The patient is positioned in the beach chair position. Before disinfection, the arm holder is attached and care is taken to ensure that, on the one hand, access to the axilla is easy for surgical preparation and, on the other hand, the arm can be freely flexed upward (Figure 16-1). The axillary body hair is shaved. After disinfection and sterile covering of the surgical area, the arm is fixed in an arm holder. It is essential that sufficient flexion of the shoulder is possible so that the so-called “Statue of Liberty” position can be achieved with the affected upper limb, which is important for tendon-muscle harvesting.

The operation is started with arthroscopy. The preoperatively determined irreparability is confirmed again intraoperatively. If, contrary to expectations, the flexibility of the tendon stumps is very good, direct rotator cuff repair is attempted. It is important that patients are always informed preoperatively that, in the event of unexpected reparability, a decision will be made intraoperatively as to whether a direct repair or a tendon transfer will be performed. If, as in most cases, the intraoperative findings are consistent with the preoperative findings of irreparability, the portion of the rotator cuff that is still repairable is reconstructed in the sense of a partial repair. In most cases, a partial repair is possible, and we firmly believe that this should be always attempted as part of the tendon transfer surgery. After the partial repair, the shuttle path is prepared intra-articularly for the subsequent tendon transfer. The scope is inserted from the lateral viewing portal in order to have the best possible view of the former infraspinatus tendon path in the direction of the infraspinatus fossa. The layer between the deltoid and the infraspinatus tendon is then dissected free using electrocautery electrocaustics via the posterior and posterolateral portals. Especially in patients without previous surgery, this layer should be very easy to defuse. In most cases, the layer can be defused by increasing the water pressure of the scope. The layer can also be prepared bluntly with the aid of the trocar. In preoperated patients, the layer is often more scarred and it is more challenging to prepare the layer. If the scarring is very severe, then the spina scapulae should be visualized first from the lateral
subacromial side and then the layer should be prepared freely dorsal to this landmark. Superiorly, the deltoid muscle should be identified, and inferiorly, the infraspinatus muscle. Preparation into the infraspinatus fossa should be as deep as possible (to the point where the preparation instruments stop at the arthroscopy portals), as this will facilitate later open dissection of the shuttle path across the axilla. When preparing with electrocaustics, care should be taken to ensure that the dissection is performed along the infraspinatus muscle so that the axillary nerve, which lies directly on the deltoid, can be protected throughout the procedure. After optimal preparation of the shuttle path, a blue cord cut from a sterile abdominal drape is used to serve as a shuttle suture. This cord is inserted into the joint via the anterior portal. Before inserting the cord through the anterior portal, both the anterior and anterolateral portals are cannulated to allow easy handling of the shuttle sutures and later fixation of the transferred tendon (Figure 16-2). Using the longest possible grasping forceps, the end of the blue cord is grasped via the posterior or posterolateral portal and then advanced as far as possible into the infraspinous fossa. This blue cord helps for later orientation and will also serve as a shuttle suture. The dorsal portion of the suture including the self-locking grasping forceps inserted over the posterior portal is then left in the infraspinous fossa. The other end of the cord is passed out via the anterior portal (Figure 16-3). The procedure now switches to the open part of the operation.