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Current Concepts With Video Illustration

The Geometric Classification of Rotator Cuff Tears: A SystemLinking Tear Pattern to Treatment and Prognosis

James Davidson, M.D., and Stephen S. Burkhart, M.D.

Abstract: A valuable classification system allows for communication among surgeons and/or otherinvestigators and offers information on treatment and prognosis. It provides a means for comparisonof epidemiologic data and treatment outcomes. There is no current standard classification for rotatorcuff tears. Authors and practicing orthopaedists use a variety of descriptions when communicatingabout cuff tears. Older classifications do not use 3-dimensional information derived from the presentuse of arthroscopy and magnetic resonance imaging. The new geometric classification offersguidance on treatment and prognosis. Type 1, crescent-shaped tears are repaired end to bone and havea good to excellent prognosis. Type 2, longitudinal (L- or U-shaped) tears are repaired side to sidewith margin convergence and have a good to excellent prognosis. Type 3, massive contracted tearshave coronal and sagittal dimensions greater than 2 � 2 cm on preoperative magnetic resonanceimaging; are repaired with interval slides or partial repair; and have a fair to good prognosis. Type4, rotator cuff arthropathy tears have end-stage degenerative changes of the glenohumeral joint andhave articulation of the humeral head with the undersurface of the acromion; are irreparable; andrequire arthroplasty if surgery is considered. This classification describes complete tears of thesuperior and posterior rotator cuff, supraspinatus, infraspinatus, and teres minor. Additional notationcan be made regarding the presence of related pathology including tears of the subscapularis, biceps,or labrum; instability or arthritic change of the glenohumeral or acromioclavicular joints; or fattydegeneration of the cuff.

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n 1944 McLaughlin1 described lesions of the cuffas (1) transverse ruptures, (2) vertical splits, and

3) retracted tears. The geometric classification de-cribed in this article shares common features withcLaughlin’s classification. However, McLaughlin’s

From Canyon Orthopaedic Surgeons (J.D.), Phoenix, Arizona,nd The San Antonio Orthopaedic Group (S.S.B.), San Antonio,exas, U.S.A.The authors report no conflict of interest.Received May 12, 2009; accepted July 6, 2009.Address correspondence and reprint requests to Stephen S.

urkhart, M.D., The San Antonio Orthopaedic Group, 150 Eonterra Blvd, Ste 300, San Antonio, TX 78258, U.S.A. E-mail:sburkhart@msn.com

© 2010 by the Arthroscopy Association of North America0749-8063/10/2603-9261$36.00/0doi:10.1016/j.arthro.2009.07.009

bNote: To access the video accompanying this report, visit theMarch issue of Arthroscopy at www.arthroscopyjournal.org.

Arthroscopy: The Journal of Arthroscopic and Related S

ystem was not widely adopted. Later cuff tear clas-ifications often described the 1-dimensional length oftendon tear or the number of tendons torn. They didot take advantage of 3-dimensional information onear pattern that is obtained from preoperative mag-etic resonance imaging (MRI) or at arthroscopy torovide guidance on treatment technique such as end-o-bone repair, side-to-side repair, or interval slides.eOrio and Cofield2 used the length of the greatestiameter of the tear to categorize the tear into 1 of 4roups: small, medium, large, or massive. However, a-dimensional description of a tear can be misleadingecause a complete cuff avulsion described as mas-ive, implying a difficult repair and unfavorable prog-osis, may in fact lie directly over the bed of thensertion site, be easy to repair, and have a predictablyood result. The systems of Harryman et al.3 anderber et al.4 each characterized the status of the cuff

ased on the number of tendons torn. These systems

417urgery, Vol 26, No 3 (March), 2010: pp 417-424

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o not differentiate specific tear pattern or method ofepair (Table 1).

ROTATOR CUFF GEOMETRIC TEARPATTERNS, METHODS OF REPAIR,

AND PROGNOSIS

The geometric classification has 4 types (Table). Type 1, crescent-shaped tears are relatively shortnd wide.5-8 The medial-to-lateral length of theseears is less than the anterior-to-posterior width.ype 1 tears are typically mobile from medial to

ateral and can usually be repaired by fixing theendon end directly to the bone bed on the greaterumeral tuberosity (Fig 1). It has been shown thatepair of crescent-shaped tears with end-to-boneechniques results in good to excellent modifiedniversity of California, Los Angeles (UCLA) scores

