Surgical Technique to Repair Musculotendinous Junction Tear of Supraspinatus Using Lateral-Row Anchors to Avoid Cut-Through  Bancha Chernchujit, M.D.Ortho., Prashant H. Parate, D.Ortho., D.N.B.Ortho.  Arthroscopy Techniques  Volume 6, Issue 1, Pages e65-e71 (February 2017) DOI: 10.1016/j.eats.2016.09.001 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The patient is in the beach-chair position; the right shoulder is being operated on. A standard posterior portal (white arrow) is used for diagnostic arthroscopy. An anterosuperior portal (yellow arrow) is placed just anterior to the acromioclavicular joint. The lateral border of the acromion is divided into 3 equal parts by making 2 lines. An anterolateral portal (red arrow) is created 1 inch laterally on the anterior line, and a posterolateral visualization portal (black arrow) is created 1 cm lateral to the posterior line. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 The arthroscope enters through the posterolateral visualization portal. Tear identification is performed. The lateral stump, which is still intact over the footprint, can be seen along with the tear. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 The arthroscope is kept in the posterolateral visualization portal, and the shaver blade is inserted through the posterior portal. Cleaning of the edges of the torn tendon is performed. This improves the healing potential of the tendon. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 The camera is in the posterolateral visualization portal, and the shaver blade is inserted through the anterolateral working portal. Debridement of dead tissue is performed, and the complete extent of the tear is identified. Unhealthy tissue is removed. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 A probe with a scale is introduced through the anterolateral working portal to measure the length of the intact tendon attached to the footprint. Approximately 12 mm of tendon is still attached over the footprint; if removed, it will cause tendon loss and tension at the repair site. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 A Spectrum device or Accupass is used to take a bite from the medial part of the torn tendon. Polydioxanone suture (PDS) is used to shuttle the threads. Care is taken to pierce the complete tendon with the tip of the instrument; otherwise, only part of the tendon will become incorporated in the repair, resulting in a partial repair. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 Two strong threads of different colors are shuttled using polydioxanone sutures. The same procedure as in Figure 6 is repeated to retrieve both ends of the threads on the bursal side and obtain a loop on the articular side. Bites are taken from the entire cuff to cover the complete tear from the posterior (A) to anterior margin (B). Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 A total of 4 bites are taken in the tendon with 4 threads and 8 ends coming out on the bursal side. Both ends of the same thread from each of the posterior bites and anterior bites are retrieved together through the anterolateral working portal so that 2 threads with 4 ends are retrieved from the cannula. The remaining threads are retrieved posteriorly. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 One knotless anchor (Poplock; Linvatec) is inserted anteriorly, and the threads are tightened one by one and fixed on a slot provided in the handle. The anchor is hammered in completely and locked after final tightening. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 All remaining threads are retrieved through the cannula in the anterolateral working portal. A Footprint Ultra anchor (Smith & Nephew) is loaded with threads. A pilot hole is made posteriorly on the lateral aspect of the greater tuberosity at the appropriately selected place. The Footprint anchor is inserted into the pilot hole and hammered in partially, the threads are tightened, and the anchor is hammered in completely after the threads are locked in the socket on the handle. Final tightening is performed after enough tension is achieved in the threads. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 11 Good reduction with oblique running sutures can be appreciated. The oblique direction of the threads avoids cut-through of the tendon because the pull of the threads is not parallel to the direction of the tendon fibers. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 12 The tear cannot be identified easily after repair is achieved. It can be appreciated after probing in the torn area. Arthroscopy Techniques 2017 6, e65-e71DOI: (10.1016/j.eats.2016.09.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions