Massive rotator cuff tears present unique challenges for repair. The document discusses techniques for arthroscopic repair based on tear pattern, including releases to improve mobility. For crescent tears, a double row fixation is recommended. L-shaped and U-shaped tears are repaired with side-to-side sutures converging the margin. Massive contracted immobile tears may require interval slides. Outcomes are generally good, though strength deficits can remain. Proper patient selection considering fatty degeneration and mobility is important for success.

1. M. AntonogiannakisM. Antonogiannakis
DirectorDirector
Center for Shoulder arthroscopyCenter for Shoulder arthroscopy
IASO Gen. HospitalIASO Gen. Hospital
Athens GreeceAthens Greece
Arthroscopic repair ofArthroscopic repair of
massive rot cuff tearsmassive rot cuff tears

2. Rotator cuff disease is a spectrum
of clinical conditions, which range from
asymptomatic partial thickness tears to
symptomatic rotator cuff arthropathy

3. Massive Rot Cuff TearsMassive Rot Cuff Tears
Definition:Definition:
 Involving 2 or more Tendon TearsInvolving 2 or more Tendon Tears (Gerber)(Gerber)
 >5cm Tear>5cm Tear (Cofield)(Cofield)

4. The problemThe problem
 Poor tendon qualityPoor tendon quality
 Muscle tendon retractionMuscle tendon retraction
 Muscular atrophy fatty infiltrationMuscular atrophy fatty infiltration
The three central issuesThe three central issues
 Passive range of motionPassive range of motion
 Tendon retractionTendon retraction
 Muscle viabilityMuscle viability
 Failure of healingFailure of healing

5. Techniques of releasesTechniques of releases
 The techniques adapted from openThe techniques adapted from open
surgery as described by Codmann,surgery as described by Codmann,
Rockwood, NeerRockwood, Neer
 Refined and modernized by Esch, Snyder,Refined and modernized by Esch, Snyder,
Gartsman, Burkhart and othersGartsman, Burkhart and others

6. ANY TYPE OF RECONSTRUCTIONANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOADMUST AVOID TENSION OVER-LOAD
OF THE REPAIROF THE REPAIR

7. The solutionThe solution
 Improve the mechanical strength of theImprove the mechanical strength of the
repairrepair
 Enhance the biological responseEnhance the biological response
 Abandon and replace-muscle transferAbandon and replace-muscle transfer
 Rot cuff arthropathy-reverse or extendedRot cuff arthropathy-reverse or extended
head arthroplastyhead arthroplasty

8. Recognize the TearRecognize the Tear
PatternPattern
 Tears must be repaired in theTears must be repaired in the
direction of greatest mobility ->direction of greatest mobility ->
minimal strainminimal strain

9. Mobility Check

10. Tendon debridement- Tear morphology
recognition

11. Tear PatternsTear Patterns
 Crescent shapedCrescent shaped
 L-shaped (or reverse L)L-shaped (or reverse L)
 U-ShapedU-Shaped
 Massive Contracted Immobile tearsMassive Contracted Immobile tears
S.S. BurkhartS.S. Burkhart

12. Crescent
Shaped Tear
S.S Burkhart

13. Crescent-Shaped TearCrescent-Shaped Tear
 Double row repair,Double row repair,

14. Double Row Fixation
Restoration of the footprint
www.shoulder.gr

15. Tuberoplasty

16. 1st
Anchor Insertion – Medial Row

17. 1st
suture passage- Medial row - mattress

18. suture passage- Medial row – post. anchor

19. Suture inspection – medial row - mattress

20. Lateral Row 1st
Anchor Insertion

21. Lateral Row 2nd
Anchor Insertion

22. Inspection of Suture Position

23. Knot Tying Lateral Row

24. Final Repair
Double rowDouble row
Probably stronger repair
but
Time consuming and of
raised difficulty

25. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears
Greater mobility from anterior toGreater mobility from anterior to
posterior than medial to lateralposterior than medial to lateral

26. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears
 Side to side sutures from medial to lateralSide to side sutures from medial to lateral
 Progressively converge the margin of theProgressively converge the margin of the
tear lateral to bone bedtear lateral to bone bed
 Closing 50% of a U-Shaped tear ->Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by areduces strain at converge margin by a
factor of 6factor of 6
[[S. S .Burkhart]S. S .Burkhart]

27. Closing an L-shaped or U-shaped tear is much like closing a tent flap
Closure of an U-shaped tear involves first side-to-side closure
of the vertical limb of the tear, then tendon-to-bone closure of the
transverse limb
L or U -shaped tear
S. S .BurkhartS. S .Burkhart

28.  Large U-shaped cuff tear
extending to glenoid
 Margin convergence
 The free margin of the cuff is
repaired to bone with suture
anchors

29. Side to Side Repair
Cuff repair
www.shoulder.gr

30. Side to Side Repair

31. Cuff repairCuff repair
Tendon to bone repairTendon to bone repair
www.shoulder.gr

32. Massive Contracted ImmobileMassive Contracted Immobile
TearsTears
 No mobility from medial to lateral or fromNo mobility from medial to lateral or from
anterior to posterioranterior to posterior
 Subcategories:Subcategories:
 Massive Contracted Longitudinal TearsMassive Contracted Longitudinal Tears
 Massive Contracted Crescent TearsMassive Contracted Crescent Tears
 Represent 9.6% of massive tearsRepresent 9.6% of massive tears
[[S.Burkhart]S.Burkhart]

33. Massive Contractite TearsMassive Contractite Tears
 Anterior Interval SlideAnterior Interval Slide
and/orand/or
 Posterior Interval SlidePosterior Interval Slide
Single and double interval slideSingle and double interval slide

34. Subacromial viewSubacromial view

35. Single and double intervalSingle and double interval
slideslide
 Anterior slide through release in theAnterior slide through release in the
rotator interval (supraspinatus–rotator interval (supraspinatus–
coracobrachialis)coracobrachialis)
 Posterior slide through release of thePosterior slide through release of the
interval supraspinatus-infraspinatusinterval supraspinatus-infraspinatus

36. Free sutures to the cuffFree sutures to the cuff

37. Anterior slide-
supraspinatus
from coracoid –
coracohumeral
ligament

38. Posterior slide
Infraspinatus-supraspinatus

39. Posterior slide

40. Side to side sutures

41. Final Subacromial viewFinal Subacromial view

42. Massive TearsMassive Tears
associated withassociated with
Subscapularis TearsSubscapularis Tears
 Subscapularis must be mobilized andSubscapularis must be mobilized and
repaired prior to the rest of the cuffrepaired prior to the rest of the cuff
 Interval slide in continuityInterval slide in continuity

43. Subscapularis
Repair
Recognition

44. Subscapularis
Repair
Recognition

45. Subscapularis RepairSubscapularis Repair

46. Bicepts tenodesisBicepts tenodesis

47. Massive TearsMassive Tears
May beMay be
 Eassily repairableEassily repairable
 Retracted very difficult to repair (anterior &Retracted very difficult to repair (anterior &
posterior Slides)posterior Slides)
 Medially RepairedMedially Repaired
 Impossible to repairImpossible to repair
 Incomplete RepairIncomplete Repair
 Graft JacketsGraft Jackets
 Tendon trasfersTendon trasfers
 Reverse, extended head arthroplastyReverse, extended head arthroplasty

48. Arthroscopic cuff repairArthroscopic cuff repair
Wolf, Snyder, Gartsman, Esch,
Burkhart, Tauro and others reported
84%-94% excellent and good results

49. Results for massive tearsResults for massive tears
 95% Good to Excellent Results95% Good to Excellent Results
independent to tear sizeindependent to tear size [Burkhart, 2001][Burkhart, 2001]
 With interval slideWith interval slide
 Improve UCLA score (10->28.3)Improve UCLA score (10->28.3)
 Improve Active ROM, StrengthImprove Active ROM, Strength
[Burkhart, 2004][Burkhart, 2004]
 Graft Jacket RepairGraft Jacket Repair
 Improve UCLA score (18->32Improve UCLA score (18->32))
[Snyder, 2008][Snyder, 2008]

50. ConclusionsConclusions
 Acute Crescent TearAcute Crescent Tear
Standard Techniques for tendon to bone fisxationStandard Techniques for tendon to bone fisxation
 U- or L- shaped TearsU- or L- shaped Tears
 Side to side margin convergenceSide to side margin convergence
 Partial mobile tearsPartial mobile tears
 Anterior / Posterior SlideAnterior / Posterior Slide
 Medialized RepairMedialized Repair
 Irreparable TearsIrreparable Tears
 Partial RepairPartial Repair
 GraftsGrafts
 Tendon trasfersTendon trasfers

