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Improved functional outcome with double-row repair in patients with large RC tears
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October 2013
Improved functional outcome with double-row repair in patients with large RC tears
Study Type:Meta analysis
OE Level Evidence:2
Journal Level of Evidence:N/A
Single-row or double-row fixation technique for full-thickness rotator cuff tears: a meta-analysis
PLoS One. 2013 Jul 11;8(7):e68515. doi: 10.1371/journal.pone.0068515. Print 2013Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Eight Level I and II publications (6 RCTs and 2 prospective cohort studies) were included in this meta-analysis which compared double-and single-row arthroscopic rotator cuff repair. The pooled results indicated that functional outcomes measured were superior in those who had received double-row repair, however this was primarily in patients presenting with large tears. Postoperative cuff integrity and a reduced risk of partial-thickness retear were also associated with double-row repair. For small tears that were less than 3 cm there were no differences in outcomes between double and single row repairs.
Publication Funding Details
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Funding:
Non-funded
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
4/4
Accessing Data
4/4
Analysing Data
4/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Rotator cuff tears represent one of the common pathologies of the shoulder, and their effect on daily life can be particularly debilitating. Many individuals elect to undergo arthroscopic repair in order to treat the condition. For surgery, single- and double-row techniques have been described and are performed routinely, although debate still exists about whether the increased tendon-bone contact area achieved with double-row repair actually translates into a clinical difference.
What was the principal research question?
Did double-row repair offer a better clinical outcome compared to single-row repair in the treatment of rotator cuff tears?
Study Characteristics
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Data Source:
A search of PubMed, the Cochrane Library, and EMBASE databases was conducted for articles published from database inception to November 1, 2012. Reference lists of identified articles were also manually search for additional publications.
Index Terms:
Terms used in the database searches included "rotator cuff", "single row", and "double row".
Study Selection:
Selection criteria were prospective, Level I and II evidence studies which compared both single- and double-row techniques of arthroscopic rotator cuff repair. Postoperative follow-up had to be a minimum of 24 months, and outcome must have been assessed on one of the following measurements: American Shoulder and Elbow Surgeons (ASES) score, Constant score, UCLA score, or radiographic outcome. Selection for inclusion was performed independently by two reviewers.
Data Extraction:
Data extraction was conducted by two reviewers, and disagreements were resolved through discussion and consensus. The Main outcomes of interest were the Constant scale, American Shoulder and Elbow Surgeons scale (ASES), and University of California at Los Angeles scale (UCLA). Rotator cuff integrity was divided into three degrees, full thickness retear, partial thickness retear and integrity cuff.
Data Synthesis:
Review Manager 5.1 (Cochrane Collaboration) software was used for pooling and statistical analysis. Weighted mean differences (WMD) were calculated for continuous variables, and risk ratios (RR) for dichotomous outcomes, with associated 95% confidence intervals. Heterogeneity was assessed via the Q statistic (significance P<0.10) and I^2 statistic (significance >50%), with a random-effects model used in the presence of significant heterogeneity. Otherwise, a fixed-effects model was used for the analysis. Publication bias was assessed by funnel plots and the Begg and Egger tests. Subgroup analyses were also conducted for each outcome, separating small and large tears.
What were the important findings?
- Pooling of Constant scores across all types of tears (5 studies) indicated no significant difference between double- and single-row repair (MD -1.00 (95%CI -2.37 to 0.37); P=0.15). Non-significant differences were also observed when analyzed by small tears (MD 0.06 (95%CI -1.72 to 1.85); P=0.95) and large tears (MD -4.57 (95%CI -10.39 to 1.24); P=0.12).
- ASES scores overall were significantly better with double-row repair compared to single-row (6 studies)(MD -0.84 (95%CI -1.66 to -0.02); P=0.04). This was primarily among large tears (MD -1.95 (95%CI -3.14 to -0.76); P=0.001). No significant difference was demonstrated in small tears (MD -0.14 (95%CI -1.12 to 0.84); P=0.77).
- UCLA scores overall were significantly better with double-row repair compared to single-row (4 studies) (MD -0.75 (95%CI -1.30 to -0.20); P=0.007). This finding was considerably due to improvement seen in large tears (MD -1.17 (95%CI -2.01 to -0.33); P=0.006). The difference between treatments among small tears was not significant (MD -0.44 (95%CI -1.17 to 0.29); P=0.24).
- Postoperative rotator cuff integrity was determined to be significantly better in groups which received double-row repair compared to single-row repair (RR 0.81 (95%CI 0.72-0.91); P=0.0004). Classification system(s) used to assess cuff integrity radiographically was not reported.
- Risk of partial thickness retear was significantly higher among those who received single-row repair (RR 1.93 (95%CI 1.20-3.11); P=0.007). There was no significant difference between techniques regarding the risk of full-thickness retear (RR 1.45 (95%CI 0.88-2.41); P=0.15).
What should I remember most?
Functional outcome measurements of the ASES and UCLA scores were significantly better among patients who received double-row repair, particularly in those with large tears. No significantly functional differences were seen in the Constant score, and in those who presented with small tears between single and double row repair. Double-row repair also demonstrated better postoperative cuff integrity, and possessed a lower risk of partial retear compared to single-row repair.
How will this affect the care of my patients?
Double-row repair appears to offer superior clinical outcome for rotator cuff tears, however this may only be primarily in patients presented with large tears as opposed to small tears. Future trials which clearly analyze and report the potential difference in outcome regarding tear size are crucial to this topic going forward.
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