In the past 10 years, arthroscopic surgeons have gone from being unable to
repair any rotator cuff tears arthroscopically to being able to repair virt
ually all rotator cuff tears, even complex massive tears, arthroscopically.
The factors responsible for this rapid evolution have been: (1) recognitio
n of the mechanical principles responsible for a secure repair (margin conv
ergence, knot security, loop security); (2) recognition of major tear patte
rns that require different techniques of repair; and (3) development of ins
trumentation and arthroscopic portals that predictably accomplish secure re
pair of the rotator cuff and direct access to the pathologic areas. In the
current study, the author analyzes each factor, anatomic and mechanical, th
at influences the quality of the repair, and explains how to optimize the o
verall repair by optimizing each step in the repair. In the author's series
of arthroscopic repair of rotator cuff tears, the results have been gratif
ying, with massive tears achieving final results equivalent to those of sma
ller tears.