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Humeral Insertion of the Supraspinatus and Infraspinatus. New Anatomical

Findings Regarding the Footprint of the Rotator Cuff: Surgical Technique

Article in The Journal of Bone and Joint Surgery · April 2009

DOI: 10.2106/JBJS.H.01426 · Source: PubMed

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COPYRIGHT © 2 009 BY THE JOURNAL OF BONE AND JOINT SURGERY, I NCORPORATED

Humeral Insertion of the Supraspinatus

and Infraspinatus. New Anatomical
Findings Regarding the Footprint
of the Rotator Cuff
Surgical T echnique
By Tomoyuki Mochizuki, MD, Hiroyuki Sugaya, MD, Mari Uomizu, MD, Kazuhiko Maeda, MD,
Keisuke Matsuki, MD, Ichiro Sekiya, MD, Takeshi Muneta, MD, and Keiichi Akita, MD
Investigation performed at the Unit of Clinical Anatomy, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 90-A, pp. 962-9, May 2008

ABSTRACT FROM THE ORIGINAL ARTICLE

BACKGROUND: It is generally believed that the supraspinatus is the most commonly involved tendon in rotator cuff tears.
Clinically, however, atrophy of the infraspinatus muscle is frequently observed in patients with even small to medium-size
rotator cuff tears. This fact cannot be fully explained by our current understanding of the anatomical insertions of the su-
praspinatus and infraspinatus. The purpose of this study was to reinvestigate the humeral insertions of these tendons.
METHODS: The study included 113 shoulders from sixty-four cadavers. The humeral insertion areas of the supraspinatus
and infraspinatus were investigated in ninety-seven specimens. In sixteen specimens, all muscular portions of the
supraspinatus and infraspinatus were removed, leaving the tendinous portions intact, in order to define the specific char-
acteristics of the tendinous portion of the muscles. Another twenty-six shoulders were used to obtain precise measure-
ments of the footprints of the supraspinatus and infraspinatus.
RESULTS: The supraspinatus had a long tendinous portion in the anterior half of the muscle, which always inserted into the
anteriormost area of the highest impression on the greater tuberosity and which inserted into the superiormost area of the
lesser tuberosity in 21% of the specimens. The footprint of the supraspinatus was triangular in shape, with an average max-
imum medial-to-lateral length of 6.9 mm and an average maximum anteroposterior width of 12.6 mm. The infraspinatus had
a long tendinous portion in the superior half of the muscle, which curved anteriorly and extended to the anterolateral area of
the highest impression of the greater tuberosity. The footprint of the infraspinatus was trapezoidal in shape, with an average
maximum medial-to-lateral length of 10.2 mm and an average maximum anteroposterior width of 32.7 mm.
CONCLUSIONS: The footprint of the supraspinatus on the greater tuberosity is much smaller than previously believed, and
this area of the greater tuberosity is actually occupied by a substantial amount of the infraspinatus.
LEVEL OF EVIDENCE: The present study suggests that rotator cuff tears that were previously thought to involve only the su-
praspinatus tendon may in fact have had a substantial infraspinatus component as well.
ORIGINAL ABSTRACT CITATION: “Humeral Insertion of the Supraspinatus and Infraspinatus. New Anatomical Findings Regard-
ing the Footprint of the Rotator Cuff” (2008;90:962-9).

DISCLOSURE: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess
of $10,000 from KAKENHI (19890069) Grant-in-Aid for Young Scientists (Start-up). Neither they nor a member of their immediate families received payments or
other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct,
any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of
their immediate families, are affiliated or associated.

J Bone Joint Surg Am. 2009;91 Suppl 2 (Part 1):1-7 • doi:10.2106/JBJS.H.01426

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Illustrations of the superior aspect of the right

humerus, showing the humeral insertions of the
supraspinatus and infraspinatus. A: An illustra-
tion based on the generally accepted concept of
the anatomy of the humeral insertions. The su-
praspinatus is shown to insert into the superior
facet and the infraspinatus, into the middle facet
(middle impression) of the greater tuberosity. B:
An illustration based on the findings of the
present study. The insertion area of the in-
fraspinatus occupies approximately half of the
superior facet and the entire middle facet of the
greater tuberosity. The insertion area of the su-
praspinatus is located at the anteromedial re-
gion of the superior facet and is sometimes
FIG. 1-A located at the superiormost area on the lesser
tuberosity.

FIG. 1-B

INTRODUCTION highest impression) of the higher proportion than previ-

Previous reports regarding rota- greater tuberosity, while that of ously appreciated.
tor cuff tears have stated that the infraspinatus occupied the On the basis of these
most tears primarily involve the majority of the greater tuberos- findings, when we repair full-
supraspinatus and not the ity including the anterolateral as- thickness rotator cuff tears, we
infraspinatus1-3. In the present pect of the superior facet (Fig. 1). believe that it is very important
study, however, the footprint of These results imply that the in- to bring the posteromedial leaf
the supraspinatus was found to fraspinatus tendon may be in- anterolaterally and reattach it to
be limited to the anteromedial volved in small to medium-size the anterior portion of the
aspect of the superior facet (the rotator cuff tears in a much greater tuberosity in order to
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A: A typical full-thickness rotator cuff

tear that involves the supraspinatus
and infraspinatus. B: The posterior leaf
is easily mobilized anterolaterally (ar-
row). In this situation, margin conver-
gence repair is not recommended. C:
The posterior leaf is reattached to the
anterolateral portion of the superior
facet of the greater tuberosity. The re-
pair is augmented by applying side-to-
side stitches to the anterior leaf.

FIG. 2-A

FIG. 2-B FIG. 2-C

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FIG. 3

A: A large delaminated rotator cuff tear viewed from the posterolateral portal (right shoulder). B: A grasper holds the deep layer (asterisk) of
the posterior leaf. C: The posterior leaf is easily mobilized anterolaterally. D: The posterior leaf is reattached to the anterior portion of the
greater tuberosity. GT = greater tuberosity, HH = humeral head, and LHB = long head of biceps tendon.

achieve a balanced anatomical humeral joint. An anterior por- subacromial decompression is

repair. tal through the rotator interval
In the present report, we de- is established as the working
scribe the pearls and pitfalls for portal for the treatment of
the balanced anatomical repair of intra-articular lesions. The tear
full-thickness rotator cuff tears size and the presence of delami-
on the basis of the results of our nation are carefully deter-
anatomical study. mined. The arthroscope is then
removed from the glenohumeral
SURGICAL TECHNIQUE joint and is redirected into the
Arthroscopic Evaluation subacromial space. A lateral
The patient is seated in the portal and a posterolateral por-
beach-chair position while un- tal are also established. Any
der general anesthesia. A poste- pathological bursal tissue that
rior portal is established for the impedes clearance of the space is
initial assessment of the gleno- removed, and an arthroscopic
performed to create a flat acro-
mial undersurface. Osteophytes
extending from the inferior part
of the acromioclavicular joint
and the distal end of the clavicle
are also removed as necessary.
The posterolateral portal is used
mainly as a viewing portal in
these procedures.
Repair of a Full-Thickness Tear
The tear size and pattern are
again evaluated, and the mobility
and repairability of the torn rota-
tor cuff are then estimated.
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When a full-thickness tear is re- rotator interval slide. The foot- tus was torn and retracted pos-
paired, the mobility of the poste- print of the greater tuberosity is teromedially (Fig. 4). Therefore,
rior leaf is typically better than débrided in order to expose cor- the most critical concept in our
that of the central or anterior tical bone, but excessive removal procedure is to bring the torn
leaf. If the tear is a full-thickness of bone is avoided. A double row edge of the infraspinatus antero-
u-shaped tear (Fig. 2, A), it is repair of the posterior leaf as well laterally and reattach it to the
easily reduced by pulling the pos- as a side-to-side repair are then anterior area of the greater tu-
terior leaf anterolaterally toward performed (Fig. 2, C), instead of berosity (Figs. 2 and 3).
the anterior edge of the greater performing a so-called margin
tuberosity (Figs. 2, B and 3). If convergence repair. Margin Convergence
the mobility of the tendon is in- Repair May Not Be the
sufficient in a larger tear, a ten- Advance the Posterior Preferred Procedure
don mobilization procedure is Leaf Anterolaterally In the repair of the so-called u-
performed. This includes a cap- In our anatomical study, the su- shaped tear and some of the
sulotomy at the undersurface of praspinatus inserted into the crescent-type tears (Fig. 2), the
the supraspinatus and in- most anterior aspect of the margin convergence procedure,
fraspinatus and release of the co- greater tuberosity in normal which is a direct side-to-side su-
racohumeral ligament at the specimens without a rotator cuff ture of both the anterior and
origin of the posterior aspect of tear (Fig. 1). In addition, in posterior leafs, is commonly
the coracoid process. However, most cadaver specimens with a preferred by many surgeons4. It
we do not perform the so-called rotator cuff tear, the infraspina- is true that the margin conver-

