You can appreciate the sophistication and technical ability of some of these guys and what they're doing. We all need to understand our limits, right? This is a great opportunity for you to ask specific questions about some of these technical aspects of some of these procedures. Great job. If we can get our panel up here, we've got three excellent panelists. Dan Vick from Colorado, Steve DeFroda from Missouri, and my old friend Hernandez Perez from Mexico. Great to see you guys. I look forward to talking about this. My concept of this next session, when moving from instability to rotator cuff, is that I just want to focus on everyday, regular, daily things we deal with. Because the everyday, regular cases can sometimes be kind of complex or it's hard to know exactly what the right thing to do, etc. So if you could pull my slides up, please. Thank you. So we'll just get started here. This is first case. This is a 57-year-old healthy carpenter. He'd had a two-year history of dominant shoulder progressive pain and weakness. No prior history of injury. Challenging to work in the last few months. Challenging to sleep. He's a tough guy, but he told me that his wife made him come, but it was really definitely time anyway. So he's just one of those guys that's been putting up with things for a while, like a lot of our patients do. On exam, he had a normal passive motion. He had active forward flexion of 130 degrees. Good external rotation. He had forward flexion weakness, a little bit of external rotation weakness, but normal internal rotation function. Otherwise, no positive findings except for some biceps groove tenderness. So his x-rays, it may be a little arthritis, but otherwise, just essentially normal. So I got an MRI, and it showed a full thickness supraspinatus and partial infraspinatus, too. I classified as Gatelli to intact subscapularis. So that's the presentation. That's what we did. And so each of you guys, what would you tell this person? What would you recommend to this individual, this 57-year-old carpenter? Dan? Well, for him to restore his function and have a long-term beneficial effect from your treatment, it will require a rotator cuff repair, and it's a pretty standard case. Steve? Yeah, I mean, I agree. I mean, my kind of joke and line that I tell my patients is, I don't know anyone that's ever died of a rotator cuff tear necessarily. This is not life-threatening, but he's clearly quite weak on your physical exam. He's obviously a very physically active guy. It's getting worse. It's waking him from sleep. I'd offer him conservative options, but I'd tell him more likely than not, this is going to be going the way of fixation at some point. For me, the same. The best way to treat a massive rotator cuff tear is prevent it to be a massive rotator cuff tear. So I explain, okay, the only thing that's going to happen is it's going to get bigger, so it's going to be harder and more expensive. So let's do it right now. Great. Yeah, so I think we're all in agreement that surgery is indicated. So I talked to him, and he was desirous of surgery, and that's what we did. So this is just a video. I do my cuffs in beach chair. I do instability lateral. So this is just a video showing interticular cervical cromial example of this guy's shoulder. So here's the left shoulder, beach chair. You can see his subscapularis is intact. We look up. He's got a bad biceps, of course. We kind of assume that. And there's his supraspinatus tear. No big deal, right? When you go into the cervical cromial space, though, you see that he has some really bad infraspinatus-type tissue. I mean, there's his intact infra. That looks okay. But there's a lot of kind of very thin, most peripheral cuff tissue that I just debride. There's just that very thin margin. I'm just trying to sort this out and figure out what we need to do to get it fixed. And you can notice I've cut his biceps loose. I'm going to teenadece that. So it's very important that we try to figure out where this cuff goes. And when you see here, I can lateralize it, but there's a lot of tension in the system, as you can see. You know, I'm moving it to the right. I'm moving it to the left. I really want to try to sort this out. But there's clearly tension. So what maybe had seemed like a standard, straightforward, no-big-deal thing, really, as is commonly the case, you get into surgery and you're like, wow, this is a little bit worse than I thought it was going to be. And so it's very important, I think, to try to define these tears. I spend a lot of time grabbing it and moving it around, sorting it out, because I think we want to recognize the pattern. I call this kind of a U-shaped tear. We want to assess reducibility of that tendon, right? And we want to create lowest tension orientation, because I think, you know, excessive tension really is the enemy of healing in these repairs. You can see here, this is a different patient, but I want to kind of just demonstrate this. This is a big U-shaped tear in a different patient. I pull on the various kind of leafs or components of the tear, and we can see that it's really resistant to lateralization. It's resistant to reduction to the anatomic footprint. And then this is our big U-shaped tear. And then this is another patient, same retracted U-shaped appearing tear, but only when we pull on all the different elements of the tear do we realize that this particular tear is completely repairable. So my point is that unless you grab all these parts of the tear and you really manipulate and pull and push, it's hard to know about reducibility, and