Ashraf Elazab
Background and Aims: Rotator cuff repair has evolved from open transosseous (TO) techniques to modern arthroscopic anchor-based fixation. While suture anchors and all-suture anchors improve surgical efficiency, they introduce foreign material into the footprint and rely predominantly on cancellous bone fixation, which may be suboptimal in poor bone quality. Anchorless TO repair preserves the biological environment, but remains technically demanding and less reproducible. The purpose of the study is to describe the concept, surgical rationale, and technical features of a novel guided anchorless TO rotator cuff repair system – the Elazab Apex Shoulder Arc (EASA) – designed to standardize TO tunnel creation. Materials and Methods: This technical note (Level V evidence) outlines the design principles and surgical application of the EASA system. The technique utilizes a guided 180° semicircular arc to create convergent TO tunnels with a predefined lateral cortical exit point, enabling controlled suture passage and footprint compression without anchors. Feasibility was demonstrated using a saw bone model, confirming reproducible tunnel geometry and controlled trajectory alignment. Results: The EASA-guided technique allows consistent tunnel geometry and reduces variability associated with freehand drilling. In repeated saw bone simulations, tunnel convergence toward the lateral cortical apex was consistently achieved, with minimal observed variation in k-wire trajectory alignment across trials. No cortical breach or articular violation was observed. By utilizing lateral cortical fixation, the construct may provide a theoretical biomechanical advantage in resisting pullout forces based on cortical fixation principles compared with cancellous-based fixation. The anchorless design preserves the tendon footprint and enables marrow venting through TO tunnels, which may enhance the biological environment for tendon healing. In addition, the absence of implants may reduce implant-related complications and facilitate revision strategies. Conclusion: The EASA system represents a guided approach to anchorless TO rotator cuff repair, combining biological preservation with controlled tunnel creation. While saw bone feasibility has been demonstrated, further biomechanical and clinical studies are required to validate its efficacy and safety.