0
54.0
38.0
49.0
45.0
45.5 ± 9.1

81.0
96.0
88.0
73.0
93.0
91.0
88.0
84.0
82.0
96.0
86.2 ± 10.5

2.0
11.0
8.0
8.0
8.0
8.0
11.0
8.0
8.0
8.0
7.5 ± 2.5

8.0
23.0
17.0
11.0
20.0
20.0
17.0
11.0
17.0
25.0
16.8 ± 6.2

12.0
12.0
12.0
10.0
12.0
12.0
12.0
11.0
12.0
12.0
11.4 ± 1.1

aASES, American Shoulder and Elbow Surgeons; NRS, numeric rating scale; SST, Simple Shoulder Test.
Retear represents any repair integrity that was rated type III to V according to the classification of Sugaya et al.33b

TABLE A4
Shoulder Range of Motion and NRS Scoresa
Forward Flexion, deg

External Rotation, degInternal Rotationb

Postoperative NRS Score

Patient No.

Preoperative

Postoperative

Preoperative

Postoperative

Preoperative

Postoperative

SurgeryWork

Exercise

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
Mean ± SD

90.0
160.0
145.0
120.0
120.0
110.0
90.0
110.0
170.0
140.0
130.0
120.0
160.0
140.0
140.0
140.0
160.0
60.0
130.0
140.0
120.0
150.0
140.0
90.0
130.0
100.0
150.0
110.0
140.0
110.0
127.2 ± 25.2

140.0
160.0
160.0
170.0
170.0
170.0
150.0
170.0
150.0
170.0
170.0
170.0
160.0
170.0
165.0
165.0
165.0
160.0
155.0
170.0
170.0
170.0
170.0
155.0
170.0
170.0
170.0
160.0
170.0
170.0
164.5 ± 7.9

30.0
60.0
60.0
30.0
30.0
40.0
30.0
40.0
50.0
40.0
15.0
40.0
40.0
40.0
40.0
40.0
60.0
–10.0
40.0
20.0
30.0
30.0
20.0
20.0
30.0
20.0
40.0
20.0
20.0
20.0
32.8 ± 14.8

40.0
45.0
20.0
60.0
45.0
45.0
50.0
70.0
50.0
45.0
65.0
70.0
60.0
55.0
45.0
50.0
55.0
50.0
35.0
50.0
55.0
60.0
65.0
30.0
60.0
60.0
60.0
60.0
60.0
60.0
52.5 ± 11.4

L1 (13)L1 (13)L1 (13)L3 (15)
L3 (15)
Buttock (19)
L3 (15)
L3 (15)L1 (13)L1 (13)
Buttock (19)
L3 (15)L1 (13)L1 (13)
Buttock (19)L1 (13)L1 (13)
Buttock (19)
Buttock (19)
Buttock (19)L1 (13)
L2 (14)L5 (18)
Buttock (19)
L5 (18)
Buttock (19)L1 (13)L1 (13)L5 (18)
Buttock (19)15.7 ± 2.7

L1 (13)L1 (13)
T12 (12)L1 (13)L1 (13)L3 (15)L1 (13)
T12 (12)
T10 (10)
L2 (14)L1 (13)L3 (15)L1 (13)T7 (7)
L1 (13)T8 (8)
L1 (13)
T12 (12)L1 (13)T9 (9)T9 (9)T9 (9)
L1 (13)L1 (13)
T12 (12)L1 (13)
T12 (12)L1 (13)L1 (13)L1 (13)12.1 ± 1.9

10.0
7.0
7.0
9.0
10.0
9.0
8.0
9.0
10.0
10.0
10.0
9.0
3.0
7.0
9.0
10.0
10.0
7.0
10.0
10.0
7.0
10.0
10.0
5.0
10.0
9.0
9.0
10.0
10.0
8.0
8.7 ± 1.7

9.0
7.0
9.0
10.0
7.0
5.0
7.0
7.0
5.0
10.0
5.0
10.0
3.0
5.0
5.0
9.0
10.0
7.0
7.0
10.0
5.0
10.0
10.0
9.0
10.0
9.0
9.0
8.0
10.0
10.0
7.9 ± 2.1

8.0
10.0
3.0
10.0
5.0
9.0
5.0
10.0
6.0
10.0
10.0
10.0
3.0
6.0
3.0
8.0
5.0
2.0
5.0
10.0
6.0
10.0
10.0
3.0
9.0
9.0
6.0
10.0
10.0
10.0
7.4 ± 2.8

a

NRS, numeric rating scale.
For internal rotation, we converted values into contiguously numbered groups: levels T1-T12 to 1-12, levels L1-L5 to 13-17, the sacrum to18, and the buttock to 19.
b