import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Exits quadrangular space posteriorly 5-7cm inferior to acromion, wraps anteriorly around surgical neck of humerus at level of inferior glenohumeral capsule. **Protection**: Never place portals less than 5cm inferior to acromion. Avoid aggressive inferior capsular releases. Risk highest with inferior portal placement or conversion to mini-open approach. **Location**: Passes through suprascapular notch beneath transverse scapular ligament, courses 2-3cm medial to posterior glenoid rim along scapular spine, innervates supraspinatus then infraspinatus. **Protection**: Limit depth of medial releases to less than 2cm from glenoid edge. Use blunt dissection for capsular releases. Never aggressively mobilize medially beyond safe zone. Injury causes supraspinatus/infraspinatus denervation. **Location**: Enters coracobrachialis muscle 3-8cm distal to coracoid tip (highly variable anatomy), then courses between biceps and brachialis in anterior arm. **Protection**: Keep anterior portals superior and lateral to coracoid. Avoid deep dissection in rotator interval. Risk with anterior-inferior portals or anterior capsular procedures. Injury causes biceps/brachialis weakness. **Location**: Accompanies axillary nerve through quadrangular space, wraps around surgical neck with anastomoses to anterior circumflex artery forming perihumeral vascular ring. **Protection**: Avoid over-aggressive mobilization of inferior cuff. Careful with thermal devices near inferior capsule. Injury causes significant bleeding and potential avascular necrosis of humeral head if extensive. **Location**: Runs in deltopectoral groove between deltoid (lateral) and pectoralis major (medial), drains into axillary vein proximally at deltopectoral triangle apex. **Protection**: Primarily at risk during mini-open conversion or anterior extensile approaches. Identify and protect laterally during deltopectoral split. Injury causes hemorrhage and upper extremity venous congestion. ## Rotator Cuff Tear Classification Systems **Cofield Size Classification** (most commonly used for surgical planning): - **Small**: Less than 1cm in any dimension - **Medium**: 1-3cm in largest dimension - **Large**: 3-5cm in largest dimension - **Massive**: Greater than 5cm OR involvement of two or more tendons **Patte Retraction Staging** (critical for surgical decision-making): - **Stage 1**: Tendon edge near greater tuberosity - excellent prognosis - **Stage 2**: Tendon retracted to level of humeral head apex - mobilization required - **Stage 3**: Tendon retracted to level of glenoid - often irreparable, consider SCR **Goutallier Fatty Infiltration Grading** (prognostic for healing): - **Grade 0**: Normal muscle, no fat - **Grade 1**: Some fatty streaks - **Grade 2**: Less fat than muscle - **Grade 3**: Equal fat and muscle - **Grade 4**: More fat than muscle (greater than 50%) Grade 3-4 fatty infiltration predicts poor healing and inferior outcomes regardless of repair technique. **Tear Pattern Classification**: - **Crescent**: Straight tear edge, mobile, direct repair - **U-shaped**: Retracted leaves, requires margin convergence - **L-shaped**: Apex extends anteriorly or posteriorly, repair apex first - **Massive-irreparable**: Greater than 5cm with Patte 3, Goutallier 3-4 ## Level 1 Evidence Comparing Double-Row vs Single-Row **Meta-Analysis Summary** (Cochrane 2019, multiple systematic reviews): - **Small-Medium Tears** (less than 3cm): NO difference in pain, function, ROM, patient satisfaction, or re-tear rates - **Large Tears** (greater than 3cm): Lower re-tear rates with double-row (15-20% absolute reduction) but SIMILAR clinical outcomes - **Massive Tears**: Both techniques have high failure rates, double-row may provide marginal benefit **Key RCTs**: - Burks et al. (2009): No difference in outcomes between single vs double-row at 2 years - Grasso et al. (2009): Lower re-tear rate with double-row for large tears only - Ma et al. (2012): Meta-analysis showing structural superiority (lower re-tears) but clinical equivalence **Current Evidence-Based Recommendations**: - Small-medium tears: Single-row adequate, faster, lower cost - Large tears in young active patients: Double-row preferred for structural integrity - Older patients or low demand: Single-row appropriate even for large tears - Massive tears: Neither technique reliably successful, consider alternatives (SCR, margin convergence partial repair) ## Double-Row Technique Variations **TOE (Transosseous Equivalent) Suture Bridge** (described here): - Medial row anchors at articular margin - Lateral row knotless anchors capture medial sutures - Creates horizontal suture bridges across footprint - Most common double-row configuration currently **Triple-Loaded Medial Row**: - Three suture pairs per medial anchor (6 sutures) - Allows greater lateral footprint coverage - Increased suture density - More complex suture management **SpeedBridge Technique**: - All-knotless construct - Medial anchors are knotless with tape or suture - Lateral anchors complete fixation - Faster, less subacromial bulk **Knotted Double-Row**: - Original Park-Toussaint technique - Knots tied at both medial and lateral rows - Greater subacromial bulk - Potential impingement from knots - Less commonly used now ## Rotator Cuff Anatomic Footprint **Supraspinatus Footprint**: - **Location**: Superior facet of greater tuberosity - **Dimensions**: Approximately 15mm anteroposterior x 25mm superoinferior - **Insertion**: Medial border at articular margin, extends 15-18mm laterally - **Critical interval**: Rotator interval anteriorly (biceps/coracohumeral ligament), supraspinatus-infraspinatus interval posteriorly **Infraspinatus Footprint**: - **Location**: Posterior facet of greater tuberosity - **Dimensions**: Approximately 20mm anteroposterior x 25mm superoinferior - **Three distinct insertional zones**: Superior, middle, inferior (teres minor inferior) - **Nerve supply**: Suprascapular nerve (upper two-thirds), axillary nerve contribution (lower third) **Subscapularis Footprint**: - **Location**: Lesser tuberosity - **Dimensions**: 20mm mediolateral x 25mm superoinferior - **Often involved**: 30-40% of large posterosuperior tears extend anteriorly involving upper subscapularis ## Portal Anatomy and Safe Zones **Posterior Portal** (primary viewing): - **Position**: 2cm inferior, 1cm medial to posterolateral acromion corner (soft spot) - **Trajectory**: Directed anteriorly toward coracoid - **Structures at risk**: None if proper position maintained - **Utility**: Excellent visualization of glenohumeral joint and subacromial space **Lateral Portal** (primary working - CRITICAL for double-row): - **Position**: 3cm lateral to lateral acromion edge, aligned with posterior clavicle (Nevasier) - **Trajectory**: Perpendicular to footprint for optimal anchor placement - **Structures at risk**: Axillary nerve if too inferior (must be greater than 5cm from acromion) - **Utility**: Anchor placement for both medial and lateral rows **Anterior-Lateral Portal** (accessory): - **Position**: Through rotator interval - **Trajectory**: Anterior margin visualization and suture management - **Structures at risk**: Musculocutaneous nerve if too inferior/medial - **Utility**: Anterior cuff visualization, interval closure, subscapularis repair ## Suprascapular Nerve Anatomy (HIGH RISK in mobilization) **Course**: - Originates from superior trunk of brachial plexus - Passes through suprascapular notch beneath transverse scapular ligament - Courses 2-3cm medial to glenoid rim along scapular spine base - Innervates supraspinatus, then curves around spinoglenoid notch to infraspinatus **Injury Risk Zones**: - Medial capsular releases greater than 2cm from glenoid - Aggressive mobilization of chronic retracted tears - Placement of medial anchors beyond safe zone - Thermal device use medially **Clinical Impact of Injury**: - Supraspinatus AND infraspinatus denervation - Progressive atrophy and fatty infiltration - Repair failure due to denervated muscle - Difficult to treat - nerve decompression often ineffective ## Portal Positioning Mastery **Lateral Portal Position** (CRITICAL for double-row success): - **Standard**: 3cm lateral to acromion lateral edge, in line with posterior clavicle - **Why it matters**: Must place anchors at BOTH articular margin (medial) AND 15mm lateral (lateral row) - **Common error**: Portal too medial cannot reach lateral footprint - **Technique**: Use spinal needle from inside-out to confirm trajectory before cannula placement - **Alternative position**: Some surgeons use 4cm lateral for very lateral footprint in large patients **Posterior Portal Versatility**: - **Traditional teaching**: Viewing only - **Modern approach**: Can switch between posterior and lateral viewing for different angles - **Advantage**: Posterior viewing for lateral row placement provides excellent perspective - **Key**: Use 30° arthroscope, rotate to optimize visualization ## Mobilization Techniques for Maximum Tendon Excursion **Adhesion Release** (first step, mandatory): - Superior: From undersurface of acromion and CA ligament - Medial: From glenoid and superior capsule (careful - nerve 2-3cm medial) - Lateral: From deltoid adhesions - Inferior: From capsule (careful - axillary nerve) **Interval Slides** (gain 1-2cm of excursion): - **Anterior interval slide**: Between supraspinatus and subscapularis - Technique: Incise interval from medial to lateral using electrocautery - Gain: 10-15mm of anteroposterior mobility - **Posterior interval slide**: Between supraspinatus and infraspinatus - Technique: Incise interval preserving spinoglenoid vessels - Gain: 10-15mm of anteroposterior mobility **Margin Convergence** (for U-shaped tears): - Pass side-to-side mattress sutures - Approximate medial and lateral leaves - Converts U-shape to crescent configuration - Reduces footprint strain by 30-40% **Test of Adequate Mobilization**: - Arm at side, neutral rotation - Grasp tendon with forceps - Pull laterally - should reach lateral footprint edge WITHOUT tension - If inadequate, do NOT proceed until adequate mobilization achieved ## Anchor Placement Geometry **Medial Row Configuration**: - **Number**: 2 anchors for medium tears, 3 for large tears - **Position**: AT articular margin (cartilage-bone junction) - **Spacing**: 8-10mm apart, spanning tear anteroposterior - **Angle**: 45° deadman angle perpendicular to articular surface - **Depth**: Flush or 1mm below cortex - **Type**: Double-loaded suture anchors (knotless or standard) **Lateral Row Configuration**: - **Number**: Matches medial row (2 or 3) - **Position**: 10-15mm lateral to medial row at anatomic footprint lateral edge - **Spacing**: In-line with medial row anchors - **Angle**: 45° deadman angle perpendicular to lateral footprint - **Depth**: Flush to cortex - **Type**: Knotless anchors ONLY (for suture bridge completion) **Geometric Principles**: - Medial-to-lateral distance recreates native 15-18mm footprint width - Anterior-to-posterior spacing provides complete tear coverage - Parallel rows create uniform compression distribution - Too lateral = inadequate bone stock, fracture risk - Too medial = inadequate coverage, loses biomechanical advantage ## Suture Management and Limb Tracking **Color-Coding System** (prevents tangling): - Anterior medial anchor: Blue or striped sutures - Middle medial anchor: White or solid sutures - Posterior medial anchor: Green or colored sutures - Keep pairs organized throughout passage and retrieval **Passage Technique**: - Mattress configuration: 5-10mm from tear edge, 5mm spacing between limbs - Pass from bursal to articular to visualize penetration - Each mattress captures 8-10mm of tissue width - Tissue bite depth: 5-8mm (full-thickness) **Retrieval and Organization**: - Retrieve each suture pair through separate cannulas or keep tagged - Maintain organization - tangled sutures cause massive delays - Test each suture pair before proceeding to ensure correct pairing ## Tensioning Principles **Medial Row Tension**: - Goal: Approximate medial edge to articular margin - Sign of correct tension: Edge against bone, NO blanching, NO bunching - Over-tension: Tissue becomes white/ischemic = cut-through failure - Under-tension: Gap between tendon and bone = poor healing **Lateral Row Tension**: - Goal: Create compression via suture bridges - Sign of correct tension: Sutures taut but tissue maintains color - Over-tension: Can cause medial row pull-out or lateral edge cut-through - The knotless anchor insertion automatically tensions - control depth of seating **Overall Construct**: - Balanced tension between medial and lateral fixation - Compression distributed across footprint - No single point of excessive stress - Dynamic ROM test: Should NOT gap with passive motion ## Re-tear Risk Factors and Prevention **Patient-Related Factors** (pre-operative counseling): - Age greater than 65: 2x higher re-tear rate - Smoking: 1.5-2x higher failure rate - MUST quit 6 weeks pre-op - Diabetes: Impaired healing, higher infection and re-tear - Workers compensation: Higher failure