FIG. 4

A: A typical full-thickness rotator cuff tear localized to the anteromedial portion seen in a cadaver shoulder. This is generally thought to be
an isolated supraspinatus tear. B: When the overlapping coracohumeral ligament is removed, the tear also appears to involve the anterior
half of the infraspinatus tendon. C: After the anterior half of the infraspinatus tendon is removed, only a minor tear of the posterior portion
of the supraspinatus tendon is observed. However, the anterior portion of the supraspinatus tendon appears to be intact. CP = coracoid
process, ISP = infraspinatus, SSP = supraspinatus, ant = anterior, and med = medial.
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gence procedure is sometimes are amenable to successful ana- has a long intramuscular ten-
very effective in reducing the tomical repair by mobilization dinous portion located in the
size of the u-shaped tear. How- of the posterior infraspinatus anterior half of the muscle,
ever, on the basis of our ana- and supraspinatus flap. which was found to insert into
tomical study, it is evident that the most superior area of the
the posterior leaf of a so-called Preserve the “Comma” lesser tuberosity in 21% of our
L-shaped tear has retracted pos- During a Repair specimens (Fig. 5, B). We be-
teromedially to alter the final Involving the Subscapularis lieve that the comma represents
configuration of the tear to a u- Lo and Burkhart reported on this tendinous portion of the
shaped lesion in the chronic the utility of the comma sign, supraspinatus, which connects
stage. Therefore, we think that which is a comma-shaped arc of the supraspinatus and the sub-
surgeons should be more careful tissue located at the superolat- scapularis. Therefore, when we
in choosing to apply the margin eral border of the subscapularis, repair the subscapularis, it is
convergence technique in u- delineating the retracted edge of very important to preserve this
shaped tears5. We strongly rec- the subscapularis6 (Fig. 5, A). connecting tissue to avoid post-
ommend that the mobility of They also suggested that the operative structural failure as
the torn rotator cuff be evalu- comma is actually the remnant well as to restore the function of
ated to determine the repair de- of the medial sling of the bi- the supraspinatus.
sign because the posterior leaf is ceps, which is composed of fi-
normally very mobile com- bers of the medial head of the Rotator Interval Slide
pared with the anterior or the coracohumeral ligament as well May Not Be a
central leaf; this would allow as a portion of the superior gle- Preferable Procedure
conversion of many u-shaped nohumeral ligament. We re- The interval slide, either anteri-
lesions to L-shaped tears that ported that the supraspinatus orly or posteriorly, has been re-
ported to be a very effective
procedure for mobilization of
retracted massive rotator cuff
tears7,8. However, as we demon-
strated in our anatomical study,
the distal end of the infraspina-
tus tendon courses anterolater-
ally and inserts into the
anterolateral portion of the su-
perior facet. Further, some of
the tendinous fibers of the su-
praspinatus run across the bi-
cipital groove and insert into the
lesser tuberosity. We believe that
FIG. 5
these structures work as a hori-
zontal link of each rotator cuff
A: The comma (black star) viewed from the posterior portal (right shoulder). The comma-
shaped arc of tissue leads to the superolateral edge of the subscapularis tendon. B: The
tendon, especially in large re-
fibers from the supraspinatus tendon insert on the lesser tuberosity (superior aspect of tracted tears. Therefore, it is
the right shoulder). SSC = subscapularis, HH = humeral head, Bg = bicipital groove, CP = very important to preserve
coracoid process, GT = greater tuberosity, ISP = infraspinatus, LT = lesser tuberosity, these structural interconnec-
SS = scapular spine, SSP = supraspinatus, med = medial, and ant = anterior.
tions in order to avoid failures
after repair.
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CRITICAL CONCEPTS

INDICATIONS:
This procedure is applicable for every reparable rotator cuff tear.

CONTRAINDICATIONS:
There is no specific contraindication to this procedure if the tear is reparable.

PITFALLS:
Margin convergence repair is not the preferred method for repairing u-shaped rotator cuff tears because most u-shaped
types of tears are chronic and represent an advanced stage of the L-shaped tear. Surgeons should evaluate the mobility
of the posterior leaf of the tear before applying the margin convergence technique.

The rotator interval slide as a method to increase mobility in large retracted tears is not preferred because the tendinous
fibers intermingle with each other and work as a horizontal link at the distal end of the rotator cuff tear. If surgeons vio-
late this structure, the risk of postoperative failure may be increased.

AUTHOR UPDATE:
Through our clinical experience, we believe that, normally, the posterior leaf of the torn rotator cuff is more mobile com-
pared with the anterior or central leaf. Furthermore, we have wondered why the integrity of the repair is relatively poor af-
ter the use of the margin convergence suture technique and the rotator interval slide in larger tears. Therefore, we are
very reluctant to use the margin convergence technique for large u-shaped tears or to use the rotator interval slide as a
mobilization procedure for large retracted tears.

Tomoyuki Mochizuki, MD
Mari Uomizu, MD
Ichiro Sekiya, MD
Takeshi Muneta, MD
Keiichi Akita, MD
Unit of Clinical Anatomy (M.U. and K.A.) and Sec-
tion of Orthopaedic Surgery (T. Mochizuki, I.S.,
and T. Muneta), Graduate School, Tokyo Medical
and Dental University, 1-5-45 Yushima, Bunkyo-ku,
Tokyo 113-8519, Japan. E-mail address for T.
Mochizuki: mochizuki.orj@tmd.ac.jp. E-mail
address for K. Akita: akita.fana@tmd.ac.jp
Hiroyuki Sugaya, MD
Kazuhiko Maeda, MD
Funabashi Orthopaedic Sports Medicine Center, 1-
833 Hazama, Funabashi, Chiba 274-0822, Japan
Keisuke Matsuki, MD
Department of Orthopedic Surgery, Teikyo Univer-
sity Chiba Medical Center, 3426-3 Anegasaki Ichi-
hara, Chiba 299-0111, Japan
The line drawings in this article are the work of
Joanne Haderer Müller of Haderer & Müller
(biomedart@haderermuller.com).
REFERENCES
1. Jerosch J, Müller T, Castro WH. The
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2. Lehman C, Cuomo F, Kummer FJ, Zucker-
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3. Harryman DT 2nd, Mack LA, Wang KY,
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