The Accessory Posteromedial Portal Revisited: Utility for Arthroscopic Rotator Cuff Repair

Arthroscopic rotator cuff repair is a technically challenging procedure. Accessory arthroscopic portals have been described that allow for optimal suture anchor placement, suture management, and knot tying. We describe here the usefulness of an accessory posteromedial portal that facilitates direct suture retrieval through the posterior aspect of a rotator cuff tear. This portal is created approximately 4 to 5 cm medial to the posterolateral corner of the acromion and 2 cm inferior to the scapular spine. The accessory posteromedial portal is especially useful when a retracted tear of the infraspinatus or teres minor is encountered. Because these tendons retract in a posterior and medial direction, the accessory posteromedial portal places the tendon-penetrating device in an ideal position for suture passage through the posterior portion of the rotator cuff tear. This portal also allows placement of margin convergence sutures for large U-shaped or L-shaped tears by permitting a direct “hand-off” of the suture to or from a second penetrating device that is placed through a standard anterior portal. If multiple suture anchors are required (as in the case of large or massive cuff tears, or when double-row fixation is employed), sutures can be pulled out through the accessory posteromedial portal to facilitate suture management.     

The low-profile Roman bridge technique for knotless double-row repair of the rotator cuff

With advances in arthroscopic surgery, many techniques have been developed to increase the tendon–bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint and providing a better environment for tendon healing. We present a low-profile arthroscopic rotator cuff repair technique which uses suture bridges to optimize rotator cuff tendon–footprint contact area and mean pressure. A 5.5 mm Bio-Corkscrew suture anchor (Arthrex, Naples, FL, USA), double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL, USA), is placed in the anteromedial aspect of the footprint. Two suture limbs from a single suture are both passed through a single anterior point in the rotator cuff. One suture limb is retrieved from the cannula. The second suture limb is passed through a single posterior point in the rotator cuff producing two points of fixation in the tendon, with a tendon bridge between them. The same suture limb is retrieved through the lateral portal, and then inserted into the bone by means of a Pushlock (Arthrex, Naples, FL, USA), placed approximately 1.5–2 cm posterior to the first anchor. This second suture is passed again in the posterior aspect of the cuff. The limbs of the first suture are pulled to compress the tendon in the medial aspect of the footprint. The two free suture limbs are used to produce suture bridges over the tendon by means of a Pushlock (Arthrex, Naples, FL, USA), placed 1 cm distal to the lateral edge of the footprint relative to the medially placed suture anchors anterior to posterior. This technique allows us to perform a low-profile (single pulley–suture bridges) repair for knotless double-row repair of the rotator cuff.     

Arthroscopic Rotator Cuff Repair Using the Suture Loop Shuttle Technique

With the arthroscope in the posterior portal, several suture loops are passed through the rotator cuff via the superior lateral portal before the first anchor is inserted. The suture loop is created by passing both free ends of a No. 2 monofilament (48-inch Prolene, Ethilon, or PDS; Ethicon, Somerville, NJ) suture into an arthroscopic suture passing device. The free ends and the loop of each suture loop are temporarily transferred into the anterior cannula. Anchor insertion and passage of the anchored sutures are performed from posterior to anterior. With standard suture anchors, the loop end of the suture loop must be located on the undersurface of the cuff. The suture anchors are inserted one at a time through the superior lateral portal and are placed into the prepared holes. Anchored sutures are temporarily pulled out through the inferior lateral portal. Next, the free ends of the most posterior suture loop are retrieved through the superior lateral portal. The looped end of this suture loop is retrieved through the inferior lateral portal. The suture loop is used to shuttle a single anchored suture through the rotator cuff and out through the superior lateral portal. Then, the other anchored suture is retrieved through the superior lateral portal with a suture grasper and tied.     

The Double-Pulley Technique for Double-Row Rotator Cuff Repair

In an effort to maximize the area of footprint coverage, we developed the “double-pulley technique” for double-row rotator cuff repairs. Two suture anchors are inserted at the articular margin of the greater tuberosity (one anterior and one posterior). All 4 suture strands from each anchor are passed through a single medial point on the torn cuff. In this way, the 4 suture strands from the anteromedial anchor pass through 1 point in the cuff and the 4 strands from the posteromedial anchor pass through a different point in the cuff. A suture strand from 1 anchor is tied extracorporeally to a suture strand of the same color from the other anchor. The other ends of those 2 strands are then pulled, thereby delivering this extracorporeal knot into the joint and over the medial footprint. These 2 free suture strands are then tied together as a static knot. The procedure is repeated with the other sutures. This technique creates a double mattress suture medially, which compresses the intervening tendon bridge against its bone bed. We call this procedure the double-pulley technique because it uses the anchor eyelets as pulleys to deliver the extracorporeal knot into the shoulder. After the lateral row repair is performed, the rotator cuff footprint will be completely reconstituted.     