an MRI a lot of times won't tell you. So now that we see our tear, back to our original guy, what do each of you want to do? What are you going to try to do? We're here in the operating room. We see this tear. So let's start with Fernando on that end first. I'm getting my threshold for medializing. The footprint is very low, so in this case I will medialize maybe at least 5 millimeters. I think it's repairable. And nowadays I would use the biceps probably. I'm switching to use even a really bad-looking biceps is going to be better than any other kind of graft. Yeah, I completely agree. I mean, I tell all these patients, I mean, typically this is, for me, this patient shows up like 20 years later, so maybe it's even worse because it's like the farmer guy in Missouri. But typically I tell them my goal is always to try to repair it, so be very aggressive. Releasing medially, I'll use a traction stitch once I kind of figure out the orientation of the tear, which way to retract. I'll kind of place a traction stitch outside the skin and put a snap on it to kind of gauge my reduction and kind of continue to make releases and then medialize the footprint if needed and then try to go for as tension-free repair as possible with potentially augmentation with like a patch or something of the sort if I feel the biology is not that great. But I've also been starting to use some augmentation of that biceps once again just adds biology to the area. Dan, your thoughts? Very similar to what has been described before. I also would do a capsular release to make sure that there is no tethering at the undersurface of the tear. And when they are truly U-shaped tears, I don't think that we do much justice by doing marginal convergence, but an A-shaped tear, marginal convergence would be indicated in this case. I medialize the footprint a little bit and would not be adverse to going to a genitin if I'm worried at all about the tension. Great. Those are all good comments. So I think we're all in agreement. We might medialize. We're going to do some type of releases. And I agree, these mobilization techniques, you know, capsular release, interval slides, as were mentioned, are as important. This is a different patient, but I want to show on the left is an anterior interval slide. I'm going to do it on the right, a posterior interval slide, different patients. But on the anterior interval slide, of course, we release along the anterior supraspinatus. On the posterior interval slide, we release between the supraspinatus and infraspinatus. So you can see that although it's difficult to predict our ability to lateralize it, in my experience, you can often lateralize these seemingly irreparable tears and get good repairs in that situation. There's something else, though, that almost never comes up in meetings about assessing reducibility of tears. And it's a point I want to make because the panelists, nobody ever really mentions it. And that's this contribution that glenohumeral joint abduction plays in our assessment of rotator cuff reducibility. Whether you do a beach chair or lateral cubitus operation position, there's almost always some degree of abduction. And so we make our assessments, we assess reducibility, et cetera. But we really often, at least I don't, often incorporate that into my thinking of what that really translates into. And so this is our same original patient. This is our guy, remember? I'm pulling on his tear and I'm reducing it. But if I then let the arm down, it's about 25 degrees of abduction. I just let it down by its side. And then I pull on it again. You can really see the challenges to get this thing reduced. And so it's an appeal, really, I think, to understand and think about the contribution. Because sometimes, especially in lateral cubitus position, there's a great amount of abduction. And that can really change, really, what you think you can do. But, of course, at time zero, you're back to zero degrees. So I took you guys' advice. I medialized the footprint, in this case about a centimeter. And all that amounts to is just removing some of that articular cartilage from the suprahemeral head to create a bleeding, bony bed. And then I can move my entire construct medially so that I have bone underneath the tendon. In this particular example, I'm just using a single-row ripstop construct. I just pass sutures and retrieve. But you can tell I'm intentionally medializing everything. Now, I think because I felt like it was best reduced in the orientation that I showed, that that's an opportunity to converge to the otherwise intact infraspinatus. Burkhart and others have told us that you can reduce the rotator cuff repair construct tension when you incorporate in this situation. So I tried to emphasize, there's my stitch. I just kind of look back and forth because I've already concluded that that's not going to offset or compromise a repair. So note that I've repaired it, but it's all medialized one centimeter, as was my footprint. So I've still got good bone there underneath the tendon. And I used vented anchors. And so we really, I think, hopefully, will accomplish our ends. But the point about augmentation is a good one. The biceps is a good one. Now, I want to make one little point about this footprint medialization because not everybody is familiar with this. But this is a well-accepted technique for these medialized tears. I commonly use it both in index and revision repairs. This is a different patient. But all you really do is just remove, in this example, I'm removing about a centimeter of articular cartilage from the humeral head. And it changes how we can re-approximate the capsule. There's the capsule and the rotator cuff tissue to get us back to something that we can sew to and hopefully heal with. Here's a study. There are a lot of studies that talk about medialization and its value. This particular study, 24 medialized footprints versus 36 not, they averaged about a centimeter of medialization in their study and had significantly increased healing rates when they medialized these tears compared to not. And there are other studies that show improved patient outcomes. So can I just ask the panel about medialization? Is this something that you do rarely, commonly, it just depends? Any thoughts about that? Dan? I think it's a case-to-case decision. But yes, I think it probably occurs maybe 20 to 25% of the cases. Steve, anything? I agree completely. I mean, I think it's a case-by-case. And just quickly point out, I mean, I think you demonstrated a great technique with the single-row repair. I feel like everyone gets beaten into them, especially newer trainees now. Double row, double row, knotless this, knotless that. But I think especially for these ones that are under a lot of tension, doing a nice single-row repair and knowing how to tie knots is hopefully not going to become a lost art, but a really good skill to have, especially for these challenging tears. Fernando? In my practice, most of my cases are long-standing cases. They're already retracted. They're not as reductible. So I do almost all my cases medialization. Unless it's a really, really easy one that I can cover all the footprint very easily, then those are the ones I won't do it. But as I said, do at least five millimeters at least. Yeah. So Steve brings up a good point about single-row versus double-row. So what percentage of all comers, rotator cuff tears, let's say medium to large tears, do you do a double-row rotator cuff repair versus a single-row? So double-row, what percentage? 80. Yeah, same, probably 75, 80%. Yeah, around half. Yeah. If it's larger than a one-anchor, then I'll tend to do a double-row. Or depending on the activity level of the patient or the bone quality. Yeah. I'll make those decisions. I have a question about your using the biceps as augmentation. Because we know that when the biceps is intact, it can be an excellent anterior cable type of device. Or you can posterize it like you've discussed in your papers. But if you've already cut it and then you get to the subacromial space, how do you then use it as an augment? Yeah, well, it's a good point. And this guy, I did this guy several years ago. And now the biceps is the last thing that I cut. I get up into the subacromial space. I make assessments. I make sure I don't need it. And then I cut it. So maybe now, that's probably six or seven years ago. Now I would leave it and see what I had to do with it. If the anterior cable is intact, then I don't like to take the anterior cable off so that I can transpose the biceps. But I'll still use it probably as Fernanda does. You may cut it more distally and then kind of rework it as an augmentation. But it's a valuable augment, the biceps tendon. And I think there's a lot of studies in the last two or three years showing different techniques. And I would encourage you, if you're not familiar with those, to maybe read those. But also in the lab, we can do these bioSCR techniques, these biceps techniques tomorrow. It would be quite helpful in a lot of clinical settings. So we talked about the augmentation. I think we mentioned that. Any other comments about the procedure? Oh, I'm sorry. Question? Yes. Okay. For that case that you had the delamination, you had the very clearly, you know, the top and the capsule. Can you talk from a technical standpoint how you passed the suture to manage that situation? I think that can be challenging. Yeah, yeah. It's a very good point. What makes it not so challenging, in my opinion, is when you put the camera in the lateral portal. You have that 50-yard line view, as Dr. Jim Ash has taught us. You really can see underneath very well. As you can see, you can see very well. Now, if I'm looking from lateral, it's a little more difficult to pass sutures unless I use a retrograde device, which is what I do. So I can come in from anterior or posteriorly and bring that underneath. The other thing is that when I fix those, if you remember, normally the capsule is only supposed to go to the medial footprint. The cuff goes more to the lateral footprint. So when I pass sutures, I'll literally pass sutures in a different position while I'm looking through the cuff and then back through the capsule so that we theoretically get this thing to lay down more anatomically when we pass the suture. So it's a great – but it's important, I think, to recognize the capsule and to incorporate the capsule. That's critical, maybe even more important than the tendon itself, in my opinion. And then with that, too, I think Pascal Boyleau has a really nice technique where he uses – anchors the knotless mechanism and a knotted mechanism. He'll pass the knotless ones kind of through that capsular layer, tension that down, and then pass his other sutures through the cuff and use that almost as a tension band construct to a lateral row, which is a pretty neat technique as well to kind of do – almost fix both independently. Yeah, that's right. That's right. So this guy did well, just not to belabor it. He did fine. And the take-homes I want to try to emphasize here is, number one, the importance of trying to assess the reducibility and the orientation