Arthroscopic Transosseous Rotator Cuff Repair (Anchorless): When I Use It, How I Do It, and What the Data Say

Why transosseous (TO) repair in 2025?

Because it’s a legitimate anchorless alternative for selected tears that can deliver broad tendon–bone compression, preserve bone stock. Below is a concise snapshot for surgeons who are deciding if and how to integrate arthroscopic TO repair into their practice.

Rationale and indications

The TO concept is familiar from open era repairs: pass sutures through a bone tunnel to compress the cuff directly onto the greater tuberosity footprint.

Cadaveric and bench studies suggest that modern arthroscopic TO constructs can achieve load to failure and gap formation characteristics comparable to transosseous-equivalent (TOE)/suture-bridge anchor repairs, recognizing construct-specific differences. Johns Hopkins University+1

Step-by-step technique (arthroscopic, lateral decubitus or beach chair)

1) Diagnostic arthroscopy & footprint preparation

Assess biceps, subscapularis, and undersurface pathology. Debride to bleeding bone and decorticate the greater tuberosity footprint. Avoid excessive troughing that thins the lateral cortex.

2) Tendon mobilization

Release adhesions in the rotator interval and along the supraspinatus/infraspinatus. Perform margin convergence if needed to reduce tension and restore length–tension balance. Adress tendon delamination and use margin convergence as nedded.

3) Tunnel planning

Outside-in guides or dedicated TO systems as the drillbone tunneler help create bone tunnels from the lateral cortex to the footprint. I use 1 tunnel centered in the trajectory of the tendon defect at the most medial portion of the footprint.

If aiming for 2–3 tunnel pairs in larger tears keep adequate bone bridges (≥5–7 mm) to limit convergence and lateral cortex fracture.

4) Tunnel creation

Drill from lateral cortex through an aiming device toward the footprint. Verify exit points arthroscopically. Use cannulated systems or nitinol wires to maintain orientation. Protect the axillary nerve by staying proximal on the cortex and respecting standard safe zones.

5) Suture passage

Shuttle 3-4 high-strength, nonabsorbable sutures (#2 UHMWPE) through the tunnel so that limbs exit medially at the footprint. Pass suture through the tendon in mattress or rip-stop configurations (e.g., tape + #2 rip-stop) ensuring broad footprint compression when tied. Retrieve lateral suture end.

6) Tensioning & tying

Sequentially reduce and tie medial to compress the tendon uniformly. Check for dog-ears and adjust with accessory stitches as needed. Confirm there’s no suture abrasion across sharp edges; smooth the lateral cortex if required.

7) Final checks & adjuncts.Cycle the shoulder through gentle ROM to confirm stability. Consider biologic augmentation (e.g., PRP) per your protocol, acknowledging mixed evidence across techniques.

Pearls & pitfalls.

• Pearl: Map tunnel before drilling—visualize footprint entry point.

  
  

• Pearl: Combine margin convergence with TO in U- or L-shaped tears to reduce tension before footprint compression. Adress tendon delamination.

  
  

• Pitfall: Lateral cortex fracture is rare but real—keep sufficient distance between lateral apertures and avoid oversized drills in osteopenic bone.

  
  

• Pitfall: In very large tears, pure TO may not restore a low-tension construct; consider hybrid approaches.

The device I trust for my transosseous cuff repairs

For my transosseous cuff repais I use the Drillbone Tunneler, a surgical guide specifically designed for transosseous rotator cuff repair. There are other devices on the market including the ArthroTunneler, TransOs, TaylorStitcher, ArthroCuff and GT Tunneler.

However, I found the Drillbone Tunneler to enable a streamlined and efficient procedure to achieves great footprint coverage, improve pressure distribution across the repair site, and reduce micromotion at the tendon-bone interface.

Follow the link: The Drillbone Tunneler

Advantages and disadvantages (pragmatic view)

Potential advantages

• Broad area compression across the footprint with adaptable suture patterns. ScienceDirect

  
  

• Bone-preserving, fast, anchorless fixation.

  
  

• Cost awareness: multiple studies report lower implant costs vs. anchor-based TOE repairs; total procedural cost varies with OR time and system used. ScienceDirect+1

Potential disadvantages

• Learning curve & OR time: drilling and managing sutures can add steps early in adoption.

