This chapter describes a revision rotator cuff repair using an arthroscopic transosseous technique with a dedicated transosseous tunneling device. We discuss and demonstrate the use of arthroscopically placed tunnels with large numbers of suture to provide load spreading and compression for repair of a large complex recurrent cuff tear. The positioning, portal placement, and post-op rehabilitation timeline are addressed. The relevant supporting literature is discussed.
Keywords: arthroscopic osseous repair, revision rotator cuff repair, rotator cuff repair, rotator cuff tear
? Following intubation, the patient is positioned supine on the beachchair positioner.
? The head support height and patient adjustment is corrected to keep the back support below the level posterior glenohumeral portal incision. The facemask is then placed with no pressure on the eyes.
? The leg elevator pillow is placed under the patient?s legs, with heels and other prominences padded.
? The patient is elevated to 60 in the beach chair positioner, and the head and neck immediately adjusted for optimal neck position and tension cooperatively by the surgeon and the anesthesiologist, using the adjustment knobs.
? The well arm is supported in the arm holder.
? The patient?s operative shoulder is examined under anesthesia for range of motion and ligamentous laxity.
? The operative arm is prepped in its entirety with chloraprep and allowed the appropriate time to dry. A sterile impervious stockinette is placed from the hand past the elbow. Impervious blue U-drapes are placed medially, tails up then down, with a shoulder arthroscopy drape. The arm is placed into a padded Smith & Nephew Spider arm positioner, then overwrapped with Coban proximal to the elbow.
? The bony landmarks are traced at the margins of the clavicle, acromion, and scapular spine. The acromioclavicular (AC) joint is marked.
? The posterior midglenoid portal is placed based on AC joint position and humeral head ballotment. A small longitudinal stab incision through the skin only is made with a #11 knife. The arthroscopic cannula with a tapered-tip obturator is placed through the subcutaneous tissue, muscle, and to the medial humeral head, then through the posterior capsule into the glenohumeral joint.
? The anterior midglenoid portal is typically established with the outside-in technique with the spinal needle technique under direct visualization from the posterior portal, with incision along Langer?s lines and a clear threaded operating cannula placed over a blunt trocar.
? The lateral subacromial portals are placed under direct visualization with spinal needle guidance in the subacromial space. The initial lateral portal is typically made 3?4 cm lateral to the anterolateral edge of the acromion. If needed for a large or massive tear, a second is typically made posterior to this, with the goal of placing the portals and cannulas at the anterior third of the cuff tear, and the middle-third-posterior third junction.
? Diagnostic arthroscopy of the shoulder is performed, primarily from the posterior portal. In a revision cuff repair, particular attention is paid to checking the inferior pouch and lateral subacromial space for debris, and for locating prior sutures for removal.
? In the glenohumeral position, any procedures indicated for noncuff structures, such as biceps tenotomy, labral debridement, or anterior capsular release, are performed prior to cuff repair.
? The scope is repositioned to the subacromial bursa space through the posterior portal, and the anterolateral subacromial portal is established with an outside-in technique.
? An extensive bursectomy is performed with shaver and ablator, with the soft tissue removed from the underside of the acromion, and the bursal curtain debrided medially and laterally, with attention to exposure of the lateral greater tuberosity (GT) without damaging the deltoid muscle fascia. Subacromial decompression with a bur is performed if indicated by bony morphology.
? The footprint of the GT is debrided with shaver and ablator in the case of a revision cuff repair.
? During revision cuff repair, in the course of the two steps above, all sutures and other loose debris from the failed repair are removed with a combination of shaver and graspers. The previously placed anchors are left in place if stable.
? The frayed edges of the cuff tear are debrided with a shaver, and if the cuff is significantly retracted and adherent to the superior glenoid, cuff release is performed off the glenoid and/or acromion with ablator, elevator, and lateral traction of the cuff with a grasper. This is performed with the scope in the posterior portal and/or lateral portal as needed.
? The medial tunnel sites are punched at the medial GT articular margin with a round tapered awl through a lateral portal. This is performed with the arm in adduction to make the medial side of the tunnel as ?vertical,? or parallel to the lateral cortex of the GT, if possible (? Fig. 30.1).
? The arthroscopic tunneler instrument (in this demonstration, the Tensor TransOs) is then placed into the joint through the lateral portal, and the capture hook tip fully inserted into the punched medial tunnel. The hook is typically most easily introduced into the subacromial space in an inverted position, then rotated into position for tunnel insertion. This maneuver is reminiscent of the way an anterior cruciate ligament tibial tunnel guide is typically introduced and positioned in the knee.
? Placement of the protector sleeve down to bone is directly visualized with the arthroscope in the subacromial space.
? The punch needle is then loaded with a small guagehigh-strength shuttle suture, and placed through the soft tissue sleeve to the bone, and advanced with a series of gentle taps with a mallet. The punch needle is then retracted and the capture hook extracted from the medial tunnel with the shuttle suture captured (? Fig. 30.1).