Mattress suture-bridge technique for bursal-side partial-thickness rotator cuff tears

The standard procedure used to repair partial-thickness tears involves initial progression of the lesion to a full-thickness tear prior to tendon repair. However, the option for a bursal-side partial-thickness rotator cuff tear includes the preservation of as much of the remaining intact fibers as possible. Instead of inserting suture anchors in the medial row, as in the conventional suture-bridge technique, two mattress sutures are inserted into the rotator cuff. Full-thickness access is achieved using a percutaneous spinal needle and medial mattress sutures to preserve the articular bone attachment of the remnant fibers and to compress the repaired tendon on the footprint. Our method can help preserve the remnant rotator cuff tendon without tissue damage and can restore the normal rotator cuff footprint.     

A Modified Suture-Bridge Technique for a Marginal Dog-Ear Deformity Caused During Rotator Cuff Repair

Recently, the suture-bridge technique was found to maximize the utility of a single-row construct by using the suture limbs from the medial mattress sutures to bridge and compress the repaired tendon. However, the formation of marginal dog-ear deformities at a repaired rotator cuff is not uncommon with the suture-bridge technique. If a dog-ear deformity is observed at the margin after completion of the rotator cuff repair, the detached marginal cuff is pierced via a suture hook. One strand of the uncut suture in the lateral row is transported through the deformed cuff. A nonsliding knot is seated on top of the detached cuff and presses this area of soft tissue firmly onto the bone. If necessary, these steps are repeated for the other side of the detached rotator cuff. After completion of the rotator cuff repair, a “zigzag” pattern of compression of the cuff against the bone footprint without detachment of the rotator cuff is observed. After repair of the rotator cuff tear via the suture-bridge technique, the benefit of our simple technique for treating a marginal detached cuff is that the footprint contact area of the rotator cuff is restored completely, without the need for additional suture anchors.     

Arthroscopic Fixation for Displaced Greater Tuberosity Fracture Using the Suture-Bridge Technique

With the described technique, two bioabsorbable suture anchors are inserted to create a medial row through the intact cuff for fixation of the fragment of the greater tuberosity. The medial row is repaired with a sliding knot. After confirmation of the fracture site, pilot holes for a PushLock anchor (Arthrex, Naples, FL) are prepared directly in line with the medial anchors and approximately 5 to 10 mm distal to the lateral edge of the fragment of the greater tuberosity. A suture strand from each anchor in the medial row is retrieved. Both suture strands are threaded through the PushLock eyelet on the distal end of the driver. The anchor is advanced completely into the pilot hole. These steps are repeated for a second anchor. If a dog-ear deformity is observed at the margin after complete reduction of the greater tuberosity, a stitch is made by use of a suture hook and one strand of the uncut suture from the lateral row of the joint via the modified suture-bridge technique. Arthroscopic reduction and internal fixation of displaced greater tuberosity fractures with the suture-bridge technique described by us provide adequate fixation with improvement of the pressurized contact area of the fracture and can be used as an additional modality of arthroscopic treatment.     

Arthroscopic Technique for Patch Augmentation of Rotator Cuff Repairs

The patient is placed in the lateral position, and an arthroscopic cuff repair is performed according to standard techniques. The line of repair is usually in the shape of a “T” or an “L.” The repair is viewed through the lateral portal, with fluid inflow through the scope. Mattress sutures are placed in the anterior and posterior portions of the cuff, with respect to the line of repair, just medial to the most medial point of the tear. The sutures are placed in accordance with margin convergence suture passing methods. Next, 2 double-stranded suture anchors are placed into the lateral aspect of the greater tuberosity, which can be used to secure the anterior and posterior portions of the rotator cuff as well as the patch. The cuff sutures are tied first; then, the patch is addressed. The graft is sized by placement of a ruled probe or similar device into the subacromial space. The length of each side of the “rectangle” is measured to obtain the dimensions of the patch. The patch is then cut to fit the measurements. If the patch material is elastic, a slightly smaller than measured graft is cut to provide tension on the repair. The arthroscope is then moved to the posterior portal, and a large (8 mm) cannula, with a dam, is placed into the lateral portal. All sutures are brought out of the lateral cannula, and corresponding ends of each suture are held together in a clamp. The sutures are placed in their respective orientations once outside the cannula (e.g., anterior-medial, anterior-lateral), covering all 4 quadrants. Care is taken to ensure that the sutures have no twists and are not wrapped around one another. The sutures are passed through the graft, in mattress fashion, with a free needle, in their respective corners and clamped again. The graft is then grasped with a small locking grasper on its medial edge and is passed through the cannula into the subacromial space. The clamps holding the sutures are then gently pulled to remove the slack. A smaller (5 mm) cannula is placed through 1 of the anchor incisions into the subacromial space. The medial 2 sutures are retrieved, a pair at a time, through the small cannula and are tied according to standard arthroscopic techniques; then, the lateral 2 sutures are retrieved from the anchor. The graft should cover the area of repair completely and should be under slight tension. Additional sutures may be placed to further secure or tension the graft as necessary, with the use of standard suture passing techniques, similar to those used when margin convergence is performed. Passive shoulder motion, pendulum exercises, and active elbow and wrist motion begin 2 days after surgery when the dressing is removed. Active assisted motion and active motion begin at 6 weeks, with integrated periscapular stabilization exercises. Formal cuff strengthening begins no sooner than 12 weeks after surgery for large and massive tears.     

Arthroscopic Fixation of Bursal-Sided Rotator Cuff Tears

Subacromial decompression and debridement of partial-thickness bursal-sided rotator cuff tears are often reported with a high rate of unsatisfactory outcomes. We describe an arthroscopic procedure to repair partial-thickness bursal-sided rotator cuff tears without converting to a full-thickness tear in patients with a normal articular-sided rotator cuff and an A0B2 or A0B3 pattern of tear (minimum thickness of 25% to 75%). The articular side of the rotator cuff experiences greater tension than the bursal side of the cuff. As such, by leaving the articular footprint intact, we accomplish 3 goals: the intact articular fibers act as an internal splint to protect the bursal-sided repair, a wide and anatomic footprint is recreated, and we are able to minimize any length-tension mismatch because the tissue is not excessively lateralized with repair. After bursectomy and acromioplasty, the frayed edges of the bursal flap are gently debrided and the tuberosity is excoriated to bleeding bone. One or two bioabsorbable anchors are placed, and both sutures are placed through the full thickness of the rotator cuff (one anterior and one posterior) by use of a percutaneous suture lasso in this manner: (1) the lasso is passed through the full thickness of the cuff, and the nitinol wire is shuttled out of a single cannula along with the more medial of the suture limbs; (2) the nitinol wire is then pulled back out of the percutaneous portal along with the suture limb, with the suture being passed through the full thickness of the cuff; and (3) the procedure is repeated for the posterior limb of the suture after a lasso is again passed through the full thickness of the rotator cuff in a more posterior position. This subset of patients is treated with an aggressive rehabilitation protocol because the intact articular rotator cuff fibers act as an internal splint to protect the bursal repair.     

Arthroscopic Rotator Cuff Repair Using a Triple-Loaded Suture Anchor and a Modified Mason-Allen Technique (Alex Stitch)

Surgical repair of the rotator cuff must have good resistance and should restore the tendon footprint. To attain this goal, a stitch with a strong biomechanical profile that avoids tissue strangulation should be used. We describe an arthroscopic suture technique undertaken to repair rotator cuff tears with a single triple-loaded suture anchor. The technique consists of a combination of a horizontal mattress and 2 vertical simple sutures that are positioned medial to the mattress suture. The suture anchor used is the 5-mm self-tapping ThRevo (Linvatec). This anchor is loaded with 3 sutures: 2 No. 2 nonabsorbable braided polyester sutures of different colors and a central high-strength No. 2 polyethylene suture. The shape of the anchor eyelet permits all 3 sutures to glide freely. A modified Mason-Allen technique (Alex stitch) that combines a horizontal side-to-side suture and 2 simples sutures as vertical loops is used. With use of the Spectrum suture passing device and shuttle relay system (Linvatec), both limbs of the centrally located polyethylene suture are passed through the cuff from bottom to top, approximately 1 cm from the tendon edge. This suture is not immediately tied. Next, with use of the same system, the other 2 sutures are placed medially and over the previous horizontal suture. Simple sutures are placed at an approximately 30° angle from the center of the anchor; 1 is placed anterior and the other posterior. The sutures are tied through the lateral portal. The mattress horizontal central stitch is always tied first, followed by the 2 vertical sutures. The horizontal mattress suture serves as a “rip stop stitch” and theoretically reduces the possibility of cutting out of the simple sutures.     

“Transosseous-Equivalent” Rotator Cuff Repair Technique

In order to optimize healing biology at a repaired rotator cuff footprint, we have developed a “transosseous-equivalent” rotator cuff repair that can be performed arthroscopically. What the arthroscopically repaired tendon experiences is “equivalent” to what is experienced with a traditional open suture-bridge technique. This repair maximizes the utility of a single-row repair technique by preserving the suture limbs of the medial single-row and bridging these sutures over the footprint insertion with distal-lateral interference screw suture fixation; the medial row uses a mattress suture configuration. The geometry of the construct compresses the tendon, optimizing tendon-to-tuberosity contact dimensions, while providing strength sufficient to withstand immediate postoperative rehabilitation.     

The new subclavian portal and modified neviaser portal for arthroscopic rotator cuff repair

Shoulder arthroscopy and the introduction of suture anchors has provided the surgeon with the ability to repair rotator cuff tears through minimal incisions. Rotator cuff repair involves the use of several portals, such as the posterior portal, the anterior portal, the anterior superior portal, the anterior inferior portal, and the Neviaser portal. The authors have developed 2 additional portals, the new Subclavian portal and the modified Neviaser portal, to improve the safety and efficacy of rotator cuff repair and solve a number of problems associated with traditional repair techniques. The subclavian portal is located directly below the clavicle, 1 to 2 cm from the acromioclavicular joint, and instruments are aimed medial to lateral. The modified Neviaser portal changes the angle of insertion of the Neviaser portal. Instruments are aimed 20° from the horizontal plane and 45° anterior, directly at the suture anchor. Repair techniques using each portal were reviewed. Twenty cadaveric shoulders were dissected for each portal and the anatomy from each portal was documented. The cadaveric dissections showed that this portal passes greater than 6 cm from the brachial plexus, musculocutaneous nerve, and subclavian artery and vein, and 4.7 cm from the cephalic vein. The modified Neviaser portal was shown to be safer than the Neviaser portal because it passes on top of the supraspinatous muscle, thereby protecting the suprascapular nerve. These portals provide an optimal angle of approach to the rotator cuff tendon and suture anchor as well as improved safety and efficacy in the repair of rotator cuff tears.     

Arthroscopic Double-Row Suture Anchor Fixation of Minimally Displaced Greater Tuberosity Fractures

In cases of displaced greater tuberosity fractures, treatments by arthroscopic-assisted reduction and percutaneous screw fixation have been reported. However, in cases in which there is a comminuted fracture or a minimally displaced fracture combined with concomitant lesions such as rotator cuff tear or labral pathology, it is difficult to reduce the fracture and to treat other pathologies by use of a percutaneous screw. Recently, many surgeons have used the double-row repair method in rotator cuff repair, which provides a tendon-bone interface better suited for biologic healing and restoring normal anatomy. In accordance with this method, we used the arthroscopic technique of double-row suture anchor fixation for a minimally displaced greater tuberosity fracture without additional incision. Initially, debridement was performed on the fracture surface by use of a shaver, and the medial-row anchor was inserted through the anterior portal or the intact cuff. Two lateral-row anchors were inserted just anterior and posterior to the lower margin of the fractured fragment under C-arm guidance. The medial-row sutures and lateral-row sutures were then placed. Arthroscopic double-row suture anchor fixation of a displaced greater tuberosity fracture restores the original footprint of the rotator cuff and normal tendon-bone interface of the displaced greater tuberosity fracture.     

