This is Joe Toro from Ocean County Sports Medicine and Rutgers Medical School. And I'm going to talk to you about large and retracted rotator cuff tears and when and how to do soft tissue releases. I have disclosures and a complete list of my disclosures can be found at the AAOS website. So why do some rotator cuff tears need a release? Well, it's because the capsule on the cuff are attached at their insertion and they stay attached when the tendon tears. The capsule scars down and contracts and that tethers the cuff and that's why some rotator cuff tears need a release. Now do all large rotator cuff tears need a release? Well, the answer to that is no, especially if they are relatively acute. So here's a case of a left shoulder, the patient's lateral tiny upper subscap tear, a very degenerative superior labrum and obviously a partially torn biceps. But the big problem is this large rotator cuff tear and it's all of the supraspinatus as you can see. And as we rotate back, there's some troubling tendon that's still left on the greater tuberosity. We're going to talk about what that means in more detail as we go along. And here's the upper teres minor and then the face of the infraspinatus. So we're going to come back to this again and again, but debridement of bad tendon and bursal tissue is critical and we always start with that. But you can see that this tear, which actually was fairly acute, is quite mobile and I can pull it down to the greater tuberosity without any significant tension. So this is a tear that really doesn't need a release. Once again, we're going to be coming back to this over and over, but debridement of that posterior bursa is very important to be able to see the whole tear from the bursal side, which is where you're going to repair it. And you can see the infraspinatus and the supraspinatus there. And we'll put our grasper on it again and you can see this reduces very nicely without any soft tissue releasing. It's a crescent shaped tear because when I pull on it, the whole cuff reduces down and there's no side to side component. And I'm going to repair this with two triple loaded anchors. It's a single row repair. We'll discuss the role of single or double repair as we go forward in these talks. So in this talk, we're going to be pretty much confining our discussion to posterior superior tears. In other words, the supraspinatus and the infraspinatus. And the key thing to understanding these larger tears and especially the infraspinatus component is that it's retroversal. The bursa is anterolateral. As you can see from the picture in the upper right hand corner of this slide, the anterolateral corner of the acromion is the center of the bursa. So that means that the infraspinatus is retroversal. So here's an initial view of a large rotator cuff tear. And you can see there's a lot of bursal tissue there. So we're intra-articular. We can see the infraspinatus right there in the upper border of the terrace with that troubling tendon on the tuberosity. But once we go on the bursa, the posterior wall of the bursa is in our way. And that posterior wall has to come out in order for us to be able to repair this tendon because we're putting the sutures in and doing our visualization from the bursal side. So any bursal tissue that obscures our view needs to come out. And it's always the posterior part of the bursa for the most part. Now, the first thing you're going to do is assess cuff quality and mobility. And so, here is another tear that is really kind of large and in poor shape. You can see it is pretty friable, and you can see it's really retracted all the way to the glenoid rim, and has very poor mobility. So, let's talk about soft tissue releases for a tear such as this. And as we've already said, the capsule and the cuff are attached at their insertion and stay attached when the tendon tears. So, that means we have to detach this contracted capsule from the cuff. And that's superior capsule and rotator interval for the supraspinatus. That's anterior capsule, sometimes parts of the rotator interval for the subscap. And the posterior superior capsule for the infraspinatus. There can be extra articular adhesions, too, especially in revision cases. That's between the coracoid and the subscap for subscap tears, a bursal tissue for the supraspinatus, retrobursal tissues we've spoken about for the infraspinatus, and adhesions to the scapular spine between the supraspinatus and the infraspinatus. And that's really where we get into double interval releases that we will discuss. So, as you can see in these pictures, when we do a superior capsular release, that releases the supraspinatus from its capsular attachment on the top of the glenoid and lets you get the tendon down to the tuberosity under less tension. What about for these bigger tears? This is a large crescent-shaped tear. And what I'm trying to illustrate in this picture is how it's attached anterior to the rotator interval and the coraco-humeral ligament. And so if you try to repair this, because of that anterior tether, it's going to tension overload as you move towards the front of the supraspinatus, and that repair will fail postoperatively. Same way with this larger L-shaped tear, it's tethered, again, to the rotator interval and the coraco-humeral ligament. And if you try to repair this side to side, as you would for an L-shaped tear, it's going to tension overload side to side, and that repair will fail. So that's why we do an anterior interval release schematically. Here you see I'm coming in with a basket punch, although we now use an RF device. But that basket punch is separating the supraspinatus anterior border from the coraco-humeral ligament and the rotator interval. And when you do that, as you can see in this illustration, you can reduce the supraspinatus back to the grid of tuberosity and do a low-tension repair. Same thing for that L-shaped tear. Once you release it, you're going to do your side to side repair and your end-to-bone repair, but it's going to be under much lower tension. What about the double interval release? Well, the supraspinatus and the