of my friends and colleagues, Ian Lowe from Calgary, Canada. Ian's gonna be coming in via Zoom just because of Canadian travel issues. And Pat is, of course, here to my left. So let's dive into it. You know, first, let's talk about our definition of large. And as you can see from this slide, it varies depending on who you are, what you think large is. And for me, a large tear starts with a really large tear, and that's three tendons, subscap, supraspinatus, infraspinatus, and then sort of large tears, which by far is the majority of the tears I see in my practice, which are two-tendon tears, either posterior-superior tears, supraspinatus, infraspinatus most commonly, or anterior-superior tears, supraspinatus subscapularis. And, you know, by far, and I think everybody probably has a similar experience, that your posterior-superior tear is gonna be, you know, the most common. Anterior-superior tears, we're not gonna talk too much about subscap repair today because it's a whole different topic, but, you know, subscap is like its own independent repair, usually, right? And when I have to repair subscap along with the rest of it, I'm thinking, oh my God, now I've got two rotator cuff repair cases to do instead of one. Sometimes it comes across as a sleeve. I refer you to this article, which I refer to all of my students, and that's this one by Jamie Davidson and Steve Burkhart, all the way back from 2010, I know. It seems like a long time ago. But it's the geometric classification of rotator cuff tears, a way for you to look at MRIs and know what you're kind of, what you're getting into before you walk into an operating room. And it helps me with timing. You know, like, hey, am I gonna need 45 minutes for this rotator cuff repair, or am I gonna need an hour and a half for this rotator cuff repair, and what do I need to have there? And it basically boils down to measuring the size of the tear on your coronal and your sagittal views with a T2-ish image. And if it's, if we go down to three there, if the width is greater than the length, and it's small, around two centimeters or less, it's a crescent-shaped tear. If the length is greater than the width, and it's relatively small, it's a longitudinal tear. These are your easier tears. If it's bigger, so bigger than two centimeters in two directions, you have to start thinking about needing something else maybe besides just sutures and anchors, like a patch or some sort of augment. Maybe start preparing your patient that, hey, maybe I'm gonna be doing a partial repair here, not a complete repair, which will change your prognosis. And then if they're really big, you really need to expect to do something else besides just a primary repair, at least in your younger, more active patients. So this is a case-based talk, so let's start with cases. This is a 55-year-old construction worker, a badly-formed gym guy with an acute injury in the gym. He did actually feel a ripping sensation in his shoulder, adequate PT without relief. He's got decent motion, both active and passive, but he's pretty weak, three-on-five forward flexion, doesn't have any biceps pain, standard impingement signs, standard complaints of pain with overhead use, can't do stuff that he wants to do in the gym, night pain, I don't know about everyone in the room, but for me, night pain is what really drives people to my office, especially in the older group. So here's his MRI, coronal, doesn't look too bad, certainly a full thickness tear, but not retracted, at least on this. And here's the sagittal, can't really judge atrophy on a T2-weighted image, but a lot of changes underneath the tendon there, it gets pretty thin as we come out laterally, and as you come out laterally, maybe a little bit of tendon all the way out on the outside of that tuberosity. So this is all the stuff that goes in the computer, uh-oh, some tendon still on the tuberosity. So, this is interactive, so let's discuss. Anybody gonna continue to just try to treat this guy conservatively? Nah, we're all surgeons in this room. Well, Joe, I have a question on that. So, he's a young guy, weightlifter, and you put in your introduction that he had failed conservative treatment for three months. If this guy walks in your office, he wants to go back to weightlifting, and you have an MRI like that, do you always do three months of conservative treatment to satisfy that requirement, or do you talk to this guy about immediately going to surgery? You know, young patients with full thickness tears, most of us, I think, in this room would agree that it's better to be more aggressive, because you don't want the thing to get bigger, you don't want it to retract more. In the long run, he'll probably do better. So, I didn't treat him with three months of PT, he came to me after three months of PT. So, and look, from a practical point of view, how many in this room can get an MRI the first time somebody walks into your office and they haven't had physical therapy? Heh, not me. I got Dr. Blue Cross telling me I can't do that. So, you know, but he came to me after conservative treatment already. All right, how about Magic Juice? PRP, stem cells? I, you know, I got guys in the neighborhood who'll put stem cells in there for $3,000, tell