Arthroscopic Transosseous Rotator Cuff Repair Using Bone Tunneling Device

Fig 1. Optimal setup for arthroscopic rotator cuff repair using bone tunneling device. The patient is positioned in the left lateral decubitus position with low traction at an angle of less than 25°. This setup increases the subacromial space, enhancing access to the medial edge of the rotator cuff footprint. The tunneler is positioned at an ideal 45° angle to the plane of the footprint for precise tunnel creation.

Fig 2. The patient is positioned in the left lateral decubitus position. Standard arthroscopic portals used in rotator cuff repair, including anterior (A), anterolateral (AL), posterolateral (PL), and posterior (P). Additionally, the portals specifically used for the bone tunneling device, the para-acromial (PA) and lateral (L) portals, are highlighted. Landmarks such as the humeral axis (HA) and lateral epicondyle (LE) are identified for accurate portal placement. The patient is positioned in the lateral decubitus position with low traction at an angle of less than 25°.

Fig 3. Medial bone tunnel creation using the bone tunneling device. (A) The awl is placed at the center of the rotator cuff footprint for a single tunnel. (B) The awl is hammered (in the direction of the arrow) into position adjacent to the cartilage at a 45° angle to the longitudinal axis of the humerus, ensuring precise tunnel alignment for optimal transosseous fixation.

Fig 4. The position of the portal is confirmed using a long 20-gauge needle to ensure that the drilling sleeve will be properly introduced against the bone. By rotating the tunneler, the surgeon identifies the correct position for creating the low lateral portal, ensuring that the drilling sleeve accurately targets the cortex of the proximal humerus. Careful attention is given to the tunneler rotation, depending on whether the supraspinatus or infraspinatus is being repaired.

Fig 5. (A) The drilling sleeve is advanced (in the direction of the arrow) onto the bone through the body of the tunneler. The ratchet system on the drilling sleeve enables controlled, gradual advancement, ensuring secure fixation of the tunneler to the bone and stable locking in the desired position. (B) The drill (with a 2-mm-thick, 13-cm-long K-wire) is advanced (in the direction of the arrow) until it reaches the limit, making contact with the drilling sleeve. This ensures that the K-wire passes through the drilling sleeve, penetrates the bone, and exits through the opening at the fixed tip of the awl, extending approximately 1 to 3 cm beyond the tip, thereby connecting the tunnels.

Fig 6. The tunnel is cleaned of debris by moving the drill back and forth (in the direction of the arrows). The surgeon then inserts a shuttle loop through the drilling sleeve into the lateral tunnel. Clamping the loop briefly forms a pointed tip for easier insertion. The loop is advanced slowly to the end of the 13-cm tunnel until a firm stop is felt, allowing the loop to be caught by the awl.

Fig 7. Process of capturing shuttle loop by rotating awl tip. Rotation of the awl, along with its tip and the shuttle loop, is started by pushing the button on the handle (in the direction of the arrow) to release the rotational mechanism within the device body, allowing a full 360° turn.

Fig 8. The awl is rotated 360° while the shuttle loop winds around its tip. This maneuver secures the loop for retrieval through the medial tunnel.

Fig 9. (A) The awl is withdrawn from the bone, simultaneously retrieving the shuttle loop (in the direction of the arrow) from the vertical tunnel. (B) The shuttle loop is loaded (in the direction of the arrow) with braided high-strength suture. (C) As the shuttle loop is pulled back, the suture is retrieved through the tunnel (in the direction of the arrow) and out of the lateral portal.

Fig 10. Back-and-forth motion of sutures within tunnels. This action helps smooth the edges of the tunnels and ensures the stability of the bone stock.

Fig 11. (A) Passage of 3 high-strength sutures through rotator cuff using surgeon’s preferred suture-passing device. (B) Sequential knot tying progressing from posterior to anterior, ensuring optimal tension and secure fixation.

Fig 12. Repaired rotator cuff using 3 high-strength sutures in different colors for easy identification. The sutures form a classic parachute configuration, ensuring stable and secure fixation of the rotator cuff.