The authors’ preferred method depends on several factors when considering arthroscopic rotator cuff repair, particularly of the supraspinatus: (a) patient age, (b) size of tear, (c) degree of retraction, (d) chronicity of tear, and (e) tissue quality.^17,18 Other factors contribute to healing potential over a repaired rotator cuff footprint. For example, increasing the contact area and pressure distribution between tendon and tuberosity may help to optimize healing potential; in addition, repair strength may influence healing, particularly in the immediate postoperative period. Such parameters can be influenced by technique.^{17,19,20,21,22,23} Park et al.²² have found that a transosseous-equivalent repair using suture-bridges (Fig. 9-7) can improve pressurized contact area (Fig. 9-8) and overall pressure at a repaired rotator cuff insertion.

Park et al.²³ have also demonstrated that a transosseous-equivalent repair utilizing four-suture-bridges has an ultimate failure strength significantly stronger than a double-row repair; the gap formation was found to be similar to the double-row repair. Kim et al.²⁰ have also shown that a double-row repair can be significantly stronger than a single-row repair, with suture anchors that are double-loaded for the lateral row. Notably, the maximum force that can be generated by the adult supraspinatus is 302 N³. The yield failure load for all repairs has exceeded this number, except for the single-row repair with double-loaded suture anchors, which on average showed a yield failure load of 265 N⁷; this would be sufficient for a 50% tear (maximal supraspinatus force estimated to be 151 N).

Given the above considerations, our approach to arthroscopic rotator cuff repair is guided by the size of tear in the anterior-posterior direction. Given the adult rotator cuff footprint is roughly 24 mm in the anterior-posterior direction,^24,25 we simplify the approach by dividing tear size into fourths: 6 mm, 12 mm, 18 mm, and 24 mm; the estimated footprint dimension in the medial-lateral direction is 12 mm.^24,25