All-Arthroscopic Rotator Cuff Muscle Advancement With Pan Scapular Release and Using the Scapular Triangular View

An all-arthroscopic rotator cuff muscle advancement technique is presented for posterosuperior massive tears. This procedure involves subperiosteal release of the supraspinatus and infraspinatus from the scapula while preserving continuity with the levator scapulae and the rhomboid muscles. Along the medial scapular border, interposed fibrous bands, termed "Hakusen" (white lines), exist between the rotator cuff muscles and the levator scapulae/rhomboids. The superior and inferior Hakusen are continuously connected through the periosteum of the scapular triangular area. The fibrous unit comprising the superior Hakusen, triangular-area periosteum, and inferior Hakusen is defined as the Hakusen-triangular area complex. Incomplete release at the medial extent of this unit may limit cuff excursion. Our technique adds targeted triangular-area management and the scapular triangular view to maintain visualization of the medial scapular border and standardize the endpoint as complete sequential subperiosteal release of the Hakusen-triangular area complex to its medial extent. In our cadaveric comparison, conventional release left residual triangular-area periosteum, whereas this technique achieved continuous medial-end release including the Hakusen. By increasing lateral excursion and reducing repair tension, this approach may facilitate low-tension primary footprint repair.