  
  

• Tunnel-related complications: lateral cortex fracture, tunnel blowout, or suture abrasion if edges aren’t smooth.

  
  

• Evidence heterogeneity: high-quality head-to-head RCT data versus modern anchor constructs remain limited; much of the literature is cohort-based or biomechanical. Arthroskopie Sportmedizin

What do outcomes show?

Several clinical series of arthroscopic anchorless TO repair report significant functional improvement with retear rates comparable to anchor-based methods in similar tear sizes, albeit with heterogeneity in imaging protocols:

• Midterm cohort (arthroscopic TO) demonstrated significant ROM and patient-reported improvements at ≈3–5 years. PMC

  
  

• Systematic review/series indicate comparable clinical outcomes between anchorless TO and anchor-based techniques at short- to mid-term follow-up. Arthroskopie Sportmedizin

  
  

• A 2021 series of arthroscopic TO repairs reported favorable functional results and acceptable complication rates; identified complications included tunnel failure and stiffness but at low incidence. PMC

It’s important to separate anchorless TO from anchor-based TOE/suture-bridge constructs.

High-level evidence (network meta-analyses of RCTs) often favors TOE/suture-bridge for lowest retear rates among anchor techniques—useful context when counseling patients and choosing constructs, but not a direct indictment of anchorless TO. ScienceDirect+1

Biomechanics

Cadaveric studies comparing anchorless TO with anchored TOE have shown no significant difference in ultimate load to failure and cyclic displacement for certain modern TO systems, suggesting rough biomechanical equivalence at time zero—though failure modes can differ (e.g., tendon cut-through vs. lateral cortex issues). Construct design matters. Johns Hopkins University+1

Costs

Multiple analyses show lower implant costs for anchorless TO (hundreds of dollars per case in US series), with total procedural cost depending on operative efficiency. As teams move along the learning curve, some of the OR-time penalty shrinks, preserving the cost advantage. ScienceDirect+1

Rehabilitation

Rehab principles mirror those after anchor repairs and should be tension- and tissue-quality-dependent rather than dogmatic. Given the broad compression and potential for strong fixation, many surgeons use protected passive motionearly for small-to-medium tears, delaying active elevation and resisted external rotation until 6–8 weeks. Network meta-analysis data across anchor constructs suggest that later mobilization can reduce retear rates, which is a consideration for TO as well when tension is high. ScienceDirect

My decision framework (practical takeaways)

• Patient & tear factors first. If I can mobilize a small-to-medium tear to a low-tension reduction, TO is on the table; if massive or stiff, I default to techniques that simplify reduction (sometimes anchor-based with selective margin convergence or augmentation).

  
  

• Bone stock matters. TO is an option in osteopenic tuberosities where anchor purchase is suspect or in revisions with crowded hardware.

  
  

• Economics are real. In systems where implant price dominates, TO offers a credible path to lower cost—if the team is efficient. ScienceDirect

  
  

• Be honest about the evidence. Anchorless TO shows comparable clinical outcomes in many series, but the highest-level comparative data still cluster around anchor constructs. Share that nuance with patients and trainees. Arthroskopie Sportmedizin

Selected references

• Flanagin et al. Midterm outcomes after arthroscopic transosseous repair. Orthop J Sports Med (2016). PMC

  
  

• Beauchamp et al. Functional outcomes of arthroscopic transosseous RCR. J Orthop Case Rep? / PMC article (2021). Complications profile. PMC

  
  

• Kilcoyne et al. Anchored TOE vs anchorless TO—cadaveric biomechanics. AJSM (2017). PubMed

  
  

• Tauber et al. Biomechanics: Suture-bridge vs new TO with buttons. Injury (2011). ScienceDirect

  
  

• Colasanti et al. Network meta-analysis: arthroscopic anchor techniques; TOE favored for retear. Arthroscopy(2022). ScienceDirect

  
  

• Black et al.; Seidl et al. Cost comparisons—lower implant cost for anchorless TO. J Shoulder Elbow Surg (2016); Am J Orthop (2016). ScienceDirect+1

  
  

• Binder et al. Anchorless TO vs anchored techniques—comparable clinical outcomes. Arthrosc Sports Med Rehabil (2022). Arthroskopie Sportmedizin