A Novel Transosseous Button Technique for Rotator Cuff Repair

In an attempt to maximize stability by improving the lateral footprint compression of our repair in rotator cuff tears, we have been using a rotator cuff button (Arthrex, Naples, FL) passed through a transosseous tunnel as an anchor for our transosseous sutures. Our new innovation is to pass a rotator cuff button fully loaded with 4 strands around the central post, with 2 leading strands and 2 trailing strands on either end, through our transosseous tunnel. In this way, we can use the 4 central strands through our tunnel to obtain 2 good mattress sutures as a primary repair and the peripheral 4 strands passed around the lateral humerus as over sew mattress sutures to obtain good compression of the lateral tendon and so improve the footprint area. A double row equivalent is achieved. This technique has a good primary hold in the form of a device with proven history and avoids multiple anchors in the lateral humerus. Because it uses only a single fixation device, it is also significantly more economical. Theoretical risks to the axillary nerve or with osteoporosis have not been seen in practice. Tensioning the repair with suture passage through transosseous tunnels is readily achieved.     

Mode of failure for rotator cuff repair with suture anchors identified at revision surgery

Rotator cuff tears are a common cause of shoulder pain and dysfunction. After surgical repair, there is a significant re-tear rate (25%-90%). The aim of this study was to determine the primary mode of mechanical failure for rotator cuffs repaired with suture anchors at the time of revision rotator cuff repair. We prospectively followed 342 consecutive torn rotator cuffs, repaired by a single surgeon using suture anchors and a mattress-suturing configuration. Of those shoulders, 21 (6%) subsequently underwent a revision rotator cuff repair by the original surgeon, and 1 underwent a second revision repair. Intraoperative findings, including the mode of failure, were systematically recorded at revision surgery and compared with the findings at the primary repair. In addition, 81 primary rotator cuff repairs had a radiographic and fluoroscopic evaluation at a mean of 37 weeks after repair to assess for any loosening or migration of the anchors. At revision rotator cuff repair, the predominant mode of failure was tendon pulling through sutures (19/22 shoulders) (P <.001). Two recurrent tears occurred in a new location adjacent to the previous repair, and one anchor was found loose in the supraspinatus tendon. The mean size of the rotator cuff tear was larger at the revision surgery (P =.043), the tendon quality ranked poorer (P =.013), and the tendon mobility decreased (P =.002), as compared with the index procedure. The radiographs and fluoroscopic examination showed that all 335 anchors in 81 patients were in bone. Rotator cuff repairs with suture anchors that underwent revision surgery failed mechanically by three mechanisms, the most common of which was tendon pulling through sutures. This suggests that the weak link in rotator cuff repairs with suture anchors and horizontal mattress sutures, as determined at revision surgery, is the tendon-suture interface.     

Half-stained thread in shoulder arthroscopy: an improved method of suture management

Shoulder arthroscopy is used widely to treat a variety of shoulder pathologies. These include various diagnostic and stabilization procedures such as Bankart repair, treating SLAP lesions, capsular plication, and rotator cuff repair. Sutures are commonly used, particularly in stabilization procedures, with or without the use of suture anchors. Suture management is one of the prerequisites for a successful arthroscopic stabilization procedure. We describe a simple method of aiding suture management. In cases using the suture anchor, the preloaded suture is firstly removed from the anchor, and approximately half the length of the suture is stained with methylene blue. The suture is then reinserted into the same suture anchor. The suture anchor is used in the usual manner. During shoulder arthroscopy, one end of the suture is pulled, if necessary, to determine the direction of the thread, which is readily shown by the methylene blue. This simple maneuver helps the surgeon identify the desired direction of the thread and avoid the common problems of pulling out the suture and twisting the sutures.     

Arthroscopic Intratendinous Repair of the Delaminated Partial-Thickness Rotator Cuff Tear in Overhead Athletes

A distinct type of partial-thickness rotator cuff tear has been observed in overhead athletes, characterized by partial failure of the undersurface of the posterior supraspinatus and anterior infraspinatus tendons with intratendinous delamination. We present a technique of percutaneous intratendinous repair using nonabsorbable mattress sutures designed for the management of articular-side delaminated partial-thickness tears. After tear evaluation and preparation, the torn rotator cuff undersurface is held in a reduced position with a grasper through an anterolateral rotator interval portal while viewing intra-articularly. Two spinal needles are then placed percutaneously through the full thickness of the torn and intact rotator cuff. A polydioxanone suture is passed through each needle, retrieved out the anterior portal, and used to shuttle a single nonabsorbable No. 2 suture through the tissue, creating a mattress suture. Multiple mattress sutures can be placed as dictated by tear size and morphology, with suture retrieval and knot securing then proceeding in the subacromial space. We have adopted this approach with the goals of anatomically re-establishing the rotator cuff insertion and sealing the area of intratendinous delamination while preventing significant alteration to the anatomy of the rotator cuff insertion, which could lead to motion deficits, internal impingement, and potential tear recurrence.     