Table 3).5 Tear patterns can be determined on preop-rative MRI in the manner previously described and asummarized in Table 4 and Figs 2, 3, and 4.6 An MRIcan showing a tear with a coronal length (L) that isess than or equal to the sagittal width (W) and aength less than 2 cm (L � W, L �2 cm) predicts arescent-shaped tear and an end-to-bone repair (Figs 5nd 6).6 By recognizing a type 1, crescent-shaped tear

TABLE 1. Previous Cuff Tear Classification Systems

SystemMethod of

Classification Downside

cLaughlin1 Transverse, vertical,retracted

Not widely recognized;created before MRIbecame available

eOrio andCofield2

Length of greatestdiameter of tear

Not 3-dimensional; canoverestimatedifficulty of repair

arryman et al.3 No. of tendons torn Does not differentiatetear pattern ormethod of repair

erber et al.4 No. of tendons torn Does not differentiatetear pattern ormethod of repair

TABLE 2. Geo

Type Description Preoperative MRI Findings

1 Crescent Short and wide tear2 Longitudinal (L or U) Long and narrow tear3 Massive contracted Long and wide, �2 � 2 cm

4 Cuff tear arthropathy Cuff tear arthropathy Art

attern, the surgeon can anticipate an end-to-boneepair and a predictably good to excellent result.

Type 2, longitudinal (U-shaped and L-shaped)ears are relatively long and narrow (Figs 7 and).5-8 The medial-to-lateral length of these tears isreater than the anterior-to-posterior width. Type 2, lon-itudinal tears are typically mobile in an anterior/osterior direction and can usually be repaired by aide-to-side/margin convergence technique. Attempt-ng to laterally mobilize the medial apex of a longi-udinal tear to the lateral bone bed can result in sig-ificant tensile stress in the middle of the repairedotator cuff margin and lead to ultimate failure. Side-o-side closure of longitudinal tears has been shown toeduce the strain of the lateral free margin of the cuffn its converged configuration, by the biomechanicalrinciple of margin convergence,5,7,8,9 so that theconverged margin” can then be repaired to bone withuture anchors. It has been shown that repair of lon-itudinal tears with side-to-side/margin convergenceechniques combined with tendon-to-bone repair re-ults in good to excellent modified UCLA scores.5 An

RI scan with length (L) greater than width (W) and

IGURE 1. (A) A type 1, crescent-shaped tear is short and wideith a medial-to-lateral length (L) less than the anterior-to-poste-

ior width (W). (B) Crescent tears can usually be repaired with airect tendon end–to–bone technique. (IS, infraspinatus; SS, su-raspinatus.)

Classification

Treatment Prognosis Reference

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419CLASSIFICATION OF ROTATOR CUFF TEARS

idth less than 2 cm (L � W, W �2 cm) predicts aongitudinal tear and side-to-side/margin convergenceepair (Figs 9 and 10).6 This classification systemoints out that a type 2, longitudinal tear should bexed without tension side to side and leads to aredictably good to excellent outcome.Type 3, massive contracted tears are long andide (Fig 11). They are too long for the tendon end

o be pulled laterally directly to bone and, similarly,re too wide for the edges to be closed directly sideo side. Other repair techniques such as intervallides or partial repairs are necessary for this type of

TABLE 3. Modified UCLA Scoring System

Category Points

ainPresent all of the time and unbearable; strong

medication frequently 1Present all of the time but bearable; strong

medication occasionally 2None or little at rest, present during light

activities; salicylates frequently 4Present during heavy or particular activities only;

salicylates occasionally 6Occasional and slight 8None 10

unctionUnable to use limb 1Only light activities possible 2Able to do light housework or most activities of

daily living 4Most housework, shopping, and driving possible;

able to do hair and dress and undress, includingfastening brassiere 6

Slight restrictions only; able to work aboveshoulder level 8

Normal activities 10ctive forward flexion�150° 5120°-150° 490°-120° 345°-90° 230°-45° 10°-30° 0

trength of resisted external rotation (manual testing)Grade 5 (normal) 5Grade 4 (good) 4Grade 3 (fair) 3Grade 2 (poor) 2Grade 1 (muscle contraction) 1Grade 0 (nothing) 0

atisfaction of patientSatisfied and better 5Not satisfied and worse 0

NOTE. UCLA rating results: poor, 0 to 21; fair, 22 to 27; good,8 to 33; and excellent, 34 to 35.

