Abstract
Arthroscopic repair of massive rotator cuff tears can be technically challenging but is achievable in many cases. Performing adequate releases are important for successful tendon mobility and avoiding excessive tension in the final repair, thus restoring the native anatomy and biomechanics. This Technical Note provides a step-by-step approach to release and mobilize massive rotator cuff tears to or near anatomical tendon footprints.
Technique Video
The video of a stepwise approach to arthroscopic repair of a massive rotator cuff tear on a right shoulder in a patient in lateral decubitus position.
Introduction
Massive rotator cuff tears comprise 40% of all rotator cuff tears.1 These tears are often technically challenging to manage and retear rates are high.2 The goal of arthroscopic repair is to restore force couples that provide stability to the glenohumeral joint, while reducing pain and improving function. Tendon repairability relies on a variety of patient factors and tendon characteristics. The quality of remaining tendon tissue, bony adaptive changes, and presence of muscle fatty infiltration and atrophy, as well as patient age and comorbidities, contribute to reparability.1,3,4 Despite these factors, 80% of massive cuff tears were repairable, with 58% of these achieved through advanced arthroscopic releases in one report.4 With physiologically repairable tears, a systematic release and a sound construct can reapproximate tear margins to the original tendon footprints without excessive tension, thus restoring the native anatomy and biomechanics. This Technical Note aims to provide a comprehensive stepwise approach to the release and repair of massive rotator cuff tears.
Surgical Technique
Patient Positioning and Anesthesia
The patient is placed in the lateral decubitus position. Intravenous tranexamic acid (TXA) may be considered to improve visualization, given the need for medial dissection during cuff identification and mobilization. Visualization is also improved by the lateral decubitus position, which allows the blood pressure to be safely maintained at ∼100 mmHg systolic, the addition of epinephrine to arthroscopic irrigation, and an arthroscopic pump, which starts at 40 mmHg.
Surgical Approach
The step-by-step approach is provided in Table 1, and the technique is shown in detail in Video 1.
Table 1.
Steps for Arthroscopic Repair of Massive Rotator Cuff Tears
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Diagnostic Arthroscopy
A posterior viewing portal is established, and a diagnostic arthroscopy is performed using a 30° arthroscope. It is important to first inspect for pathology of the biceps and subscapularis tendon. The comma tissue, comprising the coracohumeral and superior glenohumeral ligaments, is the landmark for the superolateral subscapularis, and it is essential for identifying the subscapularis tears that have retracted. Medial biceps subluxation and medial biceps tearing are pathognomonic for a subscapularis tear. If the subscapularis tendon is not immediately obvious, the comma tissue can reliably be found anterior to the glenoid between the 12 and 3 o’clock positions on a right shoulder. If there is a subscapularis tear or biceps disease, these should be addressed prior to superior rotator cuff repair.
Biceps Preparation
Removing the biceps tendon improves the ability to work on the subscapularis tendon. Our preference is to perform a tenodesis, but the first step is to tag the biceps and remove it from the joint. An anterosuperolateral (ASL) portal is established at the anterolateral corner of the acromion to provide access to the superior bicipital groove and have 10° of approach to the subscapularis if it is torn. A threaded cannula is inserted at this portal. The biceps tendon is tagged and tenotomized at its origin. We prefer to exteriorize and whipstitch the tendon for subsequent tenodesis. This provides greater control of the tendon while working on the subscapularis. If the subscapularis tendon is intact, it is possible to use an all-inside technique.5 After biceps preparation, the tendon is placed outside the ASL cannula, and the sutures are clamped just above the skin to hold the biceps tendon in place.
Subscapularis Release
Subscapularis repair is essential to restore force couples in the shoulder and to reduce tension on the superior cuff during repair. Mobility, retraction, and tear pattern are assessed. It is also important to preserve this tissue during release, as it can provide a rip-stop in the tendon for stronger repair. A 70° arthroscope is inserted for further improvement in visualization. Retracted tears require a 3-sided release for complete repair: anterior, superior, and posterior. Additionally, a lateral release is required if the tendon is adhered to the anterior deltopectoral fascia.
The rotator interval is first opened with electrocautery (Apollo RF90; Arthrex Inc, Naples, FL), taking care to preserve the comma tissue, which connects to the supraspinatus tendon and, therefore, helps provide reduction of the supraspinatus tendon. For nonretracted tears, this release is at the level of the coracoid tip. For retracted tears, the release is just medial to the comma tissue. The ASL cannula and shaver (Bone Cutter; Arthrex Inc.) are then directed anterior to the comma tissue, and the anterior release is performed by dissecting the tip of the coracoid and clearing bursal tissue from the anterior subscapularis. Dissection is carried medially along the coracoid until the base of the coracoid is reached to complete the anterior release. If the subscapularis is adhered to the anterior deltoid, a lateral release is required to access the subcoracoid space. This is performed with electrocautery about 5 mm lateral to the comma tissue. Once this space is established, a traction stitch is used for retracted tears.
The superior release is performed by releasing the superior subscapularis tendon from the base of the coracoid (Fig 1) and by releasing the coracohumeral ligament. The latter structure requires dissection of the confluence of the glenoid and coracoid base. Release of the rotator interval and this ligament with preservation of the comma tissue is what also constitutes an anterior interval slide in continuity.
Fig 1.
Arthroscopic view of a right shoulder through a 70° arthroscope via the posterior portal in a patient in lateral decubitus position showing superior release with debridement between the superior supscapularis tendon (SSc) and coracoid base (CB). CB, coracoid base; RF; radiofrequency ablator; SSC, subscapularis.
The posterior release is performed by using electrocautery to clear the glenohumeral ligament adhesions between the labrum and the posterior subscapularis. This is done with an electrocautery device facing the working end toward the glenoid to avoid damage to the subscapularis.
Adequate mobility of the subscapularis is confirmed when the tendon reaches the lesser tuberosity and the comma tissue can be brought down just medial to the bicipital groove. In some cases, 5 to 7 mm of medialization of the subscapularis footprint is necessary and can be functionally tolerated.6
Subscapularis Repair and Biceps Tenodesis
Next, the subscapularis is repaired. A complete tear usually requires 2 anchors from superior to inferior, and retracted tears are often only amenable to a single-row repair. We typically use a knotless approach with rip-stop configurations. With a knotless technique, suture sets should be placed in the inferior and superior half and then anchored sequentially, as fixation of even the inferior anchor limits the ability to place further sutures in the superior half. The biceps tenodesis is performed with a knotless technique in conjunction with the superior medial anchor placement of the subscapularis repair.
Subacromial Prep and Bony Work
Attention is next turned to the subacromial space. The posterosuperior rotator cuff is viewed from a 30° arthroscope inserted through the posterior portal. The shaver, accessed through the lateral portal, is used to release fibrofatty bursa extending from the acromion superiorly. The subacromial space is accessed. The acromion is cleared with electrocautery (Fig 2), and limited decompression is performed. We place emphasis on a lateral bevel and preserve the coracoacromial ligament. The greater tuberosity bone bed is prepped by removing soft tissue, but electrocautery and bone removal are avoided.
Fig 2.
Arthroscopic view of a right shoulder through a 30° arthroscope via the posterior portal in a patient in lateral decubitus position displaying clearing of the acromial (A) undersurface with electrocautery (RF). A, acromion; RF, radiofrequency ablator.
Posterosuperior Rotator Cuff Excavation
A 70° arthroscope is inserted for further visualization. This allows dissection to continue to be carried out via the lateral portal. Debridement is carried medially until the scapular spine is identified (Fig 3). This bony landmark defines the division of the supraspinatus and infraspinatus tendons, and clearing allows for additional mobility. Frequently, electrocautery is used, as this area is prone to bleeding, which impairs visualization. The spine is cleared until the anterior and posterior sides can be seen, and the tendon surfaces are visualized at the base. Next, the dissection is carried posteriorly and laterally following the superior surface of the infraspinatus. Bursal leaders in the posterolateral gutter are released using a shaver and electrocautery. These leaders are extensions from the bursa into the deltoid, and this attachment to the deltoid distinguishes leaders from tendon tissue. To improve access to the posterolateral gutter, the shoulder can be internally rotated to help identify leaders, as these do not rotate accordingly. If the subscapularis was intact and, therefore, anterior dissection had not been performed previously, the process is repeated anteriorly in the anterolateral gutter with the arm in external rotation. After excavation, rotator cuff mobility is assessed for repair. If suboptimal mobility is determined, advanced releases are performed.
Fig 3.
Arthroscopic view of a right shoulder through a 70° arthroscope via the posterior portal in a patient in lateral decubitus position showing exposure of the scapular spine (SP with excavation of the posterosuperior cuff. SP, scapular spine.