rates (multi-factorial) - Fatty infiltration Goutallier 3-4: 40-50% failure rate regardless of technique **Tear-Related Factors**: - Size: Massive tears greater than 5cm have 40-50% re-tear even with double-row - Chronicity: Chronic tears more difficult to mobilize - Quality: Thin degenerative tissue prone to cut-through - Retraction: Patte Stage 3 often irreparable **Technical Factors** (surgeon-controlled): - Inadequate mobilization: THE #1 cause of failure - Over-tensioning: Tissue ischemia and cut-through - Poor anchor position: Medial row not at margin, lateral row too far - Inadequate footprint preparation: Poor biological environment - Missed concomitant pathology: Biceps, subscapularis **Prevention Strategies**: - Complete mobilization achieving tension-free repair - Appropriate technique for tear size (not all need double-row) - Optimize biology: PRP controversial but may help in high-risk patients - Strict post-operative immobilization 6 weeks minimum - Patient selection: massive tears in elderly = low success regardless ## Stiffness Prevention **Risk Factors**: - Prolonged immobilization (double-row often 6 weeks vs 4 weeks single-row) - Increased surgical trauma (more anchors, longer case) - Pre-existing diabetes or adhesive capsulitis history - Over-aggressive acromioplasty with capsular scarring **Prevention Protocol**: - Early passive motion starting week 2-3 (controversial - balance with protection) - Avoid prolonged immobilization beyond 6 weeks - Aggressive ROM therapy from week 6 onward - NSAIDs for inflammation control - Intra-articular corticosteroid if early stiffness (after 8 weeks) ## Anchor-Related Complication Avoidance **Pull-Out Prevention**: - Adequate bone stock (osteoporotic bone relative contraindication) - Proper deadman angle 45° perpendicular to surface - Flush or 1mm deep placement (proud anchors pull out easier) - Test security after placement before loading - Appropriate anchor size for bone quality **Prominence/Impingement**: - Countersink anchors flush or below cortex - Low-profile knotless designs for lateral row - If tying knots, keep posterior and inferior - Adequate subacromial space assessment **Intra-articular Placement**: - Medial row AT margin not medial to margin - Confirm position with articular-side viewing before final seating - If recognized, remove immediately - causes chondrolysis ## Neurologic Injury Prevention **Axillary Nerve**: - All portals greater than 5cm from acromion - No inferior portals - Careful with inferior capsular releases - Conversion to mini-open requires identification **Suprascapular Nerve**: - Limit medial releases to less than 2cm from glenoid - Blunt dissection for capsular releases - No aggressive medial anchor placement - Avoid thermal devices medially **Musculocutaneous Nerve**: - Anterior portals superior and lateral to coracoid - No deep dissection in rotator interval - Avoid anterior-inferior portals ## Phase 1: Protection (0-6 weeks) **Immobilization**: - Abduction brace 30-45° OR sling with abduction pillow - 24/7 wear except for hygiene and therapy - Rationale: Reduces supraspinatus tension 30% vs arm at side - Controversy: Some studies show no benefit, others suggest lower re-tears - Duration: 6 weeks strict for large tears, 4-5 weeks for medium tears **Passive ROM Only**: - Week 0-2: Pendulums only, elbow/wrist ROM - Week 2-4: Passive forward flexion in scapular plane to 90°, passive ER to 20° - Week 4-6: Progress passive FF to 120°, ER to 30°, begin supine passive ER - NO active motion - NO resisted exercises - Therapist-controlled or pulley-assisted only **Goals**: - Protect biological healing (peak healing 6-12 weeks) - Prevent stiffness (especially important for double-row with longer immobilization) - Patient education on compliance (non-compliance = re-tear) ## Phase 2: Active Motion (6-12 weeks) **Brace Weaning**: - Week 6-8: Transition from abduction brace to simple sling - Week 8: Wean sling during day, continue at night - Week 10: Discontinue sling entirely **Active-Assisted ROM**: - Week 6-8: Begin active-assisted with cane, pulley, or therapist - Progress to full active-assisted ROM all planes - Goal: 140° FF, 40° ER by week 8 **Early Active ROM**: - Week 8-10: Begin active ROM against gravity - Progress to full active ROM by week 12 - Goal: 160° FF, 60° ER, hand behind back by week 12 **Light Isometrics**: - Week 10-12: Begin submaximal isometrics in neutral - NO resisted exercises with arm elevated **Goals**: - Restore full active ROM - Prevent stiffness while protecting repair - Transition to strengthening phase ## Phase 3: Strengthening (12-20 weeks) **Progressive Resistance**: - Week 12-14: Theraband resistance exercises, scapular strengthening - Week 14-16: Light dumbbell weights 1-3 lbs - Week 16-20: Progressive strengthening 3-8 lbs - Emphasize rotator cuff and periscapular muscles **Functional Activities**: - Week 12: Light ADLs (feeding, grooming) - Week 16: Moderate ADLs (dressing, light household) - Week 20: Most ADLs unrestricted **Proprioception**: - Closed-chain exercises (wall push-ups) - Rhythmic stabilization - Perturbation training **Goals**: - Progressive strength restoration - Functional return to ADLs - Prepare for return to sport/work ## Phase 4: Return to Activity (20+ weeks) **Full Strengthening**: - Progressive resistance to full strength - Sport-specific training if applicable - Occupational therapy for work conditioning **Return-to-Activity Criteria**: - Full pain-free ROM - Strength 80% of contralateral (isokinetic testing) - Functional testing: lift 10 lbs overhead, load washing machine - No pain with activity **Timelines**: - Return to desk work: 2-3 weeks (in sling) - Return to light duty: 8-12 weeks - Return to full duty manual labor: 5-6 months minimum - Return to overhead sports: 6-9 months minimum (throwing athletes 9-12 months) - Biologic maturation: 12-18 months (may see continued improvement) **Long-Term**: - Lifelong rotator cuff and scapular strengthening maintenance - 10-15% will have persistent symptoms despite intact repair - Re-tear rates: 10-20% overall by 2 years, higher for large tears and elderly **Patient Position**: Beach chair position (preferred): head elevated 60-70°, arm in pneumatic holder with 10-15lbs gentle traction, neutral rotation, 20-30° abduction allowing dynamic ROM testing. Alternative: lateral decubitus with arm in 45° abduction, 20° forward flexion, 10-15lbs traction. **Surgical Approach**: Arthroscopic technique utilizing posterior viewing portal, lateral (mid-lateral) primary working portal, anterior-lateral