of that reduction. And again, that 50-yard line view, that lateral viewing perspective can be very helpful in helping you assess it. Recognizing that abduction is always playing this kind of role that disguises the true reducibility of the tear. There have been studies, like Pandy's study, that shows that when it's repaired in abduction, which is essentially everybody repairs all these tears in some degree of abduction, it decreases blood flow and increases rotator cuff tension. And also importantly, I think the value of footprint medialization in some of these because it really can make some tears that are irreparable quite repairable. So any other comments? And we'll move on to the second case. Yeah. Yeah, of course. Sorry. I think Mark Dillon and Steve Snyder would be upset if I didn't make the distinction between single row and SCOE row. And so all that stuff you showed, medialized fixation, low-tension repair, really appropriate. A lot of the studies that compare double row and single row are putting their single row anchors much more laterally than that. So you're totally losing that low-tension construct that promotes healing. So it's important to take a look at the literature really carefully. Yeah. It's a very, very good point. I think tension and the tendency is to over-tension these, in my opinion, when you do a double row. The majority of patients I do rotator cuff surgery on are single row repairs for that reason. I get them. It's kind of brainwashed me too. So. repair that builds up for a double row you've got to thank you that's right right very good point yes sir well i think i think there are a lot of ways that you can do the different kind of constructs for rotator cuff repair if you look at the literature on the strength of a rip stop orientation construct is a very strong construct and i use it just because i like it i do a lot of single rows in that setting and so i just prefer to do it that way but i think there are a lot of ways to skin that cat so to speak so this is a 60 year old uh male with a three-week history right shoulder pain and decreased function after a fall he had no previous symptoms and his exam uh shows significant active forward flexion uh limits to 90 degrees external rotations okay but he has a lot of weakness especially in internal rotation as a positive liftoff test and clinically seems to have a subscapularis tear and that's what he has on mri he has what i thought was probably an acute subscapularis tear otherwise good muscle and so the question is what to do would anybody on the panel rehabilitate this fellow after an acute subscapularis tear no i think he has a the best opportunity to fix it is now and if you wait and he's symptomatic then you end up with a much more difficult retracted uh tendon and that that would make it a tougher case great great thank you so this is a video of this guy right shoulder beats here there's my biceps up there okay and i'm looking at the anterior shoulder now the problem with subscapularis tears is it's very distorting i don't really know what i'm looking at i can't make sense of this but i can see that structure right there and so dan what is that structure that's been coined as a comma of the shoulder exactly by dr burke and that that's a very important what we're looking at right there for subscapularis because that is the key to identifying the pathology anteriorly and to its repair and i'll show you why so now that we know that's the comma what i realize the comma tissue which is made up of the sghl and corcohumeral ligament importantly travels medially with the subscapularis when the subscapularis is torn so now that i know where the comma tissue is i know where the interval is and i can put my cannula in the rotator interval and look see when i just rotate that cannula now i can see the upper board of the subscapularis and i understand what i have and what i have to do and so on these type of tears these subscap tears for just quickly from the panel would uh would you do this operation arthroscopically or open arthroscopically scope arthroscopically yeah uh i do think i do these arthroscopy too but i do think depending on your skill level your experience with these it's not unreasonable to do this open so here's me i've got there's my biceps and here's my little technique steps just for the sake of time the first thing i do is excise the rotator interval capsule the next thing i do is get this biceps out of the way because it's subluxated and you you can't see very well i also establish an accessory portal because we've got a lot of work to do here now if you look through the defect created by the rotator capsule removal i'm just gonna debride the tip of the coracoid and for those of you that aren't don't have a lot of experience with surgery outside or anterior to the interval the coracoid tips right there it's nothing really to be afraid of or worried about so now i've done my debridement and what i see here is this i see the coracoid tip there's my comma tissue well defined and there's my upper board of the subscapularis so now that i've done this excision of the rotator interval capsule and i've done this other debridement now i really feel quite confident and comfortable with the pathology that i have and i'm ready to do the repair so one question i have for the panel is when you do this operation you can either continue to look from interticularly which is my current view or you can go into the subacromial space to do the repair so to eat just briefly each one of you what do you prefer your view your visualization when you do