Journal of Shoulder and Elbow Surgery

Significance of the acromiohumeral distance on stress radiography for predicting healing and function after arthroscopic repair of massive rotator cuff tears

Published:November 30, 2020DOI:


      A decreased acromiohumeral distance (AHD) is commonly detected in patients with massive rotator cuff tears (mRCTs). Most studies evaluating fixed humeral elevation have used preoperative or postoperative standardized radiography and not stress radiography. This study aimed to evaluate the predictive role of the preoperative AHD measured using stress radiography (AHD_stress) in rotator cuff healing and function after arthroscopic repair of mRCTs.


      The data of 113 patients who underwent arthroscopic repair of mRCTs were analyzed. Postoperative cuff integrity was evaluated using magnetic resonance imaging at 1 year, and shoulder function was evaluated at a mean of 34.9 ± 17.8 months (range, 24-92 months) postoperatively. Forty-seven patients showed healing failure. Propensity score matching (1-1) was performed between the healed group and healing failure group. Thirty-eight patients in each group were matched in the final analysis. The AHD and AHD_stress were defined as the shortest distances from the inferior acromion to the superior humerus on standard anteroposterior radiography and stress radiography (5.4-kg weight applied inferiorly in a neutral position), respectively. The AHD difference (AHD_diff) was defined as the difference between the AHD and AHD_stress values. Receiver operating characteristic curve analysis was performed to determine cutoff values for significant variables.


      No difference in the mean preoperative AHD was found between the healed group (7.5 ± 2.0 mm) and healing failure group (6.9 ± 2.2 mm, P = .234). The AHD_diff value was significantly higher in the healed group (4.4 ± 2.1 mm) than in the healing failure group (3.0 ± 2.0 mm, P = .002; cutoff, 3.2 mm). Patients with an AHD_diff value ≥ 3.2 mm showed a lower healing failure rate (28.9% vs. 71.1%, P < .001) and higher functional scores than patients with an AHD_diff value < 3.2 mm. The AHD_diff value was higher in patients with an American Shoulder and Elbow Surgeons (ASES) score ≥ 80 (4.9 ± 1.9 mm) than in those with an ASES score < 80 (3.1 ± 2.1 mm, P = .024). Among patients with healing failure, only the postoperative AHD showed a significant difference between those with an ASES score ≥ 80 (7.0 ± 2.5 mm) and those with an ASES score < 80 (4.8 ± 2.1 mm, P = .009; cutoff, 4.8 mm).


      A reducible AHD, which increased by ≥ 3.2 mm under stress radiography, can be a favorable predictor of rotator cuff healing and function after arthroscopic repair of mRCTs. Our findings suggest that this new and simple radiologic parameter should be considered preoperatively and would be helpful to determine appropriate treatment strategies.