and posterior-lateral accessory working portals for suture management. Subacromial space is primary surgical field. **Incision**: Four 5-8mm portal incisions: (1) Posterior viewing portal: 2cm inferior, 1cm medial to posterolateral acromion corner, (2) Lateral working portal: 3cm lateral to lateral acromion edge in line with posterior clavicle (Nevasier), (3) Anterior-lateral portal: via rotator interval, (4) Posterior-lateral portal (accessory): for suture management and medial row visualization. ### Step 1: Patient Setup, Portal Planning, and Glenohumeral Diagnostic Arthroscopy Patient Setup, Portal Planning, and Glenohumeral Diagnostic Arthroscopy: Beach chair positioning: 60-70° upright, pneumatic holder with 10-15lbs traction, arm neutral rotation, 20-30° abduction. Prep and drape widely. Mark landmarks: acromion borders, clavicle, coracoid, spine of scapula. Inject joint with 30-50ml saline/epinephrine (1:300,000) for distension and hemostasis. Establish posterior portal at soft spot (2cm inferior, 1cm medial to posterolateral acromion). Insert 30° arthroscope. Systematic glenohumeral examination: biceps (greater than 50% tear or instability requires management), subscapularis (comma sign for tear), anterior/posterior labrum, articular cartilage, glenohumeral ligaments. Assess cuff from articular side: crescent sign (exposed tuberosity), tear margins, tissue quality. Document findings. **Technical Tip**: EXAM KEY: 'I begin with complete glenohumeral arthroscopy because 40-50% of cuff tears have concomitant pathology requiring treatment: biceps pathology (most common, 60-70%), subscapularis tears (30-40% of large cuff tears), SLAP tears, arthritis. I systematically assess for these - missing biceps or subscapularis pathology leads to failed surgery with persistent pain. The articular-sided view UNDERESTIMATES tear size - bursal side view shows true extent. I use the posterior portal as primary viewing throughout the case.' - Missing biceps pathology (persistent anterior pain post-operatively) - Missing subscapularis involvement (repair failure, instability) - Underestimating tear size from articular view only - Hypotension with beach chair (maintain cerebral perfusion) ### Step 2: Lateral Portal Establishment and Subacromial Space Entry Lateral Portal Establishment and Subacromial Space Entry: Establish lateral portal using outside-in technique with spinal needle from glenohumeral space for orientation, then transition to subacromial space. Position: 3cm lateral to lateral acromion edge, in line with posterior clavicle (Nevasier portal). This provides optimal trajectory: perpendicular to footprint for medial AND lateral row anchor placement. Insert switching stick, then cannula. Camera remains in posterior portal for most of case (alternate to lateral for different viewing angles as needed). Lateral portal is the PRIMARY WORKING portal for anchor placement in double-row repair. **Technical Tip**: EXAM KEY: 'Lateral portal position is CRITICAL in double-row repair - more critical than single-row because I need to place BOTH medial and lateral row anchors through this portal. Position 3cm lateral to acromion in line with posterior clavicle provides perpendicular trajectory to both the articular margin (medial row) and lateral footprint (lateral row). Poor portal position makes anchor placement technically difficult or impossible. I use inside-out technique for precise placement.' - Portal too anterior: difficult posterior cuff access, poor lateral row angle - Portal too posterior: difficult anterior cuff access - Portal too inferior: axillary nerve risk (less than 5cm from acromion) - Portal too medial: cannot reach lateral footprint for lateral row anchors ### Step 3: Complete Subacromial Bursectomy and Visualization Complete Subacromial Bursectomy and Visualization: Camera in posterior (or lateral) portal, shaver via lateral (or posterior) portal. Perform METICULOUS bursectomy - this is the foundation of the entire procedure. Systematically remove bursa: anterior to posterior, medial to lateral, superior to inferior. Work in quadrants. Use motorized shaver and radiofrequency device. Remove ALL bursal tissue until crisp visualization of: undersurface of acromion (smooth bone), coracoacromial ligament, entire cuff tear with anterior and posterior margins, greater tuberosity footprint, humeral head. The bursa is often thickened, inflamed, and adherent in chronic tears - requires patience. Switch camera between portals for complete visualization. Consider anterior-lateral accessory portal if needed for visualization. **Technical Tip**: EXAM KEY: 'Complete bursectomy is THE most important step for successful arthroscopic cuff repair - I cannot overemphasize this. Poor visualization guarantees technical difficulty and suboptimal repair. In double-row repair, visualization is even more critical because I need to see BOTH the articular margin (medial row) AND lateral footprint (lateral row). I take as much time as needed - complete bursectomy may take 15-20 minutes but saves time later. Once complete, the anatomy should be crystal clear: acromion above, cuff tear in center, tuberosity footprint below, all margins visible.' - Incomplete bursectomy: persistent poor visualization, longer case time, technical errors - Aggressive shaving damaging remaining cuff tissue edges - Bleeding from bursa obscuring field (use epinephrine infiltration, radiofrequency) - Damaging CA ligament if planning to preserve it ### Step 4: Acromioplasty Assessment and Minimal Decompression Acromioplasty Assessment and Minimal Decompression: Assess acromion morphology using Bigliani classification: Type I flat (15%), Type II curved (70%), Type III hooked (15%). Modern evidence suggests acromioplasty does NOT improve outcomes in most cuff repairs. Perform MINIMAL acromioplasty ONLY if: significant Type III hook, large anteroinferior osteophyte causing mechanical impingement, evidence of outlet stenosis. Technique: use burr to flatten undersurface, remove 3-5mm anteroinferior acromion creating smooth surface. Work anterior to posterior. Goal: smooth gliding surface, NOT over-resection. Preserve deltoid origin. CA ligament management controversial: traditional teaching releases it, modern practice often preserves it as superior restraint. Remove osteophytes from greater tuberosity. In double-row repair, adequate subacromial space is important for the increased tendon bulk at repair site. **Technical Tip**: EXAM KEY: 'The role of acromioplasty is CONTROVERSIAL and has evolved significantly. Historical