the repair and maybe why i've done it several ways and i found that this interarticular view continues to be my preferred way i have a i used to have a pretty good assistant who does a little maneuver with the elbow anterior and pull the head a little posterior i use an accessory anterolateral superior portal where you can shave the lesser tuberosity and just down just a just a bleeding subchondral bone and i use a single pass technique with a or i don't want to use any names but the trigger kind of device that passes and you can use that as a traction and you can place place your sutures and and rip stop technique and you can tie from either that portal or from the anterior portal so i usually use an interarticular view right so i've done both kind of depends on the size of the tear if it's like an upper third upper border tear right just think i need to maybe pass one stitch and put it into a knotless anchor i'll just kind of stick interarticular do that work and then come up top for a bigger tear like this one i'd probably go subacromial kind of get that 50 yard line view that you talked about i'll make an accessory anterior lateral portal kind of in line parallel with my subscap to use that self-retrieving device then i'll shuttle my sutures out the front for kind of tying and can do any number of suture configurations decide to add a lateral row etc that's great fernando i can as him always go in particular i always use the anterior lateral accessory portal in this case that's kind of a grade two it will be just viewing from the back and i use a lasso loop lasso locking loop in on all my cases but if it's retracted like a grade three or grade four then you need to look from the anterior lateral portal and you need to release the subscap from the from the coracoid and you use a combination of both very good just a matter of course sorry to interrupt but i have had a an axillary nerve injury releasing the subscapularis so that's something to be aware of at the inferior border of the subscapularis we all know the anatomy and i thought i was well aware well away from it but it the arm jumped and and she had symptoms of it so it's something just to keep in the back of your mind yeah when you get yes sir Yeah. It's a very important point he makes, that the comma connects the subscapularis to the supraspinatus. So, in anterior superior tears, you leave that comma intact because it's going to help your reduction. So, here I am. You can do this from any direction. I'm looking from subacromial. There's my coracoid tip on the right. There's the glenohumeral joint on the left. Now, I've already abraded the lesser tuberosity, which is what Dan talked about. Now, I'm going to grab this comma tissue, which is what you just said, and I can reduce the subscapularis to the lesser tuberosity. Notice that we have a really good view. I don't have to use a 70-degree scope. And one thing I like about this subacromial perspective is I can externally rotate the humeral head and I can really see the lesser tuberosity quite well, which I can't do from interticularly. It allows me to do a double row repair here. Notice how in line with the subscapularis we are. You can see it quite well. Maybe it's protective for the axillary nerve, hard to say. And if we look back in the joint, you can see that good rolled upper subscapularis border. So there are a lot of ways to skin this cat, and I think you can do it interticularly or subacromial, but I would suggest in big tears, maybe just look from subacromial. I think you might like it. So any comments? Last comments before we move on. Yeah. Well, that's a trick I found from one of my residents I have struggling passing the tutors. You can always even move 90 degrees your camera and you can repair it as a supraspinatus. Very good. Very good. A very quick comment here. Yes. As my former fellowship boss, George Othwell, coined it, he called it sort of an out-of-the-box subdeltoid view, where you actually put the camera in your anterior supralateral portal, so you're looking even more anteriorly, and then you're fixing everything from the front, which essentially looks like you're looking through a magnified delta pectoral approach, which is very similar to what you showed there. Yeah. Yeah, Bill. Good comment. And just one quick thing. So what I do a lot of times is when you cut the biceps there, you've got to find it. You can put a marker stitch in there or whatever. Sometimes you can just put tag stitches into the biceps and just pull the biceps back into the groove, and then you just kind of clip those outside your cannula, and then you can just fix your subscapular like you do normally, exactly like you did, which is a great way to do it. And then your biceps is still there, so you can still use it for anything that you would need later. Yeah. That's great. And that's a really good point. And I think your point about the subscapularis and portals, I teach the fellows, you know, when we do bankarts, we don't use one portal anteriorly to do a bankart repair. And subscapularis tears are big pathology anteriorly. So you might need two or three portals. Whatever you've got to do, you've got to do to be able to manage sutures and to see what you need to see in those cases. So thank you very much. I appreciate it. So the next session is anatomic total shoulder. Rob Hartzler is coming back up with his gravelly voice. I actually think it's kind of sexy, his voice. Thank you. You're welcome.

shoulder repair

rotator cuff tear

subscapularis tear

surgical techniques

arthroscopic approaches

tension management