you you're fine. Nah, okay, good. Everybody in the room is sane. Scope to BreedMod? Nah, right, probably not. Anyone? Bueller? All right, so we're gonna repair this guy. Let's look at our diagnostic scope. Eh, maybe a little bit of subscap tearing there, not much. Pretend that's not there. Let's concentrate on his, there's his biceps. Now, he had no biceps pain. We could talk about what you wanna do with that biceps. And then here's his tear. A little bigger than I thought, right? Supraspinatus for sure, off the tuberosity. Uh-oh, there's that tendon remnant on the greater tuberosity. Hate that. Looking down posteriorly now, there's the top of the tear. And, oops, okay, I just lost my monitor here, but you guys can still see it. So, to BreedMod, there it is, it's back. From inside and from outside. And so, pretty big tear, right? This would be a sort of large tear. Supraspinatus infraspinatus. Let's do that important kind of check of mobility. Seems to come across pretty well, right? So, it looks pretty mobile. All right, so single row rotator cuff repair, anyone? Show of hands. Okay, soft tissue release? Yeah, probably not, right? I mean, the tendon's mobile. It's coming across on its own. I don't think you need much of a soft tissue release. Double row rotator cuff repair, anyone? Show of hands. Oh, boy, all right, you got some people who are doing consulting work for the anchor companies. All right, how about, Jimmy, yeah. He's like, Toro, shut up. So, I'd like to ask the question, who would repair that subscap? Good one. How many repair it? Yeah, you know, in the words of, well, one of the Bugs Bunny characters, I might, Travis, I might. So, you know, you have to, from the purposes of discussion, you have to take a better look at it. If you have an upper tendon tear and it's, you know, significant, you can certainly put an anchor in that. It's a whole separate case, right? Because now you're working from inter-superior, and yeah, so I didn't show it to you well enough on purpose. But, so I would say if there's one thing that's changed in my practice in the last five to 10 years is doing more subscap repairs. And if I see a tear of that superior border, it's always worse than you think. And it really, once you get facile at that technique, it's, you know, you put three suture tapes and one anchor into that, and they do so much better. They really do. I think that in the old days when we really couldn't see those, and we didn't know what to do with them anyway, so we just trimmed and said, it'll be okay, because there's still tissue there. And those are the ones that did worse. So I'd say it's, I don't know the arthroscopic thing you do, but one thing I've changed is the subscap repair. Way more aggressive, and it doesn't take that much longer. How about the biceps? Nobody talked about his crummy-looking biceps even though he has no biceps pain. So, anybody gonna just cut it, tenotomize it? Nobody? Anybody gonna just leave it alone, not do anything? No? Anybody gonna do a tenodesis? I think that's the default. Okay, pretty good agreement. I mean, we don't have all day here to talk about this case about, you know, how you're gonna tenodesis it. I kind of worry about a guy who has poor lifting style, if I'm gonna put a hole in his humerus up there. So, you know, if you wanna do an open subpec, it's a little bit of a problem putting a hole in the diaphysis there. Yet mentally, I have not had anybody break through those holes, and I still do open subpec predominantly with a drill hole, and I have not had a fracture, but it's something to put in the computer. Okay, so here's the repair. And this is with two triple-loaded anchors, and pretty standard stuff, so I'm not gonna show you anything magical here. Nowadays, I pretty much switch to ribbons, and I think it's just a little broader fixation on the tendon. But you can see, this is single row for me. And although I didn't really show it to you, I try to medialize the footprint a little bit by five millimeters, and I'll vent out on the lateral tuberosity here with an awl to try to stimulate a little bit more healing. So any more discussion? So we start simple, right? With a large tear, but it's mobile. You don't need a release. And my lessons for this are that you don't always need a release if it's relatively acute. Your intraoperative assessment's critical. Move that tendon around, get a grasp of it, move that tendon around, get a grasper on it, make sure you understand the configuration of that tear. Is it a crescent? Is it L-shaped? Do I need some longitudinal repairing? So understand the shape of it. Your pre-op MRI helps you a lot. Make sure you can debris the bursa enough. You're gonna see that, you know, I'm gonna be showing you all these posterior superior tears, and the infraspinatus is retroversal. And if you don't debris out the bursa, you're not gonna see the tear. So you have to take the time to be able to see the entire tear, and you'd be surprised at how many people I've seen do arthroscopic bursal repairs. Okay. And medializing is a safe maneuver. Case number two, 60-year-old phys ed teacher, another three-month history. She had physical therapy, acupuncture, cold laser, searing hot laser. No, just kidding. I don't know. Anybody think cold laser does anything? We don't have any chiropractors in here. Okay. It's all right. I get lots of referrals from chiropractors. They're cool. 80% active and passive range, so a little stiff, a little weak, usual symptoms. This patient has biceps pain. Here's the MR. Quite a bit of fluid in the front there. Hmm. What's that in the tendon over there? Makes me a little worried. Sagittal. Again, hard to judge atrophy on a T2, but looking out laterally, there's that, wow, lots of high signal underneath that tendon there. And then as we get out there, certainly looks full thickness, and uh-oh, tendon on the tuberosity again. So. Anything bother you about this tear? Pat? Well, I think you're gonna have to address the biceps and do a repair. See, what's bothering me about this is this big hole here, sort of in the critical zone. Well, I was gonna ask you that, because you mentioned that in the first case that you had the tear, but I guess you just debrided it on that first one. That's right, well, because I didn't, you know, as you saw, there really wasn't any viable tendon. Right, and that's what I do too. I mean, if there's something that's really repairable, I may do a combination type thing and repair some to the tendon that's already still attached because that's a firm attachment, and tendon heals, and can be just as good, if not better, than tendon to bone. So I assess, you know, there's nothing on here that makes me not want to do this case or think it's gonna be a reverse or anything else. This is a case I'm gonna do, but I'm gonna assess it very well intraoperatively, I think. Right, it's just a matter of being prepared and looking at stuff and being suspicious, right? So that when you get in there, and so, you know, size, retraction, location, what I'm trying to lead you down the road of is location, right? This area of a lot of high signal in the tendon just makes me nervous. And so all that stuff on the tuberosity. So here's this case. Now this is a little different, right? So yeah, there's tendon on the tuberosity, but this is a different animal from the last case, right? So as Pat was kind of talking about here, that's viable tendon on the tuberosity, right? You wouldn't want to take all of that tendon out to expose the tuberosity, right? So I mean, it's not, you wouldn't call this really a critical zone tear because you're not to muscle, but definitely this is a little bit of a different animal, right? And yeah, I'm not showing it again, but if you medialize here a little bit, it's gonna help you. So if you take three, four, five millimeters of this cartilage here, I think you're gonna give yourself a little more surface and cells to repair. So side to side repair on this, anyone? So tendon to tendon by show of hands, tendon to tendon repair. You mean side to side, medial to lateral or lateral? No, no, yeah. Medial to lateral now we're talking, right? Nope, I see someone shaking their head no. Debride that tendon and then just go end to bone. I see someone nodding his head up and down there, yes. Medialize the footprint. Well, that's easy, that's a no brainer. How about a ripstop stitch? Something to kind of help this because I'm worried about it. How about like magical stuff like collagen patches and BMAC? There's one, got one taker. Yeah, two takers. All right, let's take a look at it. So I'm gonna save that tendon. I think that's a lot of tendon myself. And if I can get biology and mechanics working for me here, I'll do it. So I'm gonna start with a ripstop stitch, right? So if you're gonna do a ripstop, right? It's an inverted mattress from A to P. It's sort of like an arthroscopic Mason-Allen stitch, right? And I'll diagram this for you in a minute, but we're gonna take that bottom limb, feed it back through my punch, and then feed it back up from bottom to top. So you're gonna have a loop underneath and a limb anterior and posterior with this nice big wide ribbon. And when you pull that down, you're gonna wanna put your sutures in. So I've got a small anchor in with ribbon here, and I'm using a percutaneous technique with a little guide wire and system. You can use this for trans tendon posture repairs too, and of course for instability repairs. So I've got two suture anchors in on this tuberosity. And I'm gonna take these sutures and I'm gonna go medial with one limb, lateral with another limb, and then tie those over the top. The lateral limb's gonna be on the other side of that ripstop, so it's gonna kind of reinforce the tendon in that area. Let's see. Okay, let's go to the next slide. So here's this repair. I always start with white instead of blue. It's very important. Just kidding. Okay, just everybody awake. So again, if you're gonna utilize this ripstop technique, you want to go medial to where that inverted mattress is crossing and you want to be inside the box of that inverted mattress. And so that's going to be one side of my suture. I'm going to put the other suture in too from the other more posterior anchor. Same principle. And then here's a retrograde suture device. And I'm just going to feed a PDS through this. And then retrograde the other limb of that suture back out so I can tie over the top. And I like this device. What you want to do is just make small holes. Some of the disposable devices make bigger holes, and I kind of tend to shy away from them. So we're feeding both of those through under the tendon. And then we're going to tie those over the top. And the ripstop is the last thing that you set. So I like to get my tension done first with the actual repair. And then once I'm happy with that, now I'll pull the ripstop down laterally. And there's a million ways you can do ripstops. And I can't show you every configuration here. This particular lateral row anchor has a positive locking mechanism, and I like it for that. So I'm just going to feed those two ripstop stitches through it and then bring it back down into the tuberosity. And you don't have to kill it with this ripstop stitch, right? You've already got the tension you want with your repair over the top. And so you just tension it, pop it, and cut it. And that's my completed repair. All right. So who wants to spend money? Put a patch on this. I think we had a couple of takers, right? Pat? I don't think this tendon looks that bad. But when there's any question about quality and you have an insurance payer or you're in the hospital, you can do a patch. And so oftentimes for something like this, I would do the rotation medical with a Regenitin patch now and have no financial disclosures with them. Another technique is to do the BioWick, which has a wick underneath. So if you're concerned about the tendon bone healing part, which I really went there, then I can sometimes use that. I think when everybody answered about double row versus single row on your first case, that's really what I do. So I do that type of ripstop repair a lot, and I'll just take those sutures just to bring it out laterally so that you have some lateral force when they start doing this. You've got somebody pulling in the other direction, and it takes all the knots out of the top. And that usually is one or two more anchors. So it doesn't cost a lot more, but it provides those two aspects. And that's kind of what I was thinking on most of those tears. That's the way I do it now. You could certainly on that first case, you could have done a ripstop and you use those same anchors, right? And done an inverted, used a pair of those anchors, tied them together and done an inverted stitch, go from anchor to anchor. How about subacromial decompression in this case? Yeah, I mean, look, it depends on the acromion morphology, right? I mean, if you've got a type one acromion, you're going to sort of just rough it up a little bit so that you get some bleeding. If you have more acromial hooking or lateral acromial hooking, you're going to do that. But I tend to just do a little bit just so I get some bleeding from that area on top. And yeah, this is a patient that, you know, back at you Blue Cross. So I'm going to put a patch on this. And you know, these patches now are, you know, once you do a few of them, they're very fast, five minutes, you know, 10 minutes to do a patch. I use that lateral acromial portal right from the top. The hint I would tell you with these patches is use that little plastic cannula that they give you to control the patch. And you know, in this case, since it's all tendon, I'm not going to put in any peak anchors laterally. My experience with these patches has been, okay, you know, you're going to see presented lots of papers on these patches. And you know, what you're going to see in those papers is, yeah, they're safe, but there's no controlled studies that I've seen that show that it matters one way or another. And yep, I'm going to do some BMAC underneath this patch. So I tend to do like a patch BMAC sandwich. So I took 60 cc's of bone marrow from the proximal humerus, got five cc's of BMAC out of it. And I'm putting it underneath the tendon now. Obviously, if you do this, you want to evacuate the fluid out of the space before you inject underneath. You don't want to sort of inject and then evacuate out all your expensive BMAC. So that's a belt and suspenders case. This is the rip stop stitch, in case you don't understand it, right? It's an inverted mattress underneath. This Pat Denard, actually, I didn't know that, actually published this way back on, again with this guy, Steve Burkhardt, who seemed to think of everything. So, all right, case three real quick. 68-year-old retired firefighter, shoulder pain through his whole career, lots of cortisone shots. Last injection three months ago, no better. Progressive pain. He's very weak with poor active range of motion. The usual symptoms, doesn't have biceps pain. This is an old case, actually. And so it's an old MRI, and it's not all that high quality. It's amazing. This case is, believe it or not, from 10 years ago. I keep using it because it's a good one. And the MRI, boy, it doesn't look that bad, right? Not that bad. It doesn't look like a really big tear. You figure based on your preoperative planning, this is going to be a 45-minute case. Come on. Uh-oh. So, right shoulder, patient's lateral, as have all these cases been. And, wow. Surprise. Big tear, right? Standard tendon on the tuberosity, right? But that's a different animal. But this is a good case because it shows how the bursa posteriorly can obscure