Table 1.

Surgical Pearls

1. The surgeon should be sure to perform a thorough bursectomy to view the entire cuff defect to the glenoid surface.

2. A spinal needle should be used to localize the anterior and posterior glenoid anchor trajectory. The posterior glenoid anchor trajectory can be variable and may be best established from the Neviaser portal, the portal of Wilmington, or a mid-lateral approach, which is established off the lateral edge of the acromion.

3. The surgeon should pass the glenoid anchors and medial row of tuberosity anchors before graft passage. Suture passage should be performed outside of the shoulder.

4. For graft passage, a large cannula such as the Arthrex 10-mm Passport can ensure ease of passage without soft-tissue interposition.

5. A double-pulley technique should be used to advance the medial side of the graft, and the surgeon should be sure that the sutures stay on tension during graft passage to ensure that they do not become entangled. Passing all 4 limbs of the medial suture through the graft allows it to sit more flush on the glenoid surface.

6. The medial-row sutures should be secured to a second lateral row of anchors to maximize healing surface area.

7. The surgeon should ensure that the peripheral edges of the graft (anteriorly and posteriorly) are secured to the native remnant tissue to relink the construct. Posteriorly, this should be a complete reapproximation to the intact cuff, whereas anteriorly, the lateral-most aspect of the rotator interval should be closed.

8. The graft should be fixed with the arm in neutral rotation with approximately 20° to 30° of abduction.