This is Rob Hartzler with TSAOG Orthopedics in San Antonio on pre and intraoperative identification of rotator cuff tear shape. I do have relevant financial disclosures which are available on the ANA and AAOS websites. In illustrative case, this is a 55-year-old gentleman who had prior rotator cuff surgery with a very retracted rotator cuff tear. In this repair, we can see the prior suture that had been placed actually in the articular cartilage and it appears that there is an absence of the supraspinatus. However, if we assess the tear margin, we can see that with posterior to anterior reduction, this is a very repairable rotator cuff tear which actually has enough tendon to have a linked double row repair with complete footprint coverage. Some of the principles that we have for approaching these difficult rotator cuff tears, particularly very retracted ones with reasonable muscle, are that most of these are operatively repairable, particularly subscapularis tears that look intimidating. Repairability is difficult to predict preoperatively and we can try liberally for repair for the right patients, particularly those that are young and active and who are poor candidates for an arthroplasty. Good visualization is imperative when attempting to repair these and advanced techniques for mobilization and reduction are often needed. In addition to knowing the operative tricks for repairing these challenging rotator cuff tears, we need to remember that patience is necessary, tenacity, organization in our intraoperative tactic, and a great team. During the early SCR era, we investigated the rate and risk factors for operative irreparability. We documented a high rate of fully repairable massive rotator cuff tears and a low predictive value for preoperative imaging. The main message of this paper is that the majority of bad-looking rotator cuff tears were fully repairable. One of our foundational principles in repairing rotator cuffs is to maximize visualization in order to achieve technically sound repair. In order to maximize visualization, I prefer the lateral position and certain ways of managing fluid, which we'll go over. For me, the chief reason for preferring lateral position is that the anesthesiologist will typically be much more comfortable in performing hypotensive anesthesia during the case. Limiting fluid extravasation from portals is one of the key ways to maintain pressure in the shoulder and therefore enhancing the visual field. While there's some role for adjuvant medications in managing the fluid during shoulder arthroscopy, our primary way to improve the visual field is to run the pump high enough to be able to see well, which for us is typically 50 to 60 millimeters of mercury. In my practice, I found that utilizing these techniques has allowed me to achieve very good outcomes in large and massive rotator cuff tears equivalent to those that I've achieved in small and medium-sized tears. The overriding principle for this subject is that the rotator cuff tear pattern is the repair pattern, and we establish that by intraoperative assessment of the rotator cuff tear aided by a careful scrutiny preoperatively of the MRI images. In the following cases, we'll highlight testing of the mobility of the entire rotator cuff tear margin after mobilization, debridement, and preparation of the working space have been achieved. I would encourage everyone to read this classic article carefully, The Geometric Classification of Rotator Cuff Tears, which was established by Dr. Burckhardt and popularized by him, and there are a few principles that are very helpful here for understanding how rotator cuff tears appear on MRI and in the operating room. Type 1 crescent rotator cuff tears are the ones that we're most familiar with and are characterized by width that is greater than length and equal mobility of the tear margin rolling in a medial to lateral direction. Again, we see on preoperative MRI the non-retracted appearance of these tears with width in the AP direction greater than length. In this illustration, we see testing of the margin of the rotator cuff tear with equal mobility along the entire margin from medial to lateral. This is an example of a right shoulder with a full thickness retracted rotator cuff tear involving the supraspinatus in a crescent-shaped pattern. This is another example of a classic crescent-shaped supraspinatus tear with equal mobility along the tear margin, and this was repaired using a linked double row repair construct. Type II or longitudinal rotator cuff tears include subtypes L-shaped, reverse L, and U-shaped tears. Longitudinal tears are characterized by the length greater than the width, or in other words the retraction on the coronal view greater than the width of the tear on the sagittal view. These are illustrations showing L and reverse L-type tears in a right shoulder. L-shaped tears, as you see in the top two images, have a corner which requires posterior to anterior reduction, and reverse L tears have a corner that require anterior to posterior reduction. An illustration and intraoperative photograph of a longitudinal L-type tear in a right shoulder, and again we see that we have a corner that requires posterior to anterior reduction. Here we see a classic MRI image of a longitudinal L-shaped tear with good muscle quality. The width of the tear seen in the parasagittal image is smaller than the length of the tear seen in the coronal image. In this video we see examination of the tear margin, and because there was a very thick tendon here with tendinosis, we're actually using the arthroscopic suture passer in order to assess the tear mobility. When we assess this from a medial to lateral direction, we see poor mobility, but once we perform a posterior to anterior reduction maneuver of the corner of this, we can see that this reduces very well and is repaired with a linked double row repair. Again, we see an illustration and an intraoperative photograph for a right shoulder of a reverse L, and we see the corner there that requires anterior to posterior reduction. Here we see a right shoulder with a smaller size reverse L tear, and we have a clear corner of the tear that requires anterior to posterior reduction. Another example of a right shoulder with a reverse L tear, and again a very clear example of the corner, and we have to find this corner and determine that it requires reduction from an anterior to a posterior position. U-shaped tears again have a larger dimension medial to lateral than anterior to posterior and they have equal mobility of the anterior and the posterior leaf of the tear. Here we see a classic intraoperative view of a U-tear with a smaller A to P length and a larger medial to lateral length. This tear has equal mobility of the anterior and posterior leaf and requires margin convergence for repair. In this part of the video we see free margin convergent sutures being placed in each leaf of the tear which will bring those together closing down the U. In this part of the video, we see the repair steps. There are free margin sutures, which are tied and then cut. And then we see tying down of a margin to bone part of the construct, which has two separate sutures. And then we see mattress sutures in the posterior part of the cuff. And in the final construct, we see the black arrow showing the margin to bone suturing, free margin sutures in blue, and the posterior medial mattresses in red. This is another example of a U-shaped rotator cuff tear with approximately equal anterior-to-posterior mobility of each of the leaves of the rotator cuff tear. This tear was repaired with a running tape suture, which we call the shoestring-to-bone type of construct. And this tape is passed anti-grade, back and forth, and it looks like a shoelace at the end of the suturing, which brings the margin together, and then that can be fixed to bone. This is the final fixation using a knotless anchor of that tape suture, and you can see the converged margin of the tear being fixed over onto the bone bed. Massive, contracted rotator cuff tears are characterized by a large dimension both in length and width and their immobility, requiring often both anterior and posterior slides for repair. Again, these massive, contracted tears have a large length and width on preoperative MRI and the coronal and sagittal images. This case example shows a massive, contracted rotator cuff tear in a patient that is very healthy and active in her middle age years and would be a poor candidate for an arthroplasty. X-rays demonstrate preserved joint space and some chronic changes at the acromion and the greater tuberosity. On MRI, we do see some fatty changes of the supraspinatus and infraspinatus, but overall very reasonable muscle quality for attempting repair in this patient with a very intimidating retracted tear. In this video we see many of our tricks for getting these massive contracted tears repaired back over to the bone bed. We'll see a traction suture and then an anterior interval slide in continuity performed. This involves releasing the interval tissue and the capsular tissue from the base of the coracoid. Next we'll see traction sutures placed in the supraspinatus and infraspinatus and a posterior interval slide which involves incising the raffae between supra and infra toward the scapular spine. We can safely do this towards the fat pad around the suprascapular nerve. After the releases have been done we can see that the mobility of this tear has been greatly improved and there's enough excursion to get this over to the bone bed. Because of this short tendon this was repaired using a load sharing ripstop type of construct. Advanced techniques are often necessary for larger rotator cuff tears with retraction and some of these we've seen already and we'll see it in the following slides. There are some exceptions to the geometric classification but the principles of the classification system remain, the most important of which is assessing the mobility of the tear intraoperatively both before and after performing releases. This was a very young patient in his 40s with an acute on chronic history of rotator cuff tear. In this MRI we see large dimensions for both the AP and medial to lateral width of this tear and this ended up to have an L type of pattern needing posterior to anterior mobilization of the corner. In this tear we were very careful to perform a thorough debridement and removing all of the tissue which is bursal or scar tissue from the rotator cuff to the internal deltoid fascia and after assessing the mobility of this tear it did not require interval slides but only posterior to anterior reduction of the corner and once we've established the reduction maneuver then we can see that we actually have enough tissue for again a linked double row repair for this tear which appeared almost too retracted for any type of repair. The surgeon should not just assume that small rotator cuff tears are all crescent-shaped in their configuration. In this case, after a debridement of this calcific lesion and investigating the mobility of the margin, this was actually a small U-type tear with equal mobility of the anterior and posterior leaves back over to the bone bed, and this was repaired with a margin-to-bone type of configuration. Here we see the final repair, which has one suture anchor in the greater tuberosity, and each limb of the two sutures passed through the anterior and then posterior margin, which brings the margin together once the knots are tied and onto the bone bed. Not all massive rotator cuff tears are contracted, nor do they all require interval slides for repair. In this massive tear, we can see that this involved the entirety of the supraspinatus and intraspinatus tendons. A subscapularis repair has already been done. And once we assess the mobility of the tear margin, we can see that there is equal mobility from medial to lateral along the entire length of this, making this a massive crescent pattern of tear, which was amenable to a link double row repair. One of the tricks for large anterosuperior rotator cuff tears or massive tears is that a retracted subscapularis, once it's reduced and fixed, will bring the margin of the supraspinatus closer to the greater tuberosity as seen in this diagram. This was a case of a large, retracted, anterosuperior rotator cuff tear. At this point in the case, we're working on the subscapularis, and we see the comma tissue connection between the upper subscapularis and the retracted supraspinatus. We're going to preserve that and open the rotator interval, and then perform subscapularis releases. We release the subscap anteriorly and superiorly, adhesions between this, the conjoined tendon and the coracoid. We perform releases posterior to the subscap between the subscapularis tendon and the neck of the glenoid, and we perform a lateral release of any adhesions between the retracted subscap and the internal deltoid fascia, and we see that a large portion of the lesser tuberosity is bare bone. Here we see the repaired subscapularis, which has undergone a linked double row repair. We see this from both the intraarticular view with a very anatomic reduction, and from the bursal side. This is a 70 degree view from a lateral portal, and once that retracted subscap is fixed, then it really reduces the anterior margin of the supraspinatus via that capsular tissue connection, the comma tissue, and this becomes a classic crescent-shaped supraspinatus tear, which is very amenable to a linked double row repair. In conclusion, rotator cuff repair is greatly enhanced by arthroscopic visualization and our ability to assess the retraction of the rotator cuff. It's very important to investigate the tear margin to ensure that the tear is going to be repaired anatomically, and we shouldn't assume that all tears are crescent, even smaller size tears. Advanced mobilization techniques and repair for retracted tears and those with poor tissue quality are very important, and don't forget to ensure that you have excellent visualization using the techniques that we've described, and to have a lot of patience and tenacity in trying to get repairs for the right patients with these challenging tears, and you will have a lot of happy patients. Thank you very much for your time and attention today. Thank you.

rotator cuff tears

surgical techniques

tear classification

Rob Hartzler

arthroscopic visualization

preoperative MRI

repair techniques