? The shuttle suture is then used to pull several fixation sutures or tapes through the tunnel.
? Additional tunnels are created and sutures shuttled as needed depending on the size of the cuff tear.
? In this demonstration, four sutures per tunnel are used (? Fig. 30.2).
? A cannula is inserted into the superolateral portal for suture passage. A loop grasper is used to shuttle the desired medial suture limb into the cannula. Alternatively, passage can be performed without a cannula.
? Nonworking suture limbs may be shuttled to the anterior or other lateral portal to minimize risk of tangles.
? Lateral suture limbs are left out the lateral portals until needed for tying.
? A retrograde suture passer, in this demonstration a Smith & Nephew FIRSTPASS, is used to pass sutures through the cuff. Typically, and as demonstrated here, a single pass and subsequent simple suture knot is performed with transosseous tunnels, to spread load and optimize compression (? Fig. 30.3).
? Medial suture and associated lateral suture tails are selected with loop grasper and shuttled through the cannula.
? Sutures are tied using a sliding knot and a knot pusher through a cannula, with backup half-hitches. A Duncan slider is used in this demonstration but other typical sliding knots may be used according to surgeon preference and experience.
? In the center of the cuff tear, suture tails from the posterior and anterior tunnels are typically cross-tied to optimize central tear compression, as demonstrated (? Fig. 30.4).
? Knots are generally tied anterior to posterior with the arthroscope in the posterior portal.
? The large number of simple sutures distributes the fixation load through the cuff and in revision repairs allows accommodation for tendon edge irregularity to optimize tension and footprint compression.
? Perform sufficient lateral bursectomy to facilitate lateral tunnel placement and associated suture passage and management.
? Place lateral tunnel as inferiorly as possible from the GT edge to engage stronger bone; target 2 cm from the GT edge.
? Limit abduction torque on transosseous tunneler capture hook when in medial bone to avoid bending it.
? The relatively large number of available sutures facilitates use of single pass medially with simple suture tying and optimized compression of the lateral part of the tendon to the footprint.
? To mitigate ?suture madness,? pass sutures though tunnels with a snap on lateral limbs, then separate pair with medial limbs as each medial limb is passed through the cuff tendon.
? During debridement in a revision cuff repair, an ?alligator roll? maneuver with a grasper locked on the suture may facilitate unthreading a suture remnant from an anchor in a controlled and efficient manner.
? Marrow bleeding occurs from tunnels, so there is no need for additional punch or burring for marrow access.
? Early learning curve of new technology.
? Tunneler instrumentation required but largely reusable.
? More extensive lateral bursectomy may be needed versus cuff repair with anchors.
? Increased suture management complexity due to the large number of initially passed sutures.
? 0?6 weeks: Passive range of motion, consistent sling wear.
? 6?12 weeks: Active range of motion per progressive protocol, D/C sling.
? 3?9 months: progressive strengthening, activities of daily living, weight and strain limits.
? 9 months: unrestricted activity.
? Tunneling allows placement flexibility around prior anchors (adjacent, medial, or lateral, with tunnel path often deep to anchors).
? Plentiful suture availability for spreading cuff fixation load.1
? Sequential tying for optimal cuff reduction and tension balancing versus all-at-once knotless lateral row.
? Footprint compression.2
? Less medial tendon stress concentration versus a mattress suture medial row.
? Better failure mechanism.3
? Intrinsic bone marrow access.
? Implant cost savings.4
 Jost PW, Khair MM, Chen DX, Wright TM, Kelly AM, Rodeo SA. Suture number determines strength of rotator cuff repair. J Bone Joint Surg Am. 2012; 94(14):e100
 Park MC, Cadet ER, Levine WN, Bigliani LU, Ahmad CS. Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques. Am J Sports Med. 2005; 33(8):1154?1159
 Kilcoyne KG, Guillaume SG, Hannan CV, Langdale ER, Belkoff SM, Srikumaran U. Anchored transosseous-equivalent versus anchorless transosseous rotator cuff repair: A biomechanical analysis in a cadaveric model. Am J Sports Med. 2017; 45(10):2364?2371
 Black EM, Austin LS, Narzikul A, Seidl AJ, Martens K, Lazarus MD. Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair. J Shoulder Elbow Surg. 2016; 25(9):1449?1456
Bishop J, Klepps S, Lo IK, Bird J, Gladstone JN, Flatow EL. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg. 2006; 15(3):290?299
Kummer FJ, Hahn M, Day M, Meislin RJ, Jazrawi LM. A laboratory comparison of a new arthroscopic transosseous rotator cuff repair to a double row transosseous equivalent rotator cuff repair using suture anchors. Bull Hosp Jt Dis (2013). 2013; 71(2):128?131
Tashjian RZ, Deloach J, Green A, Porucznik CA, Powell AP. Minimal clinically important differences in ASES and simple shoulder test scores after nonoperative treatment of rotator cuff disease. J Bone Joint Surg Am. 2010; 92(2): 296?303