a large posterior superior tear. And you've got to get that bursa out so you can see that whole upper end of the infraspinatus and all the way to the apex that way. All right. So, let's see what we got here. Okay. So now, maybe this is living up to the large and massive tear that we were supposed to talk about. Pretty big. Anybody classify this as a small tear? It's a troublesome tear, right? I mean, it's not moving. It's stuck. Why is it stuck? Well, so, would you just debride this? You know, it's not repairable back to tuberosity the way it is. Anybody? Partial repair? Anybody? SCR? Anybody? I guess we're going to do nothing. Soft tissue release to mobilize the tendon. Yay. All right. So, that's what we're going to talk about, right? And you know, this is an old slide. I think this is Burkhardt's slide, maybe. It might be mine. I'm losing track. But the whole idea here is, you know, it's a forced couple thing, right? The capsule and the tendon are one unit when they tear off and retract. So that, you know, when you have large rotator cuff tears, you get instability, right? How many in the room here have seen, you know, these patients with these really large tears dislocate, right? And they come and they go, oh, I dislocated my shoulder. It's like, no, the problem is you have a big cuff tear. You know that, right? Because they're unstable. And that's the principle behind like even just doing partial repairs. And I can't tell you how many partial repairs I've done over the years where you're really just repairing the infraspinatus. You don't really have a good supraspinatus repair. And the patients feel a lot better because they've got a reasonable forced couple with their arm down at their side. So don't be afraid. If you, you know, are not an SCR believer or you don't have a patch there, don't be afraid to do a partial repair on these patients. Repair the infraspinatus. They will be better. So you'll be surprised. So that's my bit of advice for you here. Let's talk about these soft tissue releases that we already talked about how the capsule and cuff are one. And it, but, you know, it's going to tether that cuff. And so you need the principle is you need to detach the capsule from the cuff. And that means superior capsule and rotator interval for the supraspinatus. It means anterior capsule and sometimes parts of the rotator interval for the subscap. And it means posterior capsule for the infraspinatus. And sometimes some of this repairs around the scapular spine, some of the release, so-called double interval slide. And then especially in revision cases, you may have some extra articular adhesions also that you're going to need to take care of. So this is sort of an artist's rendition of a superior capsule release. But let's talk about an interval release, which I use pretty frequently. And we're going to use in this case. So the concept is in this big crescent-shaped tear, you've got a contracted coracolumbral ligament, which is attached to the rotator interval, which is tethering the cuff. And when you try to repair this end of bone, it tension overloads as you move from front to back, which you don't want. And here's a bigger tear. This one's going to be more of a side-to-side and end-to-bone repair. But again, it's going to tension overload with your side-to-side repair. Which you don't want. So that's the principle of anterior interval release. You're going to come in there with some sort of cutting device. Nowadays, I'll use an RF. And you're going to detach the coracolumbral ligament and the rotator interval from the supraspinatus. And this will get you a lot of increased excursion, both for these crescent-shaped tears and for these L-shaped tears. And here's the principle of a double interval slide if you're releasing around the scapular spine. The only problem with this is it leaves a really small piece of supraspinatus. And I don't know, Pat, how you feel about these double slides. For me, it's a release of last resort. And I've never really gotten quite as much excursion as has been reported. I've done them, and I haven't I've done them, and I haven't done them as, I was just thinking back, haven't done very many recently. So I'm figuring some other ways to get this done. My other concern is that when you do that release, the suprascapular nerve is right up there, right underneath the coracoid, and it pulls up into it. It's very easy to get that. So if you get a repair and you de-nervate your infraspinatus, you haven't done the guy any favors. So you have to be very careful with that release right there. I do the anterior release all the time. Yeah, and even your superior capsular release, you have to be careful. Same thing. And what'll happen is you'll directly stimulate the muscle if you're doing that superior capsular release, and you see the muscle contracting, and you're going, okay, just keep contracting, keep contracting. You don't want to see it contract and then go limp, because then you know you did something bad. Okay, so let's look at this interval release. So the first and most important thing with these big tears is you need a traction stitch. So I'm coming in from lateral, again, right shoulder, and the first thing I'm going to do is get a traction stitch