Posterosuperior Cuff Release
Undersurface releases of the posterosuperior rotator cuff include an anterior interval slide in continuity, capsular release, and posterior interval slide, which are sequentially performed in that order. The first 2 releases are performed in nearly every massive rotator cuff tear. The latter is reserved for select cases.
Anterior Interval Slide in Continuity
The anterior interval slide in continuity consists of release of the coracohumeral ligament with preservation of the comma tissue or connection between the supraspinatus and subscapularis. The anterior interval slide in continuity maintains the connection laterally between the subscapularis and supraspinatus, simplifying the repair of the anterosuperior rotator cuff. This provides 1-2 cm of additional excursion in most cases. We perform this while viewing with a 70° arthroscope from a posterior portal and working through the ASL portal. If a 30° arthroscope is preferred, this is placed in the lateral subacromial portal. Note that if a release of a retracted subscapularis tear was required, this release was already performed. Otherwise, a traction suture is placed in the anterior aspect of the supraspinatus tendon, retrieved out an anterolateral stab incision, and the release is performed at this stage. Starting just above the upper subscapularis tendon border, the rotator interval is opened with an electrocautery. Dissection proceeds medially above the subscapularis and anterior to the labrum. The glenoid neck is cleared between 12 and 3 o’clock on a right shoulder, and dissection proceeds medially until the base of the coracoid is palpated and visualized. In some cases, there is also an extension of the coracohumeral ligament that projects anteriorly to the subscapularis tendon. This can be visualized by directing the arthroscope over the top of the subscapularis and clearing from the coracoid tip to its base.
Capsular Release
The capsular release is performed via a lateral working portal and also performed with electrocautery. This release also allows for an additional 1.0-1.5 cm of supraspinatus mobility. An additional traction suture can be placed through the posterior supraspinatus and retrieved out an accessory lateral portal if needed. A hemostat can subsequently be applied to this suture and placed against the skin to facilitate reduction during suture passage, knot tying, or knotless anchor fixation. The release begins at the end point of the anterior interval slide in continuity and proceeds along the glenoid, medial to the labrum. Care is taken to not deviate more than 1.5 cm medially to avoid suprascapular nerve injury. The release continues as far posterior and inferior as can be visualized, which is typically the 7 o’clock position when viewing with a 70° arthroscope (Fig 4). Some authors have also described the use of an inferior capsular release, but we have not found this to be beneficial.
Fig 4.
Arthroscopic view of a right shoulder through a 70° arthroscope via the posterior portal in a patient in lateral decubitus position demonstrating capsular release performed medial to the glenoid (G) and extended inferiorly until reaching the 7 o’clock position. G, glenoid; L, lateral; M, medial; RF, radiofrequency ablator.
Posterior Interval Slide
With the posterior slide, the plane between the supraspinatus and infraspinatus is divided. This release targets the thick superior capsule insertion that is present at the base of the scapular spine, which is the counter to the anterior coracohumeral ligament. While this release can provide a substantial increase in excursion (2 to 4 cm), we currently use it only for young patients with good tissue quality, since the release effectively divides the rotator cable.
A traction suture is placed through the anterior leading edge of the infraspinatus tendon, and another is placed through the posterior leading edge of the supraspinatus tendon. The angle of approach should be in line with the scapular spine. If necessary, an accessory posterolateral portal is created. Then, arthroscopic scissors are used to divide the interval. As the release proceeds medially, there are typically 2 layers, the superior rotator cuff, and the inferior superior capsule, which are both divided. The release continues toward the spine until the fat pad appears on the lateral aspect. Care is taken to perform a full-thickness release and to not extend past this fat pad to avoid injury to the suprascapular nerve.
An alternative is to perform a “posterior interval slide in continuity” by avoiding division of the rotator cable, or the lateral most 1 cm of the rotator cuff. This release is the corollary to the anterior interval slide in continuity and follows the similar concept of preserving the rotator cable complex. This is performed by working above and below the rotator cuff with electrocautery. However, it is very important to do this under traction and stay 1 cm lateral to the scapular spine to protect the suprascapular nerve.
Posterosuperior Cuff Repair
Following complete release, the rotator cuff is repaired on the basis of the tear pattern and mobility. A variety of techniques can be used, which are beyond the scope of this Technical Note. Generally speaking, tears that require advanced releases are only amenable to a single-row repair, and thus, we use rip-stop configurations.7 If 75% or greater complete coverage of the greater tuberosity is possible, however, a double-row repair is performed.
Discussion
Massive rotator cuff tears pose an ongoing challenge in orthopedic surgery. This Technical Note provides a stepwise approach to systematically restore mobility and repair these tears. Mastery of subscapularis repair and advanced releases, however, allows the surgeon to repair most massive rotator cuff tears without glenohumeral arthritis.
Determining repairability can be difficult preoperatively and often varies in the literature. Sheean et al. reported on radiographic factors associated with repairability in 86 arthroscopic repairs of massive rotator cuff.4 Complete repairs were achieved in 88% of cases overall, including 82% (9 of 11) with an acromiohumeral distance <7 mm, 70% (14 of 20) with a positive tangent sign, and 57% (8 of 14) with grade 3 or 4 of the supraspinatus. In 25% of cases, advanced mobilization techniques (interval slides) were used, and a mean of 5.3 anchors per case were required. Likewise, Kim et al. reported that individual signs alone, such as the tangent sign, were not completely predictive of an irreparable tear.8 In other words, repairability is best determined arthroscopically.
Clinically, the best results following treatment of massive rotator cuff tears is with an arthroscopic repair, compared to other techniques.9 Other options include superior capsule reconstruction, cable reconstruction, tendon transfer, partial repair, and reverse shoulder arthroplasty.1,10,11 Each of these has their place in the spectrum of management, but the reconstructive and RSA options are also associated with higher complication rates.12
At the same time, an anatomically repairable tear may not have a high chance of healing. There are many tendon-related factors linked to suboptimal healing, including chronicity, muscle quality, tear pattern, and size.13, 14, 15 Additionally, patient-related factors like age, diabetes, hyperlipidemia, and smoking are known to impact healing of rotator cuff repairs.3 Ideal candidates for repair of a massive rotator cuff tear include those who have preserved joint space, those who have an absence of adaptive changes (Hamada 1 or 2), and those who have maintained a functional range of motion.1,16 Acute pseudoparalysis (<3-6 months) by itself is not considered a contraindication for repair and can be reversed with primary repair.16 On the other hand, chronic pseudoparalysis or patients with pseudoparalysis after a previous repair are less likely to have functional improvement with repair.
This technique provides a step-by-step approach to release and repair of massive rotator cuff tears. While challenging, this approach provides the best restoration of anatomy and potential function. The pearls and pitfalls are shown in Table 2. As expected, this technique also has disadvantages (Table 3), including technical difficulty and higher risk of retear.
Table 2.
Pearls and Pitfalls of Massive Cuff Release
| Pearls | Pitfalls |
|---|---|
| Prior to release, diagnostic arthroscopy allows for tear pattern and tendon assessment. | Failing to preserve the coracoacromial arch during diagnostic arthroscopy could result in iatrogenic anterosuperior escape. |
| When releasing the subscapularis, preserving the comma tissue decreases tension upon the supraspinatus repair. | When performing the superomedial capsular release, deviating medially could lead to suprascapular nerve damage. |
| Initial subscapularis release and repair facilitates subsequent supraspinatus repair. | Failing to halt exposure upon reaching the tendinous link between the infraspinatus and supraspinatus can lead to suprascapular nerve injury. |
| Important bony landmarks to guide the anterior and posterior interval slides are the base of the coracoid and scapular spine, respectively. | |
| When releasing in the posterolateral gutter, internal rotation can help differentiate bursal leaders. |
Table 3.
Advantages and Disadvantages of this Stepwise Massive Rotator Cuff Release
| Advantages | Disadvantages |
|---|---|
| Balanced force couples with anatomical reconstruction | Technically challenging to release |
| Simplified tendon release | Risk of suprascapular nerve injury |
| Allows for multiple release options | High retear rates associated with massive cuff repairs |
Footnotes
The authors report the following potential conflicts of interest or sources of funding: M.E.M. reports consulting fees from Arthrex, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
The video of a stepwise approach to arthroscopic repair of a massive rotator cuff tear on a right shoulder in a patient in lateral decubitus position.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The video of a stepwise approach to arthroscopic repair of a massive rotator cuff tear on a right shoulder in a patient in lateral decubitus position.
The video of a stepwise approach to arthroscopic repair of a massive rotator cuff tear on a right shoulder in a patient in lateral decubitus position.