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        • Balyk R.
        • Luciak-Corea C.
        • Otto D.
        • Baysal D.
        • Beaupre L.
        Do outcomes differ after rotator cuff repair for patients receiving workers' compensation?.
        Clin Orthop Relat Res. 2008; 466: 3025-3033
        • Bedi A.
        • Dines J.
        • Warren R.F.
        • Dines D.M.
        Massive tears of the rotator cuff.
        J Bone Joint Surg Am. 2010; 92: 1894-1908
        • Bellumore Y.
        • Mansat M.
        • Assoun J.
        Résultats de la chirurgie réparatrice de la coiffe des rotateurs. Corrélation radio-clinique.
        Rev Chir Orthop Reparatrice Appar Mot. 1994; 80 ([in French]): 582-594
        • Bernhardt G.A.
        • Glehr M.
        • Zacherl M.
        • Wurnig C.
        • Gruber G.
        Observer variability in the assessment of the acromiohumeral interval using anteroposterior shoulder radiographs.
        Eur J Orthop Surg Traumatol. 2013; 23: 185-190
        • Burkhart S.S.
        • Barth J.R.
        • Richards D.P.
        • Zlatkin M.B.
        • Larsen M.
        Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration.
        Arthroscopy. 2007; 23: 347-354
        • Caliendo M.
        • Kopeinig S.
        Some practical guidance for the implementation of propensity score matching.
        J Econ Surv. 2008; 22: 31-72
        • Chung S.W.
        • Huong C.B.
        • Kim S.H.
        • Oh J.H.
        Shoulder stiffness after rotator cuff repair: risk factors and influence on outcome.
        Arthroscopy. 2013; 29: 290-300
        • Chung S.W.
        • Kim J.Y.
        • Kim M.H.
        • Kim S.H.
        • Oh J.H.
        Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function.
        Am J Sports Med. 2013; 41: 1674-1683
        • Chung S.W.
        • Oh J.H.
        • Gong H.S.
        • Kim J.Y.
        • Kim S.H.
        Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors.
        Am J Sports Med. 2011; 39: 2099-2107
        • Collin P.
        • Betz M.
        • Herve A.
        • Walch G.
        • Mansat P.
        • Favard L.
        • et al.
        Clinical and structural outcome 20 years after repair of massive rotator cuff tears.
        J Shoulder Elbow Surg. 2020; 29: 521-526
        • Comtet J.J.
        • Auffray Y.
        Physiologie des muscles élévateurs de l'épaule [Physiology of the elevator muscles of the shoulder].
        Rev Chir Orthop Reparatrice Appar Mot. 1970; 56 ([in French]): 105-117
        • Ellman H.
        • Hanker G.
        • Bayer M.
        Repair of the rotator cuff. End-result study of factors influencing reconstruction.
        J Bone Joint Surg Am. 1986; 68: 1136-1144
        • Galatz L.M.
        • Ball C.M.
        • Teefey S.A.
        • Middleton W.D.
        • Yamaguchi K.
        The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears.
        J Bone Joint Surg Am. 2004; 86: 219-224
        • Gaskill T.R.
        • Braun S.
        • Millett P.J.
        Multimedia article. The rotator interval: pathology and management.
        Arthroscopy. 2011; 27: 556-567
        • Gerber C.
        • Fuchs B.
        • Hodler J.
        The results of repair of massive tears of the rotator cuff.
        J Bone Joint Surg Am. 2000; 82: 505-515
        • Golding F.
        The shoulder—the forgotten joint. The Makenzie Davidson memorial lecture.
        Br J Radiol. 1962; 35: 149-158
        • Goutallier D.
        • Le Guilloux P.
        • Postel J.-M.
        • Radier C.
        • Bernageau J.
        • Zilber S.
        Acromio humeral distance less than six millimeter: its meaning in full-thickness rotator cuff tear.
        Orthop Traumatol Surg Res. 2011; 97: 246-251
        • Goutallier D.
        • Postel J.M.
        • Bernageau J.
        • Lavau L.
        • Voisin M.C.
        Fatty muscle degeneration in cuff ruptures: pre-and postoperative evaluation by CT scan.
        Clin Orthop Relat Res. 1994; : 78-83
        • Greenspoon J.A.
        • Petri M.
        • Warth R.J.
        • Millett P.J.
        Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes.
        J Shoulder Elbow Surg. 2015; 24: 1493-1505
        • Gruber G.
        • Bernhardt G.A.
        • Clar H.
        • Zacherl M.
        • Glehr M.
        • Wurnig C.
        Measurement of the acromiohumeral interval on standardized anteroposterior radiographs: a prospective study of observer variability.
        J Shoulder Elbow Surg. 2010; 19: 10-13
        • Hamada K.
        • Fukuda H.
        • Mikasa M.
        • Kobayashi Y.
        Roentgenographic findings in massive rotator cuff tears. A long-term observation.
        Clin Orthop Relat Res. 1990; : 92-96
        • Jeong H.Y.
        • Kim H.J.
        • Jeon Y.S.
        • Rhee Y.G.