teaching (Neer impingement theory) advocated routine acromioplasty. Modern RCTs show NO difference in outcomes comparing cuff repair WITH vs WITHOUT acromioplasty - pain, function, re-tear rates are equivalent. Current evidence-based practice: MINIMAL or NO acromioplasty for most repairs. I perform acromioplasty only if clear mechanical impingement from significant Type III hook or large anteroinferior spur. When done, goal is flat undersurface - over-resection risks deltoid dysfunction, acromion fracture, and altered biomechanics. For double-row repairs, ensure adequate space for thicker repair construct.' - Over-aggressive acromioplasty: deltoid detachment (catastrophic complication), acromion fracture, cosmetic deformity - Anterior over-resection causing deltoid depression - Inadequate decompression if true outlet impingement present - CA ligament release eliminating superior restraint (some preserve for biomechanical reasons) ### Step 5: Tear Pattern Assessment, Classification, and Mobilization Strategy Tear Pattern Assessment, Classification, and Mobilization Strategy: With excellent visualization from complete bursectomy, assess tear from bursal side: TEAR SIZE (anteroposterior and mediolateral dimensions in cm), TEAR PATTERN (crescent, U-shaped, L-shaped, massive), TISSUE QUALITY (thick/thin, degenerative changes, friability), RETRACTION using Patte classification (Stage 1: near greater tuberosity, Stage 2: at humeral head apex, Stage 3: at glenoid level), MUSCLE QUALITY correlation with preoperative MRI Goutallier grading (0: normal to 4: greater than 50% fat). Use probe to assess mobility. Determine repair strategy: crescent tears = direct repair, U-shaped = margin convergence then repair, L-shaped = repair apex first (corner stitch) then margins. Plan need for releases and interval slides. **Technical Tip**: EXAM KEY: 'Systematic tear assessment determines surgical strategy. The bursal-sided view shows TRUE tear extent - typically larger than articular view. I document: SIZE (Cofield: small less than 1cm, medium 1-3cm, large 3-5cm, massive greater than 5cm - double-row indicated for medium-large 2-5cm), PATTERN (determines technique), RETRACTION (Patte predicts reparability: Stage 3 often irreparable), QUALITY (thin degenerative tissue has higher failure rate). For double-row repair, I need adequate tissue LENGTH for both medial and lateral rows - if tissue will not reach lateral footprint even after mobilization, consider single-row medialized footprint repair instead.' - Underestimating tear size leading to inadequate repair planning - Missing L-shaped component (apex extends anteriorly or posteriorly) - Proceeding with double-row when tissue insufficient (causes excessive tension) - Not correlating findings with preoperative MRI (Patte retraction, Goutallier fatty infiltration) ### Step 6: Comprehensive Mobilization - The Key to Tension-Free Repair Comprehensive Mobilization - The Key to Tension-Free Repair: Mobilization is THE MOST IMPORTANT TECHNICAL STEP. Goal: reduce tendon to footprint without tension. Systematic approach: (1) ADHESION RELEASE: release ALL adhesions between cuff and surrounding structures using elevator, shaver, and radiofrequency. Release medially (from glenoid), laterally (from deltoid), superiorly (from acromion/CA ligament). (2) CAPSULAR RELEASES if needed for chronic retracted tears: release superior capsule from glenoid, release posterior interval. Be careful: suprascapular nerve 2cm medial to glenoid. (3) INTERVAL SLIDES for large tears: anterior interval slide (between supraspinatus and subscapularis), posterior interval slide (between supraspinatus and infraspinatus). (4) MARGIN CONVERGENCE for U-shaped tears: side-to-side sutures approximate medial and lateral leaves. Test mobilization: with arm at side in neutral position, tendon should reach lateral footprint WITHOUT tension - this is the marker of adequate mobilization. **Technical Tip**: EXAM KEY: 'Inadequate mobilization is the #1 TECHNICAL ERROR causing repair failure. In double-row repair, mobilization is even more critical because tendon must reach the lateral row which is 10-15mm lateral to medial row. I perform COMPLETE mobilization: release ALL adhesions. For chronic tears with Patte Stage 2-3 retraction, I perform interval slides - these gain 1-2cm of tendon length. The SUPRASCAPULAR NERVE is at risk during medial releases - 2cm medial to glenoid, I limit depth of medial dissection. Test mobilization by pulling tendon laterally with grasper - should reach lateral footprint with arm at side. If cannot mobilize adequately, do NOT proceed with double-row under tension - consider single-row medialized repair, partial repair, or SCR.' - Inadequate mobilization causing repair under tension: #1 cause of failure (repair will fail regardless of fixation method) - Suprascapular nerve injury during medial releases (2cm medial to glenoid) - Aggressive releases damaging tissue - balance needed - Incomplete release of adhesions - palpate with probe to identify remaining adhesions ### Step 7: Greater Tuberosity Footprint Preparation for Double-Row Fixation Greater Tuberosity Footprint Preparation for Double-Row Fixation: Identify anatomic footprint: supraspinatus inserts on superior facet (anterior, approximately 15mm AP x 25mm SI), infraspinatus on posterior facet (approximately 20mm AP x 25mm SI). For double-row repair, prepare ENTIRE footprint: medial border at articular margin, lateral border at anatomic footprint edge (approximately 15-18mm lateral to articular margin). Remove soft tissue, scar, and residual cuff using shaver and radiofrequency. Decorticate to bleeding bone using burr or rasp: GENTLE decortication creating punctate bleeding, do NOT create large bony defect or trough. Over-decortication weakens bone for anchors. Create roughened surface for biological healing. Mark positions: MEDIAL ROW will be at articular margin (medial border), LATERAL ROW will be 10-15mm lateral at footprint edge. Preserve lateral bone stock. **Technical Tip**: EXAM KEY: 'Footprint preparation is critical for double-row repair - I need to prepare BOTH medial and lateral regions. The anatomic footprint spans 15-18mm from articular margin laterally. MEDIAL ROW anchors go at articular margin where native cuff inserted, LATERAL ROW anchors go 10-15mm lateral at footprint edge. This recreates the native footprint anatomy. Key principle: GENTLE decortication - use burr to expose bleeding cancellous bone with punctate bleeding, but do NOT create deep trough which weakens bone. The increased number