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Purpose: To compare the occurrence of bone tunnel laceration, the short-term clinical results, and cuff repair integrity of transosseous arthroscopic rotator cuff repair (ARCR) using a tunneling device, with and without lateral cortical augmentation. Methods: A retrospective review of patients who underwent transosseous ARCR from May 2012 to December 2017 was conducted. The inclusion criterion was repairable medium-to massive-sized full-thickness rotator cuff tear. This study included 2 consecutive series of patients undergoing transosseous ARCR with and without lateral cortical augmentation, called the ITO method and AT method, respectively. The incidence of bone tunnel laceration was evaluated intraoperatively. Patients were assessed through a range of motion and Constant scores preoperatively and at final follow-up. Further, magnetic resonance imaging was performed at 24 months postoperatively to examine the repaired rotator cuff integrity. Results: A total of 121 subjects were included: 33 in the AT group and 88 in the ITO group. The intraoperative bone tunnel laceration occurrence rate was 67% and 4% for the AT and ITO methods, respectively; the difference was significant (P ¼ .001). Anatomic failure rate (Sugaya III, Ⅳ, and Ⅴ) rate for medium-to large-sized tears was significantly lower for the ITO than for the AT method (29% vs 65%, P ¼ .004), but not for massive tears (61% vs 69%, P ¼ .515). The mean forward elevation, abduction, external rotation, internal rotation, and Constant score were significantly improved at final follow-up from preoperative values. There were no significant differences between the 2 methods. Conclusions: Transosseous ARCR using a tunneling device with and without lateral cortical augmentation is a reliable method of improving clinical results at a minimum follow-up of 2 years. The intraoperative occurrence rate of bone tunnel laceration occurrence rate and the anatomic failure rate of medium-to large-sized cuff tear were lower with lateral cortical augmentation than without it. Level of Evidence: Level Ⅳ, therapeutic cases series.