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Medium to Large Size Tears 1 to 4 Centimeters

When larger tears are encountered, the option of a simple decompression becomes less compelling. Some authors have described satisfactory early results with this approach only to discover progressive deterioration, especially in the larger tears. Although the possibility of an isolated decompression in a low demand individual with limited goals remains an option, patients with sizeable tears are more likely to benefit from a formal repair of the torn tendon.

The goals and steps outlined for smaller tears is applicable for tears of all sizes. There are, however, several technical “pearls” that can improve the ease of the procedure as well the final result in the larger and more challenging tears. Again, initial accurate identification of the tear configuration is the key step in achieving an anatomic repair.

In those with a chronic, retracted U-shaped tear, the principle of margin convergence can be used with great effect on the final construct. Converging the free margin of the retracted tear to the greater tuberosity by placing side to side sutures not only facilitates the tendon to bone repair, but also relieves the forces at the repair site as well.

For those chronically retracted L-shaped tears with an anterior extension, an interval release that divides the coracohumeral ligament can be very effective in gaining length and satisfactory mobilization such that an anatomic repair can be performed consisting of a side to side repair followed by tendon to bone. This same approach can be utilized for those L-shaped tears that exhibit a posterior extension with a diagonal retraction pattern.

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