• Beach chair, ensuring that maximal weight tolerance is not exceeded based on individual beachchair specifications

• Arm holder (pneumatic, mechanical, or battery powered); if not available, a Mayo stand or a surgical assistant can be used to hold and manipulate the arm

• Thirty-degree arthroscope, possible 70 degrees

• Arthroscopic burr

• Arthroscopic shaver

• Arthroscopic radiofrequency device

• No. 11 blade, both for skin incisions and for making a portal through the rotator cuff

• Arthroscopic biting instruments, both straight and angled

• Implants

• Anchor(s): either all suture, or absorbable or nonabsorbable nonmetallic anchors depending on preference. Metal anchors are generally avoided due to distortion of future magnetic resonance imaging (MRI) studies

• Smooth and threaded cannulas

• Arthroscopic suture passer, both straight and curved depending on tear configuration.

• Beanbag, or other lateral positioner (pegboard, lateral positioning arms) if lateral positioning is preferred

• The authors prefer beach-chair positioning for partial-thickness rotator cuff tears; lateral decubitus positioning is an option for those who exclusively use this position for shoulder arthroscopy.

• All bony prominences must be adequately padded if using a lateral decubitus position—both the elbow of the upper extremity and the fibular head of the lower extremity.

• Case reports also exist of partial-thickness ulcers at bony prominences about the pelvis due to inadequate padding of the beach chair. The authors typically add additional gel padding in the lumbosacral area (Fig. 12-1).

• Bony landmarks including coracoid, acromion, scapular spine, and clavicle are marked with a skin marker.

• A standard posterolateral portal is established first, roughly 2 cm inferior and 2 cm medial to posterolateralmost aspect of acromion.

• The anterior portal is established under direct visualization using outside-in technique, though inside-out technique can also be utilized (Fig. 12-2).

• Diagnostic intra-articular arthroscopy is performed at the outset of the procedure to evaluate for concomitant pathology, ensuring that the biceps tendon, labrum, articular surfaces, axillary recess, subscapularis insertion, and remainder of rotator cuff are completely visualized and free of lesions.

• Particular care is paid to the articular side of rotator cuff insertion if exam or imaging studies are concerning for rotator cuff pathology.

• Arthroscope is then passed into the subacromial space.

• Bony or soft tissue decompression is performed depending on preoperative symptoms and extent of pathology/spur formation.

• Complete bursectomy is performed to ensure adequate visualization of rotator cuff.

• Depending on extent and location of the partial-thickness tear, a repair is performed. Significant bursal-sided tears are generally completed and repaired in standard fashion. Repair of an articularsided tear is generally more complicated and is accomplished via the methods described in the “Tips and Tricks” section below.

Treatment of bursal-sided, partial-thickness rotator cuff repairs remains a controversial subject with regard to determining if a debridement or a repair should be performed. Previous authors have attempted to quantify tendon quality and tear thickness to set thresholds that necessitate surgical repair. Generally, the authors surgically repair bursal-sided tears that involve in excess of 50% of the normal tendon thickness (Fig. 12-3).¹,²

Arthroscopic examples of bursal-sided rotator cuff tears (Figs. 12-4 and 12-5).

Similar to bursal-sided tears, articular-sided tears have been an area of discussion and debate. Many surgeons use 50% tear thickness when compared to healthy tendon tissue as a threshold above which tendon repair is indicated. Techniques used to repair articular-sided tears vary but broadly fall into two
main groups. One technique involves an in situ repair of the partial-thickness tear through an intact tendon, while the other technique consists of completion and debridement of a partial-thickness tear with subsequent repair. Though prior studies have demonstrated little difference in long-term outcome, a 2012 study by Shin demonstrated two key differences in outcomes between the techniques.³,⁴,⁵,⁶ The completion and repair group demonstrated a higher incompetent cuff rate, while the group that had in situ fixation had a slower restoration of function and more stiffness.⁵