        Factors predictive of healing in large rotator cuff tears: is it possible to predict retear preoperatively?.
        Am J Sports Med. 2018; 46: 1693-1700
        • Jost B.
        • Pfirrmann C.W.
        • Gerber C.
        • Switzerland Z.
        Clinical outcome after structural failure of rotator cuff repairs.
        J Bone Joint Surg Am. 2000; 82: 304-314
        • Kim Y.K.
        • Jung K.H.
        • Kim J.W.
        • Kim U.S.
        • Hwang D.H.
        Factors affecting rotator cuff integrity after arthroscopic repair for medium-sized or larger cuff tears: a retrospective cohort study.
        J Shoulder Elbow Surg. 2018; 27: 1012-1020
        • Kovari E.
        • Koteczki A.
        • Kovacs B.
        • Magyar P.
        • Antal I.
        • Skaliczki G.
        Midterm outcome after rotator cuff reconstruction.
        Orv Hetil. 2012; 153: 655-661
        • Kwon J.
        • Kim S.H.
        • Lee Y.H.
        • Kim T.I.
        • Oh J.H.
        The Rotator Cuff Healing Index: a new scoring system to predict rotator cuff healing after surgical repair.
        Am J Sports Med. 2019; 47: 173-180
        • Lapner P.C.
        • Su Y.
        • Simon D.
        • El-Fatori S.
        • Lopez-Vidriero E.
        Does the upward migration index predict function and quality of life in arthroscopic rotator cuff repair?.
        Clin Orthop Relat Res. 2010; 468: 3063-3069
        • Lehtinen J.T.
        • Belt E.A.
        • Lyback C.O.
        • Kauppi M.J.
        • Kaarela K.
        • Kautiainen H.J.
        • et al.
        Subacromial space in the rheumatoid shoulder: a radiographic 15-year follow-up study of 148 shoulders.
        J Shoulder Elbow Surg. 2000; 9: 183-187
        • Leong H.T.
        • Tsui S.
        • Ying M.
        • Leung V.Y.
        • Fu S.N.
        Ultrasound measurements on acromio-humeral distance and supraspinatus tendon thickness: test–retest reliability and correlations with shoulder rotational strengths.
        J Sci Med Sport. 2012; 15: 284-291
        • McElvany M.D.
        • McGoldrick E.
        • Gee A.O.
        • Neradilek M.B.
        • Matsen III, F.A.
        Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome.
        Am J Sports Med. 2015; 43: 491-500
        • Metzlaff S.
        • Rosslenbroich S.
        • Forkel P.H.
        • Schliemann B.
        • Arshad H.
        • Raschke M.
        • et al.
        Surgical treatment of acute acromioclavicular joint dislocations: hook plate versus minimally invasive reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1972-1978
        • Michener L.A.
        • McClure P.W.
        • Sennett B.J.
        American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness.
        J Shoulder Elbow Surg. 2002; 11: 587-594
        • Misamore G.W.
        • Ziegler D.W.
        • Rushton II, J.L.
        Repair of the rotator cuff. A comparison of results in two populations of patients.
        J Bone Joint Surg Am. 1995; 77: 1335-1339
        • Neri B.R.
        • Chan K.W.
        • Kwon Y.W.
        Management of massive and irreparable rotator cuff tears.
        J Shoulder Elbow Surg. 2009; 18: 808-818
        • Niglis L.
        • Collin P.
        • Dosch J.C.
        • Meyer N.
        • Kempf J.F.
        Intra- and inter-observer agreement in MRI assessment of rotator cuff healing using the Sugaya classification 10years after surgery.
        Orthop Traumatol Surg Res. 2017; 103: 835-839
        • Norwood L.A.
        • Barrack R.
        • Jacobson K.E.
        Clinical presentation of complete tears of the rotator cuff.
        J Bone Joint Surg Am. 1989; 71: 499-505
        • Nové-Josserand L.
        • Edwards T.B.
        • O'Connor D.P.
        • Walch G.
        The acromiohumeral and coracohumeral intervals are abnormal in rotator cuff tears with muscular fatty degeneration.
        Clin Orthop Relat Res. 2005; : 90-96
        • Nové-Josserand L.
        • Lévigne C.
        • Noël E.
        • Walch G.
        L'espace sous-acromial. Etude des facteurs influençant sa hauteur [The acromio-humeral interval. A study of the factors influencing its height].
        Rev Chir Orthop Reparatrice Appar Mot. 1996; 82 ([in French]): 379-385
        • Oh J.H.
        • Kim J.Y.
        • Lee H.K.
        • Choi J.A.
        Classification and clinical significance of acromial spur in rotator cuff tear: heel-type spur and rotator cuff tear.
        Clin Orthop Relat Res. 2010; 468: 1542-1550
        • Oh J.H.
        • Kim S.H.
        • Ji H.M.
        • Jo K.H.
        • Bin S.W.
        • Gong H.S.
        Prognostic factors affecting anatomic outcome of rotator cuff repair and correlation with functional outcome.
        Arthroscopy. 2009; 25: 30-39
        • Oh J.H.
        • Kim S.H.
        • Lee H.K.
        • Jo K.H.
        • Bin S.W.