of anchors in double-row (typically 4-6 anchors total) requires good bone stock - osteoporotic bone is relative contraindication.' - Over-aggressive decortication: anchor pull-out, fracture through weakened bone - Inadequate preparation: poor biological healing environment - Insufficient lateral footprint preparation causing lateral row anchors in weak bone - Articular cartilage damage if medial row too medial (intra-articular) ### Step 8: Medial Row Anchor Placement at Articular Margin Medial Row Anchor Placement at Articular Margin: MEDIAL ROW: Place 2-3 double-loaded suture anchors (typically 2 for medium tears, 3 for large tears) at the MEDIAL BORDER of prepared footprint = articular margin (junction of articular cartilage and tuberosity bone). Space anchors 8-10mm apart spanning anterior to posterior. Insert via lateral portal using DEADMAN ANGLE: 45° to cortical surface, perpendicular to footprint. Anchor types: prefer KNOTLESS medial row anchors (faster, less bulk) OR standard suture anchors if tying. Tap pilot hole, insert anchor flush or 1mm below bone surface. Test security with gentle pull. Color-code sutures for organization (e.g., blue=anterior, white=middle, green=posterior). Retrieve suture limbs systematically - will have 8-12 suture limbs total from medial row. **Technical Tip**: EXAM KEY: 'Medial row position is at the ARTICULAR MARGIN - the junction between articular cartilage and greater tuberosity bone. This is where the native cuff inserted, and provides medial tendon fixation. For double-row repair, medial row creates the FIRST layer of fixation - tendon edge is secured to bone here. I use 2-3 anchors depending on tear size: 2 anchors for 2-3cm tears, 3 anchors for 3-5cm tears. The anchors must be AT the articular margin, NOT medial (intra-articular damage) or lateral (defeats purpose). I insert at 45° deadman angle perpendicular to the articular surface via lateral portal. Knotless medial anchors are increasingly popular - faster, less bulk, biomechanically equivalent.' - Medial row too medial (intra-articular): chondral damage to humeral head, anchor in joint - Medial row too lateral: defeats biomechanical purpose, reduces moment arm - Poor deadman angle causing anchor pull-out - Anchor proud: impingement against lateral row or acromion ### Step 9: Suture Passage Through Cuff - Medial Row Mattress Configuration Suture Passage Through Cuff - Medial Row Mattress Configuration: Pass medial row sutures through cuff tendon using penetrating suture passing device (Spectrum, Scorpion, Penetrator). Pass in MATTRESS configuration for superior tissue purchase compared to simple sutures. Technique: pass first limb from bursal to articular side 5-10mm from medial tear edge (not too close=cut-through), then pass second limb parallel 5mm lateral, creating horizontal mattress. Repeat for all medial row anchors. Each mattress captures approximately 8-10mm of tissue width. Space mattress sutures 8-10mm apart (matching anchor spacing). Ensure ADEQUATE TISSUE BITE: at least 5-8mm of tendon grasped. Retrieve sutures systematically and organize by color/anchor. For knotless medial row: pass sutures and secure anchors immediately. For knot-tying: pass all sutures first, then tie. **Technical Tip**: EXAM KEY: 'Medial row suture passage creates the FIRST fixation layer. I use MATTRESS sutures which provide superior tissue purchase - biomechanical studies show mattress sutures have 2x failure load compared to simple sutures, critical in degenerative tissue prone to cut-through. Pass sutures 5-10mm from tear edge - too close and they cut through, too far and tendon bunches creating gaps. Each mattress captures approximately 8-10mm width of tissue. For double-row, medial row mattress sutures secure the MEDIAL EDGE of tendon to articular margin - this is different from single-row where sutures go through cuff more laterally. Adequate tissue bite (5-8mm depth) is critical.' - Suture passage too close to medial edge: cut-through failure (less than 5mm is high risk) - Inadequate tissue bite: weak fixation - Passing through poor quality friable tissue (choose best tissue available) - Iatrogenic cuff extension from penetrator device (be gentle) ### Step 10: Medial Row Knot Tying OR Knotless Fixation Medial Row Knot Tying OR Knotless Fixation: OPTION A - KNOTLESS MEDIAL ROW (increasingly popular): After passing sutures through cuff, tension sutures pulling tendon medially to articular margin, then secure knotless anchors. Tension appropriately - not too tight. OPTION B - KNOT-TYING MEDIAL ROW (traditional): Retrieve both limbs of each mattress suture through same cannula. Tie using sliding-locking knot (SMC, Revo) with appropriate tension. Tighten post-limb first, then lock. Add 3 alternating half-hitches. Goal: secure medial edge of tendon to articular margin WITHOUT over-tensioning. Assess: medial edge should be at articular margin, no gap, no excessive blanching/bunching. The medial row fixation is FIRST layer - lateral row will add more fixation. **Technical Tip**: EXAM KEY: 'Medial row fixation secures the medial tendon edge to the articular margin. KNOTLESS vs KNOT-TYING is surgeon preference - biomechanical studies show equivalent strength, but knotless is faster and has less subacromial bulk. Appropriate TENSION is critical: goal is to approximate tendon to bone, NOT create drum-tight repair. Over-tightening causes tissue ischemia and cut-through failure. After medial row fixation, I should see: medial tendon edge at articular margin, no gap, sutured tissue has good color (not blanched). The lateral tendon edge remains unfixed at this point - lateral row will secure it next.' - Over-tensioning medial row: tissue ischemia, cut-through (#1 error even for experienced surgeons) - Under-tensioning: gap between tendon and bone at medial fixation - Prominent knots if tying: subacromial impingement, pain - Knotless anchor pull-out if soft bone or poor technique ### Step 11: Lateral Row Anchor Placement - Completing the Suture Bridge Lateral Row Anchor Placement - Completing the Suture Bridge: LATERAL ROW: Place 2-3 KNOTLESS lateral row anchors at the LATERAL EDGE of footprint, 10-15mm lateral to medial row anchors. Position in line with medial row (anterior lateral row aligns with anterior medial row, etc). Insert via lateral portal at 45° deadman angle. Technique: First pass medial row suture tails (already through tendon) OVER or THROUGH the lateral tendon edge. Then insert lateral row knotless anchor capturing these sutures. As anchor inserts and deploys, it tensions the