Artrhoscopic rotator cuff repair with augmentation: the V-sled technique

Numerous techniques have been described for patch positioning in rotator cuff shoulder arthroscopic surgery. These techniques seem to be difficult challenges for the majority of arthroscopic surgeons, and because of that they are called "highly demanding" techniques. Without the use of dedicated instruments and cannulas, the authors propose a V-sled technique that seems to be more reproducible, quicker and less difficult to perform for arthroscopic shoulder surgeons. The patient is placed in the lateral position. All arthroscopic procedures are performed without the use of cannulas. The standard posterior portal is used for the glenohumeral (GH) joint arthroscopy with fluid inflowing through the scope. After an accurate evaluation of the GH space, the scope is then introduced into the subacromial space. With the use of a spinal needle, a lateral portal is performed. The great tuberosity is prepared with a bur to place two 5.5 mm triple-loaded radiolucent anchors. In addition, two free high strength sutures are passed through the muscle, respectively. The repair is performed using two high strength sutures from each anchor. The third wire from each anchor is retrieved out of the accessories portals used for the insertion of the anchors. In addition, two free high strength sutures are passed through the muscle, and the patch sizing is done using a measuring probe introduced through the lateral portal. Next, the patch is then prepared and is introduced into the subacromial space, and then the patch is stabilized, and the free sutures are tied.     

Arthroscopic rotator cuff repair using a transhumeral approach to fixation

A new technique for arthroscopic rotator cuff repair using arthroscopically placed transhumeral sutures is presented. After an adequate acromioplasty is performed, a modified anterior cruciate ligament tibial drill guide is used to drill two or more transhumeral holes from the metaphyseal-diaphyseal junction of the humerus to the greater tuberosity. Sutures are then passed into these holes and through the rotator cuff using cannulated needles. The sutures are tied manually and the repair is inspected. The postoperative protocol is presented. The new technique may be superior to the current methods for arthroscopic rotator cuff repair in that (1) the strength of fixation does not rely on the quality of the bone in the greater tuberosity of the humeral head (which can be quite poor) as suture anchor techniques do, (2) the sutures are easily passed through the rotator cuff without relying on complicated suture passing techniques, (3) the knots are tied without the aide of an arthroscopic knot-tying device, and (4) in cadaveric studies, the failure strength of this new repair was equal to the strength of a traditional open repair. Prospective studies are ongoing to assess the efficacy of this new technique.Arthroscopy 1998 Jan-Feb;14(1):118-22     

Artrhoscopic Rotator Cuff Repair with Augmentation: The V‐sled Technique

Numerous techniques have been described for patch positioning in rotator cuff shoulder arthroscopic surgery. These techniques seem to be difficult challenges for the majority of arthroscopic surgeons, and because of that they are called “highly demanding” techniques. Without the use of dedicated instruments and cannulas, the authors propose a V‐sled technique that seems to be more reproducible, quicker and less difficult to perform for arthroscopic shoulder surgeons. The patient is placed in the lateral position. All arthroscopic procedures are performed without the use of cannulas. The standard posterior portal is used for the glenohumeral (GH) joint arthroscopy with fluid inflowing through the scope. After an accurate evaluation of the GH space, the scope is then introduced into the subacromial space. With the use of a spinal needle, a lateral portal is performed. The great tuberosity is prepared with a bur to place two 5.5 mm triple‐loaded radiolucent anchors. In addition, two free high strength sutures are passed through the muscle, respectively. The repair is performed using two high strength sutures from each anchor. The third wire from each anchor is retrieved out of the accessories portals used for the insertion of the anchors. In addition, two free high strength sutures are passed through the muscle, and the patch sizing is done using a measuring probe introduced through the lateral portal. Next, the patch is then prepared and is introduced into the subacromial space, and then the patch is stabilized, and the free sutures are tied.