        • Gong H.S.
        Moderate preoperative shoulder stiffness does not alter the clinical outcome of rotator cuff repair with arthroscopic release and manipulation.
        Arthroscopy. 2008; 24: 983-991
        • Oh J.H.
        • Park M.S.
        • Rhee S.M.
        Treatment strategy for irreparable rotator cuff tears.
        Clin Orthop Surg. 2018; 10: 119-134
        • Park J.H.
        • Yang S.H.
        • Rhee S.M.
        • Oh J.H.
        The effect of concomitant coracohumeral ligament release in arthroscopic rotator cuff repair to prevent postoperative stiffness: a retrospective comparative study.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 3881-3889
        • Park J.Y.
        • Kim Y.
        • Oh K.S.
        • Lim H.K.
        • Kim J.Y.
        Stress radiography for clinical evaluation of anterior shoulder instability.
        J Shoulder Elbow Surg. 2016; 25: e339-e347
        • Park J.Y.
        • Pandher D.S.
        • Moon G.H.
        • Yoo M.J.
        • Lee S.T.
        Comparison of surgical outcome in impingement syndrome with and without stiff shoulder.
        Indian J Orthop. 2008; 42: 182-187
        • Park K.J.
        • Eun H.J.
        • Kim Y.M.
        • Yoo J.I.
        • Lim C.O.
        A novel method to measure superior migration of the humeral head: step-off of the C-line.
        Clin Shoulder Elbow. 2016; 19: 125-129
        • Rockwood Jr., C.A.
        • Matsen III, F.A.
        • Wirth M.A.
        • Lippitt S.B.
        • Fehringer E.V.
        • Sperling J.W.
        Rockwood and Matsen's the shoulder.
        Elsevier, Philadelphia, PA2015
        • Saccomanno M.F.
        • Sircana G.
        • Cazzato G.
        • Donati F.
        • Randelli P.
        • Milano G.
        Prognostic factors influencing the outcome of rotator cuff repair: a systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3809-3819
        • Saupe N.
        • Pfirrmann C.W.
        • Schmid M.R.
        • Jost B.
        • Werner C.M.
        • Zanetti M.
        Association between rotator cuff abnormalities and reduced acromiohumeral distance.
        AJR Am J Roentgenol. 2006; 187: 376-382
        • Sugaya H.
        • Maeda K.
        • Matsuki K.
        • Moriishi J.
        Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study.
        J Bone Joint Surg Am. 2007; 89: 953-960
        • van de Sande M.A.
        • Rozing P.M.
        Proximal migration can be measured accurately on standardized anteroposterior shoulder radiographs.
        Clin Orthop Relat Res. 2006; 443: 260-265
        • Walch G.
        • Marechal E.
        • Maupas J.
        • Liotard J.P.
        Traitement chirurgical des ruptures de la coiffe des rotateurs. Facteurs de pronostic [Surgical treatment of rotator cuff rupture. Prognostic factors].
        Rev Chir Orthop Reparatrice Appar Mot. 1992; 78 ([in French]): 379-388
        • Walsh P.
        • Shanholtzer L.
        • Loewen M.
        • Trinh K.
        • McEnulty B.
        • Rothenberg S.J.
        A matched case control study with propensity score balancing examining the protective effect of paracetamol against parentally reported apnoea in infants.
        Resuscitation. 2012; 83: 440-446
        • Warner J.J.
        Management of massive irreparable rotator cuff tears: the role of tendon transfer.
        Instr Course Lect. 2001; 50: 63-71
        • Warner J.P.
        • Krushell R.J.
        • Masquelet A.
        • Gerber C.
        Anatomy and relationships of the suprascapular nerve: anatomical constraints to mobilization of the supraspinatus and infraspinatus muscles in the management of massive rotator-cuff tears.
        J Bone Joint Surg Am. 1992; 74: 36-45
        • Weiner D.S.
        • Macnab I.
        Superior migration of the humeral head: a radiological aid in the diagnosis of tears of the rotator cuff.
        J Bone Joint Surg Br. 1970; 52: 524-527
        • Werner C.M.
        • Conrad S.J.
        • Meyer D.C.
        • Keller A.
        • Hodler J.
        • Gerber C.
        Intermethod agreement and interobserver correlation of radiologic acromiohumeral distance measurements.
        J Shoulder Elbow Surg. 2008; 17: 237-240
        • Wright R.W.
        • Baumgarten K.M.
        Shoulder outcomes measures.
        J Am Acad Orthop Surg. 2010; 18: 436-444
        • Yoo J.C.
        • Ahn J.H.
        • Koh K.H.
        • Lim K.S.
        Rotator cuff integrity after arthroscopic repair for large tears with less-than-optimal footprint coverage.
        Arthroscopy. 2009; 25: 1093-1100
        • Zumstein M.A.
        • Jost B.
        • Hempel J.
        • Hodler J.
        • Gerber C.
        The clinical and structural long-term results of open repair of massive tears of the rotator cuff.
        J Bone Joint Surg Am. 2008; 90: 2423-2431