51. What to do???What to do???
 Patients with grade 3 or 4 fatty degenerationPatients with grade 3 or 4 fatty degeneration
DO NOTDO NOT improve with rot cuff repairimprove with rot cuff repair
[Goutallier][Goutallier]
Vs.Vs.
 Patients with grade 3 or 4 fatty degenerationPatients with grade 3 or 4 fatty degeneration
improved significant at 86% of cases afterimproved significant at 86% of cases after
arthroscopic repairarthroscopic repair
[Burkhart][Burkhart]

52. In our experienceIn our experience
Patients withPatients with massivemassive rot cuff tearsrot cuff tears
benefitbenefit from surgeryfrom surgery
but they tend to recover slowlybut they tend to recover slowly
they succeed very good pain reliefthey succeed very good pain relief
but strength deficits remainbut strength deficits remain

53. In our experienceIn our experience
 Patients with upward migration of thePatients with upward migration of the
femoral head in contact with the acromionfemoral head in contact with the acromion
do not benefit from arthroscopydo not benefit from arthroscopy
 Patients with painless external rotation lagPatients with painless external rotation lag
and inability to keep the arm in externaland inability to keep the arm in external
rotation do not benefit from arthoscopyrotation do not benefit from arthoscopy
 With raised experience more previousWith raised experience more previous
irreparable cuff tears can be repairedirreparable cuff tears can be repaired

55. Lateral Row Suture Passage

56. Knot Tying Mattress Medial Row

57. Surgical Technique
1. GH Joint and Subacromial Joint Inspection
2. Bursal debridement
3. Acromioplasty
4. Cuff mobilization
5. Repair (side to side, tendon to bone)

58. Patient position
Lateral decubitus
Traction3-4 kgr
Abduction 20 degrees

59. Portals
Outside in technique

60. Bleeding control

61. Bleeding control

62. Joint Side Inspection

63. Bursal Side Inspection-Bursectomy

64. Tendon debridement- Tear morphology recognition

65. Acromioplasty

66. Side to Side Repair
Cuff repair

67. Cuff repairCuff repair
Tendon to bone repairTendon to bone repair

68. Double Row Fixation
Restoration of the footprint

69. Arthroscopic repairs do not heal faster
Knowledge of biomechanical principles is
mandatory in choosing repair type
Cuff repair is feasible but technically demanding

70. Indications of arthroscopic cuffIndications of arthroscopic cuff
repairrepair
 Every repairable cuff tear can be repairedEvery repairable cuff tear can be repaired
arthroscopic or a cuff that can be repairedarthroscopic or a cuff that can be repaired
open can be repaired and arthroscopicopen can be repaired and arthroscopic
 The decision to repair a cuff tear open orThe decision to repair a cuff tear open or
arhtroscopic depends in the expertise of thearhtroscopic depends in the expertise of the
surgeonsurgeon
 In the long run there is no discernibleIn the long run there is no discernible
difference between mini-open anddifference between mini-open and
arthroscopic cuff repairsarthroscopic cuff repairs

71. Advantages of Arthroscopic Cuff Repair
• Atraumatic
• Deltoid sparing
• Tissue mobilization
• Cosmetic incisions
• Secure repair
• Address accompanying pathology
• No iatrogenic injury to healthy tissues
• Cost-effective on an outpatient basis

72. Disadvantages of Arthroscopic Cuff Repair
• Technically demanding
• Equipment dependent
• Steep learning curve
Know when to keep dealing
or when to pack the cards
in and go home

73.  Bennett WF. Arthroscopic repair of massive rotator cuff tears: aBennett WF. Arthroscopic repair of massive rotator cuff tears: a
prospective cohort with 2- to 4-year follow-up.prospective cohort with 2- to 4-year follow-up. Arthroscopy.Arthroscopy.
20032003
 Boileau P., Brassart N., Watkinson D.J., Carles M., HatzidakisBoileau P., Brassart N., Watkinson D.J., Carles M., Hatzidakis
A.M., Krishnan S.G. Arthroscopic repair of full-thickness tears ofA.M., Krishnan S.G. Arthroscopic repair of full-thickness tears of
the supraspinatus: does the tendon really heal? J Bone Jointthe supraspinatus: does the tendon really heal? J Bone Joint
Surg Am. 2005Surg Am. 2005
 Buess E., Steuber K.U., Waibl B. Open versus arthroscopicBuess E., Steuber K.U., Waibl B. Open versus arthroscopic
rotator cuff repair: a comparative view of 96 cases.rotator cuff repair: a comparative view of 96 cases.
Arthroscopy. 2005Arthroscopy. 2005
 Gartsman G.M., Khan M., Hammerman S.M. ArthroscopicGartsman G.M., Khan M., Hammerman S.M. Arthroscopic
repair of full-thickness tears of the rotator cuff.repair of full-thickness tears of the rotator cuff. J Bone JointJ Bone Joint
Surg. 1998 Surg. 1998
 Rebuzzi E, Coletti N, Schiavetti S, Giusto F. ArthroscopicRebuzzi E, Coletti N, Schiavetti S, Giusto F. Arthroscopic
rotator cuff repair in patients older than 60 years.rotator cuff repair in patients older than 60 years.
Arthroscopy. 2005Arthroscopy. 2005
 Tauro JC. Arthroscopic rotator cuff repair: analysis of techniqueTauro JC. Arthroscopic rotator cuff repair: analysis of technique
and results at 2- and 3-year follow-up. Arthroscopy 1998and results at 2- and 3-year follow-up. Arthroscopy 1998
 Warner JJ, Tetreault P, Lehtinen J, Zurakowski D. ArthroscopicWarner JJ, Tetreault P, Lehtinen J, Zurakowski D. Arthroscopic
versus mini-open rotator cuff repair: a cohort comparisonversus mini-open rotator cuff repair: a cohort comparison
Results of atrhroscopic rc repair

74. When to ReleaseWhen to Release
andand
When NOT to ReleaseWhen NOT to Release
 According to Tear Pattern andAccording to Tear Pattern and
MobilityMobility
 Test mobility with grasperTest mobility with grasper

75. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Medial Row
Lateral Row
Contact area

76. Lateral Row Suture Passage

77. Inspection from the
Glenohumeral Joint

78. Mobilization of the Articular
Part of the Rotator Cuff

79. 2nd
suture passage- Medial row - mattress

80. Knot Tying Lateral Row

81. Knot Tying Lateral Row

82. Knot Tying Mattress Medial Row

83. Knot Tying Mattress Medial Row

84. 4rd suture passage- Medial row - mattress

85. suture passage- Medial row – post. anchor

86. Lateral Row Suture Passage

87. Final Inspection

88. New ideasNew ideas
Knotless double row repairKnotless double row repair

89. Double Row RotatorCuff Repair
SutureBridge technique
Bio-Corkscrew FT & PushLock
2 X 5.5 mm. Bio-Corkscrew FT Medial row
2 X 3.5 mm. PushLock Lateral Row

90. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Check mobility of the tear Punch, creating Pilot hole

91. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Placement of 2 X Bio-Corkscrews FT Scorpion suture passing

92. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
2 medial anchors tied, ….
Do NOT cut the sutures
Load separate sutures through
PushLock

93. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Tensioning the sutures, will reduce
the tendon into position
Impaction of PushLock, until
Laser-line is “flush” with cortex

94. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock
Disengage driver from anchor
6 counterclockwise rotations, cut
suture
Placement second PushLock
….. Done !

95. Double Row RotatorCuff Repair
Bio-Corkscrew FT & PushLock

96. A Knotless Rotator Cuff Repair

97. Double Row RepairDouble Row Repair
Single Row RepairSingle Row Repair

98. SwiveLock
AR-2323BSL
FiberChain
AR-7270
Thumb Pad
#0 Tip Retention
Suture
Forked Tip
Anchor Body
5.5mm x 15mm
Terminal Link
Free End
(Suture Leader)
#2 FiberWire w/ten
7 mm long loops

100. Access the mobility of the tear using a KingFisher
suture Retriever / Tissue Grasper
Place both 5.5 mm. Diameter Bio-Corkscrew FT
suture anchors ( These Bio-Corkscrews come
Preloaded with FiberChain, AR-1927BFC )
AR-1927BFC

101. Retrieve the sutrure leader from one of the
FiberChain strands through the lateral portal and
Load it on the Scorpion
Retrieve both FiberChain suture ends through the
Lateral portal and tension them, ….. Decide where to
Make the 2 sockets for the lateral row SwiveLock anchors

102. Introduce the SwiveLock through the percutanious
Superolateral portal and capture the third link from
the free marginnof the Rotator Cuff
Advance the driver in the bone socket and push
The FiberChain toward the bottom of the socket

103. Advance the screw by holding the thumb pad as
the inserter handle is turned clockwise
Repeat step 5 through 7 for the second SwiveLock
To obtain the final construct

104. Double row is simplifiedDouble row is simplified
butbut
it has to pass the test of timeit has to pass the test of time

105. Stable fulcrum(SS-part IS) Unstable fulcrum(SS-IS)
Transform an unstable fulcrum to a stable one

106. 2nd
Anchor Insertion – Medial Row