sutures creating SUTURE BRIDGE - sutures span from medial row (fixed to bone), through cuff, over lateral tendon edge, to lateral row (fixed to bone). This creates compression of entire tendon footprint contact area. Tension appropriate - sutures should be taut creating gentle compression, not over-tight. **Technical Tip**: EXAM KEY: 'The lateral row creates the SUTURE BRIDGE configuration - this is the hallmark of double-row/TOE repair. The suture tails from medial row (already passed through tendon) are brought laterally and captured by knotless lateral row anchors at the lateral footprint edge. This creates horizontal sutures BRIDGING across the repair site. Biomechanical advantages: (1) Maximum footprint contact area (60-80% vs 30-50% in single-row), (2) Distributed pressure across repair, (3) High ultimate failure load. I position lateral row 10-15mm lateral to medial row - this recreates the anatomic footprint width. As I insert lateral knotless anchors, they tension the bridge sutures creating compression. The final construct looks like multiple horizontal suture bridges covering the footprint.' - Lateral row too far lateral: inadequate bone stock, fracture risk - Lateral row too medial: inadequate footprint coverage, loses biomechanical advantage - Excessive tension during lateral row placement: suture cut-through at lateral tendon edge, medial row failure - Knots under lateral row anchors: prominence, impingement ### Step 12: Suture Bridge Construct Completion and Optimization Suture Bridge Construct Completion and Optimization: After all lateral row anchors placed, assess final suture bridge construct: (1) VISUALIZATION: multiple horizontal suture bridges spanning from medial to lateral row, tendon compressed against entire footprint from articular margin to lateral edge, complete coverage, no gaps. (2) SUTURE PATTERN: sutures should form neat parallel bridges - not tangled, not crossed. (3) TENSION: sutures taut creating compression, but not over-tight causing tissue blanching or bunching. (4) KNOT MANAGEMENT: if tied medial row, ensure all knots are low-profile and posterior to avoid impingement. Some surgeons perform MARGIN CONVERGENCE side-to-side sutures at this point if U-shaped tear, to augment fixation. Adjust any sutures that appear loose or too tight (can reload and re-do if needed). **Technical Tip**: EXAM KEY: 'The completed double-row suture bridge construct should look like a neatly repaired footprint with multiple suture bridges creating compression. Visual assessment: I should see tendon covering entire footprint from articular margin (medial row) to lateral edge (lateral row), typically 15-18mm of coverage. The suture bridges create DISTRIBUTED PRESSURE across this area - biomechanical studies show contact pressures of 3-5x higher than single-row. The construct should be stable - probe testing shows no gapping. The biomechanics are superior: equivalent to or exceeding native tendon insertion strength.' - Accepting suboptimal construct (gaps, poor contact, loose sutures): will lead to failure - Over-tensioned lateral row: excessive lateral tension can cause medial row pull-out (balance needed) - Residual gaps between suture bridges: poor healing - Prominent sutures under acromion: impingement ### Step 13: Margin Convergence for U-Shaped Tears (if applicable) Margin Convergence for U-Shaped Tears (if applicable): If U-SHAPED tear pattern (retracted leaves creating U or V shape): perform side-to-side MARGIN CONVERGENCE to reduce strain. Technique: pass sutures from lateral leaf to medial leaf using suture-passing device or straight needle. Use horizontal mattress or simple sutures (absorbable suture). Place 2-3 convergence sutures spanning the gap. Tie to approximate leaves, converting U to crescent shape. This REDUCES strain on footprint repair by 30-40%. Margin convergence can be done BEFORE anchor placement (easier) or AFTER medial row fixation (for fine-tuning). The convergence sutures supplement the double-row fixation, improving biomechanics. **Technical Tip**: EXAM KEY: 'Margin convergence is CRITICAL for U-shaped tears. These tears have retracted medial and lateral leaves - attempting direct repair without convergence places massive strain on footprint causing failure. I perform margin convergence by approximating the leaves side-to-side BEFORE or during footprint repair. This reduces the effective tear size and strain on the double-row construct. Biomechanical studies show convergence reduces gap formation by 30-40% and decreases cyclic creep. Combined with double-row fixation, this provides maximum biomechanical stability for challenging tear patterns.' - Attempting to repair U-shaped tear without convergence: extremely high failure rate - Excessive convergence tension: tissue damage, tear extension - Inadequate convergence: residual gap, persistent strain ### Step 14: Dynamic Repair Assessment and Range of Motion Testing Dynamic Repair Assessment and Range of Motion Testing: Comprehensive assessment of completed repair: (1) VISUAL INSPECTION: tendon covering footprint, suture bridges intact, no gaps, no excessive bunching, good tissue color (not blanched), all anchor secure. (2) PROBE TEST: gentle probing of repair - should be very stable with no gapping even with moderate force. Double-row repair should feel extremely secure. (3) DYNAMIC ROM TEST: remove arm from traction and pneumatic holder. Perform PASSIVE ROM gently: forward flexion, abduction, internal/external rotation. Observe repair continuously - should remain intact without gapping through ROM. If gaps with normal ROM, repair is over-tensioned and at high risk of failure - must adjust (remove lateral row, retension less tightly). (4) IMPINGEMENT CHECK: passively flex and abduct arm - ensure no impingement of repair construct under acromion. **Technical Tip**: EXAM KEY: 'Final assessment is CRITICAL - this is when I verify the repair will succeed. VISUAL: complete footprint coverage with suture bridge pattern visible, tissue looks healthy (good color, not ischemic). PROBE TEST: double-row construct should feel rock-solid - significantly more stable than single-row due to distributed fixation. DYNAMIC ROM: the ultimate test - I take arm through passive ROM and watch repair - should NOT gap. If it gaps with normal motion, tension is too high and repair will fail - must adjust by loosening or removing lateral row and re-doing with less tension. The goal is MAXIMUM coverage and stability WITHOUT excessive tension - balance these competing factors.' - Accepting repair that gaps with ROM: guaranteed failure (must revise) - Over-tensioned repair causing blanched ischemic tissue: will cut through - Missed gap at repair margin - Prominent construct causing subacromial impingement ### Step 15: Final Inspection, Hemostasis, Closure, and Immobilization Final Inspection, Hemostasis, Closure, and Immobilization: Perform final 360° arthroscopic inspection: (1) GLENOHUMERAL JOINT: no loose bodies, no iatrogenic damage to cartilage, biceps intact if preserved, no intra-articular sutures or anchors. (2) SUBACROMIAL SPACE: repair intact, complete coverage, smooth contour, no prominent knots or anchors, adequate clearance under acromion. Ensure hemostasis using radiofrequency or epinephrine-soaked sponge - large hematomas impair healing. Irrigate copiously with 3-6L sterile saline to remove debris and reduce inflammation. Consider intra-articular/subacromial local anesthetic injection for pain control (20ml 0.25% bupivacaine). Remove all instruments and cannulas under visualization. Close portals: posterior and lateral with 3-0 nylon, anterior with 4-0 monocryl. Sterile dressings. IMMOBILIZATION: place arm in ABDUCTION BRACE or sling with abduction pillow maintaining 30-45° abduction. This position REDUCES supraspinatus tension optimizing healing for double-row repair. Neutral rotation. Patient education regarding immobilization compliance is critical. **Technical Tip**: EXAM KEY: 'Final steps ensure no complications and optimize healing. Systematic inspection catches any problems: loose suture in joint (remove - causes chondrolysis), prominent anchor (revise if severe), residual loose bodies. Hemostasis is important - large hematomas compress repair and impair healing. I irrigate thoroughly. Post-operative immobilization is CRITICAL for double-row repair: I use ABDUCTION BRACE at 30-45° - this reduces supraspinatus tension by 30% compared to arm at side, potentially improving healing rates especially for medium-large tears. Evidence is mixed, but biomechanical rationale is sound. Strict patient compliance with 24/7 sling wear for 6 weeks is essential - early motion increases re-tear risk.' - Loose suture or anchor fragment in joint: chondrolysis (must remove) - Uncontrolled bleeding: hematoma, infection risk - Inadequate patient education: non-compliance with immobilization causing re-tear - Portal closure complications: infection, dehiscence **Additional Important Complications**: - **Persistent pain despite intact repair** (10-15%): Multi-factorial including pre-existing arthritis, biceps pathology, acromioclavicular joint arthritis, cervical radiculopathy. Manage with diagnostic injections, treat concomitant pathology. - **Residual weakness** (variable): Related to pre-existing muscle atrophy, fatty infiltration Goutallier 3-4, age greater than 65, massive tear size. Prevention through appropriate patient selection. - **Subacromial impingement from construct** (2-5%): Thick double-row construct or prominent knots. Prevention with knotless designs, low-profile techniques. Management with debridement if symptomatic. - **Medial row failure with lateral row intact** (rare): "Chicken wing" deformity on imaging. Represents over-tensioned lateral row pulling out medial fixation. Prevention through balanced tensioning. PHASE 1 (0-6 weeks) - MAXIMAL PROTECTION FOR BIOLOGICAL HEALING: Abduction brace or sling with abduction pillow 30-45° abduction, 24/7 wear except for therapy. Passive ROM only (therapist-controlled): pendulums day 1-3, passive forward flexion in scapular plane to 90° week 2-4 (progress to 120° week 4-6), passive external rotation to 30° week 2-6. NO active motion. NO resisted exercises. Elbow/wrist ROM. Goal: protect healing while preventing stiffness. PHASE 2 (6-12 weeks) - PROTECTED ACTIVE MOTION: Wean abduction brace week 6-8 (transition to simple sling, then wean by week 8). Begin active-assisted ROM week 6-8. Progress to full active ROM week 8-12. Light isometrics week 10-12. Goal: restore full active ROM. PHASE 3 (12-20 weeks) - PROGRESSIVE STRENGTHENING: Active ROM against gravity. Progressive resistance exercises starting with theraband, advancing to light weights. Proprioception and scapular stabilization exercises. Goal: restore strength. PHASE 4 (20+ weeks) - RETURN TO FULL ACTIVITY: Full strengthening program. Return to ADLs 4-5 months. Return to sport/heavy labor 5-6 months for medium tears, 6-9 months for large tears. Full biologic healing 12-18 months. Note: Double-row repairs may benefit from slightly longer protection than single-row due to complexity and size of tears typically addressed. ## References 1. Burks RT, Crim J, Brown N, Fink B, Greis PE. A prospective randomized clinical trial comparing arthroscopic single- and double-row rotator cuff repair: magnetic resonance imaging and early clinical evaluation. Am J Sports Med. 2009;37(4):674-682. doi:10.1177/0363546508328115 2. Grasso A, Milano G, Salvatore M, Falcone G, Deriu L, Fabbriciani C. Single-row versus double-row arthroscopic rotator cuff repair: a prospective randomized clinical study. Arthroscopy. 2009;25(1):4-12. doi:10.1016/j.arthro.2008.09.018 3. Ma HL, Chiang ER, Wu HT, et al. Clinical outcome and imaging of arthroscopic single-row and double-row rotator cuff repair: a prospective randomized trial. Arthroscopy. 2012;28(1):16-24. doi:10.1016/j.arthro.2011.07.003 4. Mascarenhas R, Chalmers PN, Sayegh ET, et al. Is double-row rotator cuff repair clinically superior to single-row rotator cuff repair: a systematic review of overlapping meta-analyses. Arthroscopy. 2014;30(9):1156-1165. doi:10.1016/j.arthro.2014.03.015 5. Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl UJ. Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-analysis of level I randomized clinical trials. J Shoulder Elbow Surg. 2014;23(4):586-597. doi:10.1016/j.jse.2013.10.006 6. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007;16(4):461-468. doi:10.1016/j.jse.2006.09.010 7. Bedeir YH, Jimenez AE, Grawe BM. Outcomes of arthroscopic rotator cuff repair with and without acromioplasty: a systematic review. J Shoulder Elbow Surg. 2022;31(4):e171-e181. doi:10.1016/j.jse.2021.10.025 8. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):78-83. 9. Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res. 1990;(254):81-86. 10. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet. 1982;154(5):667-672.

Arthroscopic Rotator Cuff Repair - Double Row / Transosseous Equivalent (TOE) Suture Bridge Technique

Arthroscopic Rotator Cuff Repair - Double Row / Transosseous Equivalent (TOE) Suture Bridge Technique