Table 2.

Surgical Steps, Tips, Pearls, and Pitfalls

Surgical Step	Tips and Pearls	Pitfalls
Patient preparation and arthroscopic portals	1. Three arthroscopic portals: posterior, lateral, anterolateral	Normally the cannula is not needed.
	2. An additional anterior portal is needed for subscapularis repair.
	3. The ipsilateral lower leg is prepared simultaneously.
Harvest and preparation of lower trapezius tendon	1. An 8-cm horizontal incision is made just below the spine of the scapula over the lower trapezius tendon insertion.	Care must be taken to avoid injury to the spinal accessory nerve that runs 3 to 4 cm medial to the scapula.
	2. The LTT is detached from the scapula spine and mobilized superiorly from the middle trapezius and medially until the medial border of scapula.
	3. The tendon part of LT is whipstitched with no. 2 Ethibond.
Harvest and preparation of semitendinosus tendon with lower trapezius tendon	1. The semitendinosus autograft is harvested full length from the insertion site with a tendon stripper.
	2. Both ends are sutured with no. 2 Ethibond.
	3. One limb of semitendinosus graft is fixed with the tendon part of harvested LTT via a Krackow technique.
Superior capsule reconstruction with long head of biceps tendon	1. Viewing from lateral portal, a suture-based anchor is passed from anterolateral portal and inserted 5-8 mm posterior to the bicipital groove near the cartilage of humerus.	The proximal attachment of the LHBT on the glenoid should be preserved to avoid an unstable biceps root.
	2. One lasso-loop is made by a suture manipulator and CleverHook.	Be careful not to cut the suture during LHBT tenotomy and THL release.
	3. The radiofrequency cautery device is used to tenotomize the LHBT at the entrance of the bicipital groove.
	4. Tension of the LHBT can be made by penetrating the intra-articular LHBT in a more medial position by the 2nd and 3rd lasso-loop.
	5. The proximal attachment of the biceps on the glenoid side is preserved, providing native fixation.
	6. The lateral part of the LHBT is rerouted posteriorly, providing a strong spacer effect.
	7. The THL is released once the LHBT is rerouted and fixed posteriorly, providing better visualization for humeral tunnel drilling and graft passage.
Humeral tunnel drilling and graft passage	1. A Beath pin is introduced from anterolateral portal, aiming at the bicipital groove.	The Beath pin should be put low enough in the bicipital groove to avoid intra-operative humeral fracture during tunnel preparation.
	2. The Beath pin is drilled posteriorly until it exits at the upper part of the native infraspinatus tendon insertion point.
	3. A 4.5-mm rigid cannulated drill is first used to ream from anterior to posterior to create a humeral tunnel.
	4. The length of the tunnel is measured.
	5. An 8-mm rigid cannulated drill reams from posterior to anterior until the humeral tunnel is the desired length.
	6. A suture shuttle is passed from posterior to anterior and retrieved out of the anterolateral portal.
	7. A grasper is inserted along the length of the infraspinatus muscle, and the shuttling suture is pulled out of the opening of the infraspinatus fascia.
	8. The free limb of semitendinosus tendon not fixed with LTT is passed from the loop of a 20-mm EndoButton and works in a double fashion.
	9. The leading and flipping sutures of the EndoButton are tied with the shuttling suture and passed intra-articularly from posterior to anterior, until it exits the bicipital groove.
Tensioning of lower trapezius tendon and semitendinosus graft	1. After the EndoButton is flipped and fixed at the bicipital groove, the shoulder is placed in 45° abduction and 30° external rotation.	In osteoporotic patients, the semitendinosus should be tensioned gradually.
	2. The free limb of semitendinosus tendon is pulled backward until the desired tension checked intra-articularly.
	3. This end is fixed side by side with the LTT with a Krakow suture.

Abbreviations: LHBT, long head of the biceps; LTT, lower trapezius transfers; THL, transverse humeral ligament.