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Assessment of Rotator Cuff Tear

Discussion:  - anatomy of rotator cuff

- Assessment of Cuff Tear:
  - partial tear
   - crescent tear
          - single tear pattern
- minimal medial retraction
- allows straight forward repair
- U shaped tear
          - crescent-shaped tear with  significant central medial retraction (medialization can approach glenoid rim)
- requires convergence repair;
- L shaped tear and reverse L shaped tear
          - similar to U-shaped tears, but there also is longitudinal split posteriorly anteriorly, resulting in the posterior leaflet retracting posteriorly and medially;
- posterior leaflet needs to be reduced anatomically;
- anterior cable:
- The biomechanical relevance of anterior rotator cuff cable tears in a cadaveric shoulder model.

- massive rotator cuff tear
- reestablishment of the rotator cable;
- refers to anterior and posterior attachments of rotator cuff;
- fibers from coracohumeral ligament which transversely span distal attachments of supraspinatus and infraspinatus tendons in a curving arc;
- cable helps distributes the forces throughout the rotator cuff tendon;
- anterior cable attachment has a significant concentration of forces under rotation.
- need to repair cable reattachment prior to any margin convergence as well since it brings the supraspinatus out to proper length;
- with cuff tears extending anterior enough so that there is no remaining cuff attachment lateral to the biceps, then the anterior cable is disrupted;
- need to repair the most anterior portion of the supraspinatus with an anchor adjacent to the articular surface of the humeral head
just lateral and posterior to the biceps;
- this may convert a large tear into a U-shaped tear;

- Open Assessment:
   - after exposure, tear in rotator cuff must be identified, although this may be difficult if reactive bursal changes are present;
- freeing bursa from scar allows one to recognize normal tendon and to continue tissue dissection in the same plane over torn area;
- rotator cuff size is best described by surface area and by muscle compliance rather than a simple linear measurement;
- posterior cuff will be brought into operative field by extending and internally rotating the shoulder - which is acomplished by pinning
patient's arm between OR table and surgeons hip while it is positioned in full exernal rotation;
- assessment of size of rotator cuff tear:
- infraspinatus insertion zone was identified by laying the two branches of the forceps over the scapular spine so that the forceps were in line with the fibers of the cuff;
- fibers coming from a level inferior to the scapular spine are infraspinatus fibers;
- teres minor insertion was identified by locating its insertion on the respective tubercle, which lies inferior and slightly medial to infraspinatus insertion

- References:
      - Anatomic reduction and next-generation fixation constructs for arthroscopic repair of crescent, L-shaped, and U-shaped rotator cuff tears.
- Arthroscopic Rotator Cuff Repair
- Rotator cuff repair: Current concepts and applications
- Arthroscopic Repair of Large U-Shaped Rotator Cuff Tears Without Margin Convergence Versus Repair of Crescent- or L-Shaped Tears