Circumferential Rotator Cuff Repair With the N+4 Portal, Subclavian Portal, and High Posteromedial Portal

Passing suture during a rotator cuff repair requires proper orientation and purchase of the rotator cuff tendon. Our technique uses a new portal to improve access to the supraspinatus and infraspinatus and uses additional portals for a circumferential repair of the tear, thereby restoring the footprint. Using a penetrating suture passer through the anterior, posterior, and superomedial portals allows 270° of coverage. The lateral anchors complete the circumferential repair. Sutures from the medial anchors are passed in a retrograde fashion using 3 small incisions with no cannula. A spinal needle is used to localize the orientation of each portal. The N+4 portal is the workhorse portal, allowing access to the supraspinatus and infraspinatus. The suture retriever enters the trapezius 5 cm from the medial border of the acromion and 1 cm anterior to the spine of the scapula. It enters the subacromial space on top of the supraspinatus. This provides protection to the suprascapular nerve in the supraspinatus fossa. The cuff is lifted with a grasper to allow perpendicular passage of suture. The suture is retrieved for tying. The tissue purchase and location of suture placement help restore the footprint of the supraspinatus and infraspinatus. Additional sutures are passed anteriorly through the subclavian portal and posteriorly through the high posteromedial portal. The repair is completed with lateral-row anchors as needed.