A Majority of Single Versus Double-Row Rotator Cuff Repair Comparisons Fail to Consider Modern Single-Row Techniques

Abstract

Background: There is considerable published research comparing single-row (SR) and double-row (DR) rotator cuff repairs. Conclusions of primary studies as well as multiple meta-analyses have differed. One underexplored factor has been the variability in techniques that are identified as “single-row” or “double-row.” Our goal was to conduct a systematic review of primary research and meta-analyses comparing SR and DR fixation techniques, with attention to the specific technique types compared. Methods: We evaluated meta-analyses and individual studies that directly compared SR and DR repairs. Primary studies from 8 high-quality meta-analyses published prior to 2014, and any Level-III or higher studies published from 2014 to 2019, were included. Specific techniques of repair were identified, and the manuscripts were classified on the basis of the specific type of simple or complex SR or DR repair that was performed. Conclusions of the studies were then assessed according to these classifications. Results: Twenty-two studies met the eligibility criteria; 9 were Level-I studies, 7 were Level-II, and 6 were Level-III. Of the 22 studies, only 3 (14%) of the studies compared a biomechanically superior complex SR technique and a DR repair. The remaining 19 (86%) of the studies utilized biomechanically inferior, simple SR techniques in their comparisons. Conclusions: While there is a large amount of published evidence comparing SR and DR rotator cuff repair techniques, there are few studies assessing how the strongest SR techniques compare with DR techniques. This identifies a deficiency in the current understanding of rotator cuff repair techniques. Future studies specifically designed with these techniques in mind will help to further the understanding of which technique is clinically and financially superior in this continuously changing medical environment. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Single-Row Rotator Cuff Repair

“…Most studies used lateral single-row configurations either in vitro or in vivo, and very few a more medial single row avoiding unnecessary tension at the level of the repair (which is a must, especially in large and retracted tears) When a proper, more medial, single-row configuration was used, the results become similar. It is not fair to compare single-row configurations performed poorly and too lateral to modern double-row techniques, and despite that, clinically relevant results have failed to be obtained [37,38].…”

Editorial Commentary: Biology and Biomechanics Must Be Carefully Balanced for a Durable Rotator Cuff Repair

“…In 2005, Park et al 10 reported on a transosseous equivalent (TOE) technique consisting of 2 rows connected by the sutures bridging the rotator cuff, otherwise referred to as a linked DR repair. 11 Biomechanical studies also demonstrated that TOE repairs improved tendonto-bone contact and durability compared to SR repairs. 12,13 The technique was simplified further by replacing suture with tape for knotless repairs.…”

“…A recent systematic review summarized the results of several early comparative studies that demonstrated better healing rates and/or outcomes with DR or TOE repairs compared with traditional SR repairs employing double-loaded suture anchors typically placed away from the articular margin without any adjunctive intervention to promote healing. 11 However, modern SR repairs employing complex stitches and/or tripleloaded anchors have been shown to biomechanically outperform repairs using double-loaded anchors and simple or horizontal mattress stitches. 11,18,19 In the paper "Arthroscopic Repair of Medium to Large Rotator Cuff Tears with a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents" by Dierckman, Frousiakis, Burns, Barber, Wodicka, Getelman, Karzel, and Snyder, 20 the authors report on the outcomes of a modern SR repair strategy for medium-to-large rotator cuff tears 2 to 4 cm in length.…”

“…11 However, modern SR repairs employing complex stitches and/or tripleloaded anchors have been shown to biomechanically outperform repairs using double-loaded anchors and simple or horizontal mattress stitches. 11,18,19 In the paper "Arthroscopic Repair of Medium to Large Rotator Cuff Tears with a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents" by Dierckman, Frousiakis, Burns, Barber, Wodicka, Getelman, Karzel, and Snyder, 20 the authors report on the outcomes of a modern SR repair strategy for medium-to-large rotator cuff tears 2 to 4 cm in length. 20 They employ a consistent technique featuring triple-loaded suture anchors placed medially, only 3 to 5 mm lateral to the articular margin.…”

Statistical Fragility of Single-Row Versus Double-Row Anchoring for Rotator Cuff Repair: A Systematic Review of Comparative Studies

“…As the number of patients who undergo arthroscopic rotator cuff repair continues to rise, clinical research has focused on delineating the best possible technique for repair. Many anatomic and biomechanical factors are considered when comparing different techniques, including restoration of the anatomic footprint, 2 biomechanical strength of the construct, 30 and minimized motion at the bone-tendon interface. 18 Currently, the most frequently used techniques are the single-row (SR) and double-row (DR) repairs.…”