in here. I'm going to come in from just an adjacent little percutaneous portal, just anterior to that lateral portal, and I'm going to use that portal for a release, too. And you can see how tethered this thing is. I could talk about that biceps, too. All right, and so where do you do the release? Well, it's sort of right behind the biceps. What if there isn't a biceps? Well, you know, around one o'clock, but the key is to pull traction on this tendon and deliver the interval to you so you can get medial enough, because you've got to get all the way medial so that you're all the way past the end of the capsular release. So that you're all the way past the end of the capsule with this interval release. And I've always done this from the inside because I think I can see better, but you could do this from the bursal side, too, and many people do. But if you're lucky, what will happen is once you get through the last part of the capsule, you're going to get a real improvement in excursion of that tendon. And then I'm going to do a superior capsular release here also. But that's the release. That's an anterior interval release. Very important to have in your bag of tricks for these tears. Questions on anterior interval release? Yep, we're ready. So I did a single row repair on this, and you want to just do the most anatomically correct repair as possible. I'm not even, let me just just go to the final, if I could. There you go. You can see though there, the apex of that doesn't come to the tuberosity. So it's important to realize that this is a side-to-side repair and an end-to-bone repair. It's not like you're trying to take that apex between the inference super and bring it to the tuberosity. And here's what the interval release looks like when you're looking at it from the subacromial space. Watch out for SADs in these big patients. Okay, questions on this stuff? There's microphones up front if you want to walk up, or you can stand and talk. Yes, please. We're going to have questions and answers too at the end too, so, and Ian's patiently waiting as is Pat. So with your, can you hear me? Yes. So with your very large tears, and particularly your infraspinatus force couple concept, what do you do with the biceps tendon if it's intact, even if it's frayed, what do you do with it? Well, for me, I'm sorry Pat, if that patient has no bicep symptoms, I know it's heresy, I leave it. And now you can also use the biceps tendon the way we were doing it years ago and kind of sew the biceps tendon to the anterior edge of your repair. And you can even tenodese the biceps locally there, so you're, it's sort of a superior capsule reconstruction. And perhaps that's what you're talking about. Okay. Yep, absolutely. So using the biceps as a graft is definitely an option. It's something I think a lot of us will do sometimes. Thank you. I have an older population and I do a biceps tenodesis on probably 80% of them. And I'll use it as a graft. The new thing about leaving it attached and just tenodesing it, I think is a great idea. And there was a paper recently, I can't remember the author, that just talked about that being very effective. So especially when you have a tendon that's beat up, and then you put your suture tapes in it, and then you know they're going to pull out. So it's like you're not really doing them any favors. So sometimes I'll leave it attached and then sew it into that rotator interval in the superior or anterior part of the supraspinatus. So Pat, but do you, an important question in my mind with these is, then do you anchor the biceps to the humeral head so it's like a superior capsule reconstruction or not? I don't. You don't have to. Because now with these suture passers, you can get, I put locking stitches into the biceps and then pull that through and tie it right into that, not really rotator interval, but it's really the anterior supraspinatus tissue. And that works great. See, but what I'm referring to here, and again, I don't know the right answer to this, but using that biceps sort of as an SCR mechanically, in my mind, you need to anchor the biceps to the tuberosity also to get an SCR effect. I think that's a great point. Someone should study it. Sir. 89% were partial. They seem to do very well, better than cut it. So I think it's something that you can use as a valuable adjunct to the repair in line with a partial superior capsule repair. Earlier, I think it was Dr. Nottage and his group looked at leaving the biceps tendon, just like you described, and by repairing the infraspinatus to the biceps tendon with the idea of taking tension off of the repair. I think it acts like a superior capsule repair, in addition to the partial repair. And of all of them, they only had one patient, maybe one biceps tendon pain, one patient ruptured, but his rotator got healed. Yeah. They're not going to care about that. Yeah. I think it's a very interesting thing to do. And you know, it's sort of a natural, you've already got one side of your SCR attached. So, you know, it's not a bad idea if you have a biceps. Yeah. Okay.

large rotator cuff tears

surgical techniques

preoperative planning

MRI images

geometric classification system

interval release

individualized surgical approaches