Because risk factors for rotator cuff repair failure can be identified preoperatively, obtaining a thorough patient history is critical. This begins with identifying comorbidities and factors associated with repair failure such as smoking status, chronicity of symptoms, and history of prior rotator cuff repairs.

Initial imaging consists of radiographs that include an AP view in the plane of the scapula (Grashey) and an axillary view, at a minimum. These radiographs are used to evaluate for signs of osteoarthritis such as joint space narrowing and osteophyte formation, as well as findings consistent with rotator cuff arthropathy such as proximal humeral migration with decreased acromiohumeral distance and sclerosis of the undersurface of the acromion. Advanced imaging is typically obtained in the form of an MRI without contrast. The MRI is evaluated for three critical factors that can predict failure of rotator cuff repair: (1) tear size, (2) retraction, and (3) muscle atrophy. Studies have shown that larger tears, retracted tears, and those with higher grades of muscle atrophy are at a higher risk of retear after repair.^{7, 8 and 9} Ultrasound and CT arthrogram studies can also provide similar information but are less commonly used at our institution.

We prefer to perform arthroscopic rotator cuff repair in the beach chair position. After diagnostic arthroscopy in the glenohumeral joint is performed to evaluate for concomitant pathology, a limited subacromial bursectomy is performed to improve visualization of the rotator cuff tear. Mobilization
of the tendon tear is then evaluated to ensure that it can be reduced at least to the medial aspect of the rotator cuff footprint under minimal tension. The quality and thickness of the torn tendon is then assessed by using a cuff gasper to assess its ability to withstand the lateral traction necessary to reduce the tear without tearing. If the tendon is found to be attritional, subjectively at risk for suture pull-through, and in combination with preoperative risk factors for poor healing discussed earlier, a dermal allograft patch is used.

We perform augmentation with acellular dermal extracellular matrix allograft by the double-row technique described by Chalmers et al.¹⁰ Standard preparation of the rotator cuff footprint is performed. Depending on the size of the tear, two double-loaded anchors are most frequently used and are placed at the medial footprint. Sutures are then passed through the native tendon in a horizontal mattress configuration and retrieved out of the anterior portal ( Video 14-1). Given that the graft will cover the footprint laterally, we do not try to over-reduce the rotator cuff to cover the entire footprint and pass sutures in a manner to achieve a tension-free, often-medialized repair. We view via a posterolateral portal and use an 8.25-mm cannula in the anterolateral portal and a 5.5-mm cannula anteriorly. Our goal is to have six total limbs of suture (or three horizontal mattress sutures) passing through the graft. One of the horizontal mattress sutures near the apex of the tear is tied to reduce the cuff to the medial footprint. The medial-to-lateral dimension is measured from the medial tied sutures to the lateral aspect of the greater tuberosity with a graduated probe (Figure 14-1). The anterior-to-posterior dimension from the second most posterior to the second most anterior suture is measured ( Video 14-2). The human dermal allograft patch (ArthroFLEX, Arthrex) is cut to fit the dimensions of the rotator cuff medially and the footprint laterally. The graft is slightly oversized as it can always be shaved and downsized after the final construct is created.