Transtendon, Double-Row, Transosseous-Equivalent Arthroscopic Repair of Partial- Thickness, Articular-Surface Rotator Cuff Tears  Matthew F. Dilisio, M.D., Lindsay R. Miller, M.P.H., Laurence D. Higgins, M.D.  Arthroscopy Techniques  Volume 3, Issue 5, Pages e559-e563 (October 2014) DOI: 10.1016/j.eats.2014.06.007 Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 1 T2-weighted sagittal oblique magnetic resonance image of a right shoulder showing a high-grade, partial articular-sided supraspinatus tendon avulsion. The red arrow points toward the avulsed articular-sided tendon lamina that is retracted to the level of the humeral head. The green arrow points toward the very thin but intact bursal layer of the supraspinatus tendon. Arthroscopy Techniques 2014 3, e559-e563DOI: (10.1016/j.eats.2014.06.007) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 2 Intra-articular arthroscopic view of a high-grade partial-thickness supraspinatus tear in a 67-year-old woman 6 weeks after a mechanical fall (right shoulder, beach-chair position, posterior viewing portal). (A) A mechanical shaver is visualized superiorly piercing the intact remnant supraspinatus tendon to prepare the greater tuberosity in a transtendinous fashion. (B) With viewing laterally from the subacromial space, the supraspinatus tendon is shown to be intact. (C) The displaced articular layer of the tendon is held reduced to its footprint on the greater tuberosity with a grasper, and a spinal needle is placed parallel to the optimal anchor trajectory and is also used to hold the tendon in a reduced position. A metallic suture anchor is then placed bluntly through the tendon through a percutaneous anterolateral portal while the articular layer is held reduced. (D) Once the first few threads of the anchor pass deep to the tendon, the tendon can be steered to its anatomic insertion with the anchor itself. Arthroscopy Techniques 2014 3, e559-e563DOI: (10.1016/j.eats.2014.06.007) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 3 (A) Intra-articular arthroscopic view of insertion of second medial-row anchor (right shoulder, beach-chair position, posterior viewing portal). The arthroscope is placed in the subacromial space, and the medial anchors are “linked” by loading a free needle with 1 limb of suture and then piercing a suture limb from the opposite anchor. (B) The pierced limb is unloaded from the anchor, which effectively shuttles the suture into the islet of the opposite anchor. This medial link suture is then tied, and the remaining suture limbs are gathered and loaded into 2 knotless anchors. (C) The lateral-row anchors are then placed, and the completed transtendon, double-row arthroscopic rotator cuff repair is visualized laterally from the subacromial space. (D) The posterior intra-articular view of the completed repair shows the reduced PASTA lamina to the articular margin. Arthroscopy Techniques 2014 3, e559-e563DOI: (10.1016/j.eats.2014.06.007) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 4 Artist's depiction of transtendon, double-row, transosseous-equivalent rotator cuff repair construct. The medial row is tied using a single suture that has been shuttled through both anchors. A limb of each of the remaining sutures in each anchor is then retrieved and loaded into a knotless anchor used for the lateral row to compress the partial-thickness tear against the anatomic footprint on the greater tuberosity. (Illustration courtesy of Nicholas M. Dilisio.) Arthroscopy Techniques 2014 3, e559-e563DOI: (10.1016/j.eats.2014.06.007) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions