Thank you, Paul. Thanks John and Lou for a wonderful program, and thank God I'm not following you, John. I mean preceding you. Disclosures. So keys to rotator cuff repair that may help and improve your outcome. I've done a lot of these over the years, and clearly the main thing is to avoid tension. Tension is the enemy. It's really the main reason most cuffs fail. To do this, you have to be adaptable in your technique. You have to adjust it at the time of surgery because cuffs are not all the same. And most importantly, you have to appreciate the tissue. You have to understand the anatomy and how cuffs tear so that you can reverse the problem. And finally, be good surgeons. Minimize soft tissue trauma. Less portals, less bleeding, less pain, better outcome. What about anchors? Well, neither type, placement, number of rows should ever predetermine how a cuff should be repaired. Remember, anchors are an end to a means, not a means to an end. You have to adapt your technique to each tear. Having done a lot of cuffs, they rarely look like that picture on the left. Most often, there's an anterior and posterior component to each tear, not purely medial and lateral. And if you don't understand that, you won't see the high tension point. You can do triple loaded or triple row. It's not going to matter because you're still going to have a failure. So in order to avoid that, you really have to solve the anatomic puzzle that each cuff presents. And the goal is always a low tension repair, and so you have to have a clear picture in your mind about the insertional anatomy so you can identify the size and the pattern of each tear. The supraspinatus footprint is rectangular from the 1130 to the one o'clock position. It's 23 by 15 millimeters, and it inserts from the biceps to the top of the bare area. So that's a good arthroscopic landmark. The infraspinatus footprint is rectangular from the 1230 to the three o'clock position, 28 by 18 millimeters. And this is important because it frames the upper half of the barrier. So if you have a significant tissue loss, as you do on the right there, you can medialize right to the edge of the articular surface. Now why and how do cuffs tear? So this is the key. It's a combination of the amount of detachment laterally plus a progression pattern along the intervals. And the most common tear patterns are the crescent-shaped tear, as is shown in the bottom left, an L-shaped tear, which is shown in the bottom right, where the crescent-shaped tear then splits along the biceps interval, creating an L-shape. In the reverse L, the opposite is true. The split is between the supraspinatus and the infraspinatus, so the infraspinatus and the tear is minor, and the apex points posteriorly. In a large L-shaped tear, basically the supraspinatus slides medially. And this is always so much of a tough type tear to deal with because you've got to combine releases. If you're lucky, you can get to the edge of the articular surface. You have to adapt your tear in medializing anteriorly. You have plenty of tissue posteriorly, but when these cuffs fail, they fail right behind the biceps. It's the opposite for the reverse L tear. And here, the split is between the supraspinatus and the infraspinatus, or the infraspinatus and the tear is minor. And here, the high tension point is going to be posterior, but you can adapt that to some degree because you can medialize through the barrier area and take some tension off the repair. So what does that look like? So here's a reverse L tear and a right shoulder, and this one actually split through the bipennate infraspinatus. So the upper half of the infraspinatus is off, but the lower part is still there, so you can use that to actually re-tension. You can see the anterior medial to posterior lateral way that this cuff has to go before you can repair it to the bone, and if you don't do that, it'll fail posteriorly. And so here we are placing our anchors in, and you see how the anchor sutures actually don't run lateral to medial, they run anterior medial, so you have to actually follow the muscle belly. And if you do that, you can get a good repair. Finally, there's some things you just can't predict ahead of time. So tissue, quality, will it hold a stitch, will the bone hold an anchor? Mobility, it doesn't matter how big a tear is, if it moves, you can fix it, but you're not going to know that completely until you're in the OR. So you have to, with a combination of releases, medializing for soft tissue loss, being careful of a double row technique where you've already lost a lot of tissue laterally, you can get a good result. And what about capacity to heal? Well, that's obviously the next step, and it'll be the subject of a number of lectures over this week. So what about putting it all together? So if you look at this picture here, this is a 55-year-old guy that I did about a few months ago. So it's a revision. When I looked at this, I thought SCR for sure. So we got in there, and when you see that first picture on the bottom right, there's not much to work with. But if you really think about it and work on the tissue, actually what this turned out to be is a massive L-shaped tear. Now we didn't have great tissue anteriorly to work with, so in a trick that I've been doing a little bit more of, I tinned the biceps in situ, basically creating a mini SCR. And then I tied a remnant of his cuff to the biceps, and then medialized it anteriorly, and then with four anchors, got a good solid repair. And this guy's done quite well. So the point is that you have to solve that puzzle. You have to figure out the high tension points so that you can adapt your technique, repair the intervals to decrease tension on your repair, and then finally anchor the footprint, whichever way you like to do it. The key is to adapt the technique to the tear, not the tear to the technique. Thank you.

rotator cuff repair

tension

adaptability

anatomy

tear patterns