infraspinatus can become scarred down around the spine of the scapula. And so the posterior interval release, part of the double release, is to get that scar tissue out from around the spine of the scapula and, in effect, separate the infraspinatus from the supraspinatus from the scapular spine. And that can give you more tendon excursion for both of the tendons. This is usually a last resort release for me, as the supraspinatus piece tends to be quite small. And sometimes you don't get as much excursion out of this as you would hope. But it's worth trying. It just doesn't always work. So for these posterior superior tears, as we're discussing, should we do single row repair on these? Should we do double row repair? Well, you do the most anatomically correct repair possible. And as you saw in our very mobile tendon, even then, sometimes single row is all the tissue you have. Here's the case that we've been looking at all along of the large contracted tear. And you can see that infraspinatus is only going to make it to the edge of the greater tuberosity posteriorly. The center part of this L-shaped tear doesn't belong anywhere except at the apex of a side to side repair. So you can see that doesn't come anywhere near the tuberosity. But when we pull on our released supraspinatus tendon, that does reduce to the greater tuberosity. But again, it's really not coming all the way over. And in my experience, most of these rotator cuff tendons that need release wind up being repaired single row as opposed to double row, although there are exceptions. And double row is desirable if there's enough tissue. So here is that repair completed, by the way. So that's the infraspinatus portion of that repair. And here's the supraspinatus portion of the repair. And the side to side sutures right there in the center of the picture. So that's a released L-shaped rotator cuff tear. So here's the last case for discussion today. This is obviously a recurrent rotator cuff tear. And this is a left shoulder, as you can see. Lots of sutures in the greater tuberosity. And that's an interesting picture of an attempted double row repair that the sutures and the anchors stayed there just fine, but the tendon didn't make it. So we're going to try to reduce this tendon. And it's pretty stiff. So we're going to do an interval release. You can see that I have a traction stitch in the tendon. And I do that every time. And then using a small percutaneous portal just anterior to my lateral portal where the traction stitch is, I come in with my radio frequency device. And I work from lateral to medial. And you can see a very stout coraco-humeral ligament there incorporated into the rotator interval. And we keep working on this until I can see a chromate above and that I've got the tendon clearly released. And now we're going to do our superior capsular release, and I'm going to come along the superior border of the glenoid and release the tendon off the superior glenoid. And you have to make sure that you're pointing that RF device away from the tendon and onto the bone so that you're not cooking the tendon. And you'll know you've gotten all the way because you've hit the scapular spine. Now in this case, I've taken away a little bit of articular cartilage, about 5 millimeters. So I'm trying to medialize this repair in order to maximize the amount of footprint I have available. Again, my broken record is talking about making sure you get all of the bursal tissue out of there so you can see the entire extent of the tear from infraspinatus to supraspinatus. We'll do a trial reduction. And sometimes I find it helpful to just go ahead and repair the infraspinatus first. And once I get the infraspinatus down, I can determine what I'm going to do with the supraspinatus. This is a triple loaded anchor with a ribbon. I'm using the ribbon type sutures now. It's good common sense that says that the ribbons will distribute force maybe a little bit better across the tendon than a plain suture. And the knots do tend to sit down nice and smooth. So there's our infraspinatus repair. And now I have my traction stitch on the supraspinatus. And we'll see, should this be repaired like an L-shaped tear or is it crescent shaped? And you can see as I pull this down, it's really crescent shaped. And if I tried to repair that side to side, I'd probably just wind up with a big dog ear. Now one technique I like to use for this is to get a ripstop stitch in the tendon in order to reinforce the sutures I'm going to put in. And in this case, I'm going to utilize the two anterior anchors that I put in and take one stitch from each anchor. And I'm going to put that through the tuberosity and tie them together as you're going to see. You can also do a ripstop independent stitch and bring that down to a lateral knotless anchor and that works very well too. But in this case, since I'm doing a single row repair, I've got one white limb from each of those two anchors. I'm going to tie them together extra corporeally and pull that down to the tendon. That's going to be my ripstop. I'm going to cinch that a little bit, but I'm not going to tie it obviously because you wouldn't be able to get your other stitches in. The key, of course, with a ripstop is you've got to make sure your next suture in is medial to the ripstop, otherwise it's not going to stop the rip. And so here's one simple stitch from the more posterior of those two anchors. Here's another simple stitch and now I've tied those and now I'm going to cinch down my ripstop and I'm going to tie the ripstop. The ripstop has to be tied with a non-sliding knot. In this case, I'll do it to half hitch, which gives you a little bit of local sliding, but allows for that knot on the ripstop. So here's our completed repair, supraspinatus to intraspinatus and sure, I'll put a needle under this and put some BMAC under here when we're done. And I thank you very much for attending our lecture series and listening to this maybe a bit long lecture, but I hope it's very helpful to you.

rotator cuff tears

soft tissue release

capsular release

bursal tissue

tear repair

ripstop sutures