Codman was the first to describe open rotator cuff repair (RCR).¹ His technique involved the use of sutures passed through transosseous (TO) tunnels, and that technique was long considered the standard. In fact, the longest follow-up data available today pertain to open TO RCR. Using an open TO technique, the authors report a 24-point average improvement in the Constant score, 10% revision surgery rate, and good to excellent outcomes in most patients at 20-year follow-up after massive RCR.² With the development of suture anchors and, in particular, the transition to all arthroscopic repairs, the TO technique has been largely forgotten. Yet, for as long as surgeons have been performing arthroscopic RCR, instrumentation and methods have existed to complete these repairs without anchors, using traditional TO tunnels. Arthroscopic TO RCR was first introduced in 2002 using a cannulated, sharp, hooked bone-cutting needle through the greater tuberosity. Suture limbs were pulled through the cannulated needle and sliding knots passing through the rotator cuff defect, securing the rotator cuff to bone.³ Since the first generation of arthroscopic TO RCR, multiple devices have been introduced, attempting to facilitate the application of this technique. Regardless of the technique or implant used, the physiologic principles of RCR remained the same: ample fixation strength, minimal gap formation, marrow-element access to the healing interface, and sufficient mechanical stability for tendon-bone healing.