A patient questionnaire must be completed, providing the functional information necessary to complete the Constant University of California Los Angeles (UCLA) and American Shoulder and Elbow Surgeon (ASES) shoulder scores.⁴,⁷,²⁵ One should assess the patient’s level of pain, limitation in athletic and work activities, and limitation in his or her activities of daily living. If a patient is unclear on how to answer these questions, the physician or office staff should help clarify the questions.

Atrophy of the deltoid, the supraspinatus, and the infraspinatus muscles should be evaluated. Passive range of
motion and tenderness of the acromioclavicular and sternoclavicular joints are evaluated to rule out alternate or additional causes of pain and disability other than RCT. The passive and active mobility of both shoulders is measured, beginning with the unaffected side. The supraspinatus strength is tested with the Jobe sign.¹⁶ This may be unreliable due to pain-related weakness. The infraspinatus strength is tested by performing external rotation lag sign with the elbow at the side, and the subscapularis strength is tested by the liftoff test if internal rotation is not limited and by the belly-press test as described by Gerber et al¹² and modified by pushing against the elbow of the patient (Fig. 8-1). Clinical evaluation of symptoms from the long head of the biceps is more difficult. The author uses the abduction rotation external supination (ARES) and abduction rotation internal supination (ARIS) test. In this test the patient does a forced supination against resistance, with the arm positioned in 90 degrees of abduction and 90 degrees of external rotation (ARES) (Fig. 8-2) or internal rotation (ARIS) (Fig. 8-3). In both situations, the biceps must be a normal tendon and must have good anterior (in external rotation) and posterior (in internal rotation) ligaments at the entrance of the groove to be stable. When the biceps is damaged and/or unstable, subluxation of the tendon will occur over the edge of the bony groove and may be painful or weaker than on the other side. Strength is measured by a simple handheld spring scale placed around the wrist with the elbow outstretched.

Imaging includes:

The author uses the Patte classification,²⁴ which evaluates the retraction and location of the tear within sagittal and coronal planes (Fig. 8-4). Partial tears are classified as deep, superficial, or intratendinous (Fig. 8-5). A modified Patte classification defines massive tears: at least three involved tendons of which at least one is retracted to the glenoid.

An interscalene block is performed with or without general anesthesia. The patient is placed in a fully seated, upright position with the arm flexed forward and under traction by weights of about 3 kg (Fig. 8-6). This procedure can be done in the lateral decubitus position, but the author prefers the seated position.

Five approaches are currently used (Fig. 8-7). The first classical posterior glenohumeral approach is used for the scope, that we translate 3 cm medially as modified by Jan Leudzinger, when AC joint access is planned. A second posterosuperior approach, situated at the posterolateral angle of the acromion, is used for viewing the subacromial space. The two instrument portals are initially localized using a spinal needle working from outside-in, representing the classical lateral acromioplasty portal and another anterior portal near
the coracoacromial ligament. The fifth approach is anterosuperior at the anterolateral corner of the acromion.

Before arthroscopy, 20 cc of 1% lidocaine with epinephrine are injected into the glenohumeral articulation and the subacromial bursa to reduce bleeding.

A systematic assessment of the glenohumeral and subacromial space is done both statically and dynamically, and the tissue is probed for stability. After a complete visualization,
the degree of cuff retraction and mobilization to the insertion site is tested. When needed a periglenoid capsular and subacromial release is performed so that the tendon can be easily pulled to the tuberosity with the arm by the patient’s side. The release is essential to perform the repair without excessive tension. Mobilization is performed from medial to lateral for U-shape tears (Fig. 8-8, A-C) or by reducing with traction on the tendon combined with humeral rotation in L-shape tears (Fig. 8-8, D and E). Special attention is given when delamination occurs to repair both deep and superficial leaves of the tear; this is more commonly seen in massive posterior cuff tear.

The stability of the origin of the long head of the biceps tendon is evaluated with a probe. Its stability within the groove is inspected while the arm is passively moved into internal and external position in order to assess the anterior and posterior pulley. Instability may require repair, tenodesis, or tendon release.

The plan for further treatment is made intraoperatively based on cuff tear size as described by Patte, on the ability to mobilize the cuff to the tuberosity, and on the biceps tendon and muscle quality,.

For large retracted tears the intra-articular capsular and subacromial release is essential to mobilize the tear and decrease the traction on the repair. This is performed with a radiofrequency device (VAPR Mitek, Johnson and Johnson, Norwood, MA).

For posterosuperior cuff tears, the coracoacromial ligament is released from the base of the coracoid at the anterosuperior edge of the glenoid rim with intra-articular assessment. The capsule is released above the labrum from the anterior superior to posterior superior quadrants. Release bursal side scar tissue is removed medially until the cuff muscle is seen.

Special care must be given to the subscapularis release for massive retracted tendons because it usually requires visualization of the axillary nerve and the medial plexus with the axillary artery (Fig. 8-9). This can be a dangerous part of the surgery that should not be done by arthroscopy without advanced expertise.

Acromioplasty is systematically performed in addition to the tendon repair, except for massive, partially repairable ruptures where the CA arch is the last structural element to keep superior stability and avoid anterior superior escape of the humeral head. If lack of space impedes the exposure or the passage of the instruments, acromioplasty is performed prior to repair of the tendon. Otherwise it is done after repair to avoid additionalbleeding during the repair. The coracoacromial ligament is released with an electrocautery. A burr is used to remove bone from the acromion starting at the anterior lateral corner and proceeding medial to the AC joint to achieve a flat type I acromion (Fig. 8-10).

When necessary, AC joint resection is done after acromioplasty in three steps:

Anchors. The type of fixation depends on the bone quality and influences the technique used for anchor insertion. The use of push-in anchors (vs. thread in anchors) enables the surgeon to first pass a suture through the cuff, then load the anchor with the suture and place the anchor in bone. When using screw-in anchors or anchors with two preloaded sutures, an anchor-in first technique is required. The author typically uses metallic implants and reserves the use of absorbable anchors. Tendon attachment is close to articular cartilage when restoring the medial foot print of the rotator cuff or when performing a biceps tenodesis.

Location of the fixation is done according to the lesion, but whenever possible, restoring the normal footprint of the rotator cuff is performed by adding a double row of anchors. One row restores the lateral tendon attachment and the other medial cartilaginous attachment.

Suture No. 2 or No. 3 is always a braided nonabsorbable. PDS sutures break before tendon healing.

Different techniques to pass the braided suture through the tendon using different devices must be available.