ear.6,10-15 Treatment of massive contracted tearsequiring interval slides results in good mean mod-fied UCLA scores.10 Treatment of massive tearsith partial repair results in fair mean modifiedCLA scores.11 An MRI scan with a maximum

ength greater than or equal to 2 cm and maximumidth greater than or equal to 2 cm (L �2 cm, W2 cm) predicts that interval slides or partial repair

s necessary in over 75% of cases and that directnd-to-bone or side-to-side repair is usually notossible (Figs 12 and 13). Similarly, an MRI scanith a maximum length greater than or equal to 3

FIGURE 2. (A) The maxi-mum medial-to-lateral length(L) of the tear is measured onT2-weighted coronal obliqueMRI views by use of the scaleprinted on the MRI scan. (B)If no lateral stump of cuff ispresent, measurement is madeto the apex of the tuberosity.(C) The partial-thickness por-tion of a tear is not used in

TABLE 4. How to Predict Cuff Tear Pattern and Methodof Repair on Preoperative MRI

. Measure maximum tear length (L) on T2-weighted coronalimage.

. Measure maximum tear width (W) on T2-weighted sagittalimage.

. L �W and L �2 cm predict a crescent-shaped tear andend-to-bone repair.

. L �W and W �2 cm predict a longitudinal tear and side-to-side/margin convergence repair.

. L �2 cm and W �2 cm predict that, in over 75% of cases,direct primary repair (end to bone or side to side) is notpossible and that other techniques such as interval slides orpartial repair are necessary.

. L �3 cm and W �3 cm predict that, in all cases, directprimary repair (end to bone or side to side) is not possible andthat other techniques such as interval slides or partial repairare necessary.

measurements.

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m and maximum width greater than or equal to 3m (L �3 cm, W �3 cm) predicts that intervallides or partial repair is necessary in all cases.6 Ithould be recognized preoperatively that a 3 �

FIGURE 3. (A) The maxi-mum anterior-to-posteriorwidth (W) of a tear is mea-sured on T2-weighted sagit-tal oblique MRI views usingthe scale printed on the MRIscan. (B) In a massive tear, ifno anterior tissue is present,the shortest tangential linefrom the superior coracoid tothe humeral head is used toapproximate the location ofthe rotator interval. Mea-surement is made to thispoint. (C) The partial-thick-ness portion of a tear is notused in measurements.

IGURE 4. Tendon edges are characterized on MRI as (A) blunt,B) tapered, or (C) wispy. Measurements are made as depicted.

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– cm massive contracted tear seen on MRI willequire interval slides or partial repair for treatmentnd will have a less favorable outcome than a 1 �– cm crescent-shaped tear repaired directly toone. Similarly, it will have a less favorable out-ome than a 3 � 1– cm longitudinal tear repairedith margin convergence. In prior systems all of

hese tears would have been classified as 3-cm tearsithout distinction, failing to differentiate treat-ent method or prognosis.Type 4, rotator cuff arthropathy tears are associ-

ted with significant glenohumeral arthrosis andomplete loss of the acromiohumeral interspace.hese tears are irreparable by arthroscopic or openethods. When addressed surgically, the current

reatment is arthroplasty, with variable results andechniques reported in the literature. Imaging showsrticulation of the humeral head with the undersur-

IGURE 5. Type 1, crescent-shaped tear. The maximum medial-o-lateral length (L) measured on the T2-weighted coronal MRImages is less than or equal to the maximum anterior-to-posterioridth (W) measured on the T2-weighted sagittal MRI images, and

he length is less than 2 cm (L �W, L �2 cm).

IGURE 6. Clinical example of a type 1, crescent-shaped tear on

RI with maximum coronal length (left) less than maximum

agittal width (right).

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421CLASSIFICATION OF ROTATOR CUFF TEARS

ace of the acromion and end-stage glenohumeralrthrosis (Fig 14).

DISCUSSION

The geometric classification of rotator cuff tearsill help orthopaedic surgeons communicate about

ears of the supraspinatus, infraspinatus, and teresinor based on tear pattern recognition (Video 1,

vailable at www.arthroscopyjournal.org). It providesmportant guidance for treatment and prognosis forach type of tear. The previous studies providinghe foundation for this classification were per-ormed by the same surgeon (S.S.B.) and assessedesults by means of the same modified UCLA scor-ng system, allowing direct comparison of the re-ults of the tear types described in this report.5,6,10,11

ecause the geometric classification uses preoper-tive MRI, it can be used in the surgeon’s preoper-tive decision making and counseling of the patient.t consolidates and organizes current concepts in

IGURE 9. Type 2, longitudinal tear. The maximum length (L)easured on the T2-weighted coronal images is greater than theaximum width (W) measured on the T2-weighted sagittal im-

ges, and the width is less than 2 cm (L �W, W �2 cm).

FIGURE 7. (A) Type 2, lon-gitudinal tear. This U-shapedlongitudinal tear is long andnarrow. The medial-to-laterallength (L) is greater than theanterior-to-posterior width (W).(B, C) Longitudinal tears canusually be repaired with aside-to-side/margin conver-gence technique along withlateral suture anchors. (IS,infraspinatus; SS, supraspi-natus.)

FIGURE 8. (A) Type 2, lon-gitudinal tear. This L-shapedtear is long and narrow. Thelength (L) is greater than thewidth (W). (B, C) L-shapedtears can usually be repairedwith a side-to-side/marginconvergence technique alongwith lateral suture anchors.(IS, infraspinatus; SS, su-praspinatus; RI, rotator inter-val; Sub, subscapularis; CHL,coracohumeral ligament.)

IGURE 10. Clinical example of a type 2, longitudinal tear on MRI with

aximal coronal length (left) greater than sagittal width (right).

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422 J. DAVIDSON AND S. S. BURKHART

FIGURE 11. (A) Type 3,massive contracted tears arelong and wide. Direct end-to-bone or side-to-side repairs arenot possible. Interval slides areoften required. (B) Anterior andposterior releases are made. (C)After release, there is improvedtissue mobility. (D) The su-praspinatus can then be repairedto the bone bed. (E) The poste-rior defect is closed with side-to-side sutures. (IS, infraspina-tus; SS, supraspinatus; Sub,

subscapularis; CHL, coracohu-meral ligament.) F

iof the humeral head with the acromion.

IGURE 12. Type 3, massive contracted tear. Both the maximum length

L) measured on coronal MRI scans and the maximum width (W)easured on sagittal MRI scans are greater than or equal to 2 cm.

IGURE 13. Clinical example of a type 3, massive contracted tear

IGURE 14. Radiograph of type 4, rotator cuff arthropathy. Theres end-stage degeneration of the glenohumeral joint and articulation

Review MRI T2 Coronal & Sagi�al

Short/Wide Crescent

Long/Narrow Longitudinal

Long/Wide Massive contracted

Interval slides or Par�al Repair

Side to side repair Margin convergence

End to bone repair

Good to excellent prognosis

Good to excellent prognosis

Fair to good prognosis less predictable result

FIGURE 15. Treatment algorithm for rotator cuff tears.

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423CLASSIFICATION OF ROTATOR CUFF TEARS

rthroscopic rotator cuff repair but can be applied touff tears in open surgery as well. It will allowppropriate future comparison and contrast of epi-emiologic data and outcomes research of varyingear types (Table 4 and Fig 15).

For ease and practicality of use, this classificationoes not address numerous comorbidities such as sub-capularis tears, biceps tendon tears or instability,abral tears, glenohumeral degeneration or instability,cromioclavicular joint disease, or cuff fatty degener-tion, all of which should be considered in the treat-ent of shoulder disorders. These complicating fea-

ures can be noted separately (Table 5). Thoughotentially valuable, a universal classification thatddresses each facet of shoulder pathology woulduickly become unwieldy, sacrificing the primaryoals of simple description and categorization.Several of these comorbidities will be considered.

ubscapularis tears are frequently seen in conjunctionith supraspinatus tears and are increasingly recog-ized as a source of pain and dysfunction.16-22 In onetudy evaluating 40 patients with subscapularis tears,here were 7 isolated subscapularis tears and 33 sub-capularis tears combined with supraspinatus tears andther rotator cuff tears.16 Arthroscopic repair of theseears resulted in good mean modified UCLA scores.

IGURE 16. MRI scans showing fatty degeneration of greater than5%. (A) T2-weighted coronal image with greater than 75% fattyegeneration of infraspinatus (arrow). (B) T1-weighted sagittal

TABLE 5. Comorbidities of Cuff Tear Affecting Outcome

Subscapularis tearsBiceps tendon tearsBiceps instabilityLabral tearsGlenohumeral arthritisGlenohumeral instabilityAcromioclavicular joint diseaseCuff fatty degeneration

mage with greater than 75% fatty degeneration of infraspinatusarrow).

iceps tendon pathology is very commonly associatedith subscapularis lesions and was encountered in3% of cases in this study. In addition, radiographicvidence of glenohumeral degenerative change corre-ated with a less favorable outcome.

Similarly, SLAP tears and rotator cuff tears can beound concomitantly. In a study of type II SLAPesions, rotator cuff tears were also found in 31% ofases.23 Of the 53 SLAP lesions in overhead/throwingthletes in this study, there were 10 partial-thicknessotator cuff tears and 1 complete rotator cuff tear. Ofhe 49 SLAP lesions in the traumatic group in thistudy, there were 10 partial-thickness rotator cuff tearsnd 11 complete rotator cuff tears. Of note, it has beenur observation that simultaneous repair of cuff andLAP tears can result in an unacceptably high inci-ence of postoperative stiffness, and rehabilitationrotocols may need to be accelerated to address this.Rotator cuff tears can also be seen in conjunctionith instability cases. In a study of 33 consecutiveatients who underwent shoulder arthroscopy imme-iately before the modified Latarjet procedure, 2 ro-ator cuff tears were also encountered.24 Furthermore,n a consecutive series of 61 arthroscopic Bankartepairs by the senior author, rotator cuff tears were

TABLE 6. Fatty Degeneration: Results of Repair ofCuff Tear

% Fatty Degeneration Mean Modified UCLA Score

50%-75% Good�75% Fair/unpredictable

TABLE 7. Points, Pearls, and Pitfalls

● Preoperative MRI can alert the surgeon to cuff tear size,geometric shape, method of repair, and prognosis.

● T2-weighted MRI scans are better than T1-weighted MRIscans for determining cuff tear pattern. The intact cuff isdark, and the tear is bright.

● Some tears appear misleadingly massive on a single MRIview. It is important to characterize the tear on both coronaland sagittal views.

● The lateral arthroscopic viewing portal is best fordetermining tear pattern.

● Repairing a longitudinal tear side to side with marginconvergence significantly decreases strain and tension on therepair.

● Tears that are both long and wide require interval slides orpartial repair and cannot be repaired directly side to side orend to bone.

● High-quality MRI is necessary to make accurate

measurements and determine tear pattern.

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dentified in 14 patients (23%), with a mean tear sizef 2.6 cm (S.S.B., unpublished data, June 2006).Fatty degeneration is estimated on coronal and sag-

ttal MRI cuts as a percentage of fatty tissue in relationo normal muscle tissue in the supraspinatus and in-raspinatus (Fig 16). Severe degrees of fatty degener-tion of the rotator cuff, greater than 75%, have beenound to unfavorably affect treatment outcome.25 For-unately, this high degree of fatty degeneration isncommonly encountered. In a study of massive ro-ator cuff tears (classified by other methods), only 22f 103 cuffs had fatty degeneration of 50% or greaternd only 5 had fatty degeneration of 75% or greater.25

rthroscopic repair of tears with fatty degeneration of5% or greater resulted in fair mean modified UCLAcores. Among 5 patients, the results were excellent in, fair in 1, and poor in 3. We concluded that surgeryor cuff tears with fatty degeneration of greater than5% may be worthwhile but that results are variablend that realistic expectations should be anticipated.owever, arthroscopic repair or tears with fatty de-eneration of 50% to 75% resulted in good meanodified UCLA scores. Among 17 patients, thereere 7 excellent, 7 good, 3 fair, and no poor results

Table 6). In this study clinical improvement wasbserved in 86% of cases that would have previouslyeen predicted as likely to fail by the Goutallier cri-eria.25,26

In conclusion, over time, the methods of treatmentnd prognosis associated with each tear pattern type inhis system may improve with advances in orthopae-ics, and these features of the classification will needo be updated. Recognition of the geometric tear pat-erns described in this classification will remain usefulnd serve as a basis for communication and compar-son of treatment methods and outcomes (Table 7).

REFERENCES

1. McLaughlin H. Lesions of the musculotendinous cuff of theshoulder. J Bone Joint Surg 1944;26:31-51.

2. DeOrio JK, Cofield RH. Results of a second attempt at surgicalrepair of a failed initial rotator cuff repair. J Bone Joint SurgAm 1984;66:563-567.

3. Harryman DT, Mack LA, Wang K, Jackins SE, RichardsonML, Matsen FA. Repairs of the rotator cuff. Correlation offunctional results with integrity of the cuff. J Bone Joint SurgAm 1991;73:982-989.

4. Gerber C, Fuchs B, Hodler J. The results of repair of massivetears of the rotator cuff. J Bone Joint Surg Am 2000;82:505-515.

5. Burkhart SS, Danaceau SM, Pearce CE. Arthroscopic rotatorcuff repair: Analysis of results by tear size and by repair

technique-margin convergence versus direct tendon-to-bonerepair. Arthroscopy 2001;17:905-912.

6. Davidson JF, Burkhart SS, Richards DP, Campbell SE. Use ofpreoperative magnetic resonance imaging to predict rotator cuff tearpattern and method of repair. Arthroscopy 2005;21:1428.e1-1428.e10. Available online at www.arthroscopyjournal.org.

7. Burkhart SS. Current concepts: A stepwise approach to arthro-scopic rotator cuff repair based on biomechanical principles.Arthroscopy 2000;16:82-90.

8. Lo IK, Burkhart SS. Biomechanical principles of arthroscopicrepair of the rotator cuff. Oper Tech Orthop 2002;12:140-155.

9. Burkhart SS, Athanasiou KA, Wirth MA. Margin conver-gence: A method of reducing strain in massive rotator cufftears. Arthroscopy 1996;12:335-338.

0. Lo IK, Burkhart SS. Arthroscopic repair of massive, con-tracted, immobile rotator cuff tears using single and doubleinterval slides: Technique and preliminary results. Arthroscopy2004;20:22-33.

1. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS,Pachelli A. Partial repair of irreparable rotator cuff tears.Arthroscopy 1994;10:363-370.

2. Tauro JC. Arthroscopic rotator cuff repair: Analysis of tech-nique and results at 2- and 3-year follow-up. Arthroscopy1998;14:45-51.

3. Tauro JC. Arthroscopic “interval slide” in the repair of largerotator cuff tears. Arthroscopy 1999;15:527-530.

4. Cordasco FA, Bigliani LU. The rotator cuff: Large and mas-sive tears. Techniques of open repair. Orthop Clin North Am1997;28:179-193.

5. Codd TP, Flatow EL. Anterior acromioplasty, tendon mobili-zation and direct repair of massive rotator cuff tears. In:Burkhead WZ, ed. Rotator cuff disorders. Baltimore: Williams& Wilkins, 1996;330.

6. Adams CR, Schoolfield JD, Burkhart SS. The results of ar-throscopic subscapularis tendon repairs. Arthroscopy 2008;24:1381-1389.

7. Burkhart SS, Brady PC. Arthroscopic subscapularis repair:Surgical tips and pearls A to Z. Arthroscopy 2006;22:1014-1027.

8. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendonrepair: Technique and preliminary results. Arthroscopy 2002;18:454-463.

9. Bennett WF. Arthroscopic repair of anterosuperior (supraspi-natus/subscapularis) rotator cuff tears: A prospective cohortwith 2- to 4-year follow-up. Classification of biceps subluxa-tion/instability. Arthroscopy 2003;19:21-33.

0. Bennett WF. Arthroscopic repair of isolated subscapularistears: A prospective cohort with 2- to 4-year follow-up.Arthroscopy 2003;19:131-143.

1. Flury MP, John M, Goldhahn J, Schwyzer HK, Simmen BR.Rupture of the subscapularis tendon (isolated or in combina-tion with supraspinatus tear): When is a repair indicated? JShoulder Elbow Surg 2006;15:659-664.

2. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gob-ezie R. Structural integrity and clinical outcomes after arthro-scopic repair of isolated subscapularis tears. J Bone Joint SurgAm 2007;89:1184-1193.

3. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type IISLAP lesions: Three subtypes and their relationships to supe-rior instability and rotator cuff tears. Arthroscopy 1998;14:553-565.

4. Arrigoni P, Huberty D, Brady PC, Weber IC, Burkhart SS. Thevalue of arthroscopy before an open modified Latarjet recon-struction. Arthroscopy 2008;24:514-519.

5. Burkhart SS, Barth JR, Richards DP, Zlatkin MB, Larsen M.Arthroscopic repair of massive rotator cuff tears with stage 3and 4 fatty degeneration. Arthroscopy 2007;23:347-354.

6. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC.Fatty muscle degeneration in cuff ruptures. Pre- and postop-

erative evaluation by CT scan. Clin Orthop Relat Res 1994:78-83.