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Double-row versus single-row in arthroscopic rotator cuff repair

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Double-row versus single-row in arthroscopic rotator cuff repair

Vol: 3| Issue: 5| Number:73| ISSN#: 2564-2537
Study Type:Meta analysis
OE Level Evidence:2
Journal Level of Evidence:2

Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears

J Shoulder Elbow Surg. 2014 Feb;23(2):182-8. doi: 10.1016/j.jse.2013.08.005. Epub 2013 Oct 31

Contributing Authors:
C Xu J Zhao D Li

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Nine studies (5 level I evidence and 4 level II evidence) were included in this review which compared the clinical outcomes of single-row and double-row arthroscopic rotator cuff repair. Pooled results indicated significant differences in favour of double-row repair when considering re-tear rate, function on the American Shoulder and Elbow Surgeons (ASES) score, and range of motion in internal rotation. No significant differences were established for overall Constant score, UCLA score, range of motion in external rotation and forward flexion, and muscle strength. Double-row tended to be better for large-massive tears (>30mm).

Publication Funding Details +
Not Reported
None disclosed

Risk of Bias


Reporting Criteria


Fragility Index


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.




Accessing Data


Analysing Data





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?

Arthroscopic rotator cuff repair has become increasingly popular in the management of torn cuff tendons. Standard intervention has predominantly been through the single-row technique. Despite good clinical results, there has been debate about whether the single-row technique offers sufficient anatomic healing. Accordingly, some suggest the double-row technique may be better suited, with an increased tendon-bone contact area and more anatomic footprint. How the clinical results compare between these two techniques needs to be investigated.

What was the principal research question?

Is there a difference in clinical results between single-row and double-row arthroscopic rotator cuff repair?

Study Characteristics -
Data Source:
A search was performed of the databases MEDLINE (from 1950), EMBASE (from 1980), and Ovid (from 1982) for articles up until July 2012. Reference lists were also search for additional articles, and authors of studies were contacted if necessary.
Index Terms:
Keyword search terms included "single-row", "double-row", and "rotator cuff".
Study Selection:
Eligibility for inclusion in the study were as follows: randomized controlled trials (Level I and II evidence) which compared double-row repair and single-row repair in human subjects undergoing either unilateral or bilateral arthroscopic rotator cuff repair. Selection was carried out by two independent reviewers.
Data Extraction:
Data was extracted on outcomes including the UCLA (University of California, Los Angeles) score, ASES (American Shoulder and Elbow Surgeons) score, Constant score, shoulder range of motion, muscle strength, and re-tear rate. Patients were also divided in subgroups based on tear size: small- and medium-sized tear <30mm, and large- and massive-sized tear >30mm. Data extraction was carried out by two independent reviewers.
Data Synthesis:
Pooling and statistical analyses were performed using Review Manager software (RevMan version 5.1.6). Mean differences (MD) were calculated for continuous outcomes, and risk ratios (RR) were calculated for dichotomous outcomes. Heterogeneity was assessed using the I-squared statistic, with >60% representing significant heterogeneity. A fixed-effects model was used when heterogeneity was non-significant, and a random-effects model for when heterogeneity was significant.

What were the important findings?

  • The search and study selection yielded a total of 9 studies for inclusion (5 Level I; 4 Level II), comprising a total of 651 patients.
  • Pooling of 7 studies indicated there was no significant difference in the comparison of Constant score between double-row and single-row repair (MD -0.31 [95%CI -2.71, 2.09]; p=0.80). Significance did not change based on analysis by subgroup (Small-Medium: MD -0.23 [95%CI -1.78, 1.31]; p=0.77) (Large-Massive: MD 2.41 [95%CI -1.95, 6.76]; p=0.28).
  • Pooled UCLA scores (5 studies) demonstrated no significant difference between double-row and single-row (MD -0.64 [95%CI -0.22, 1.50]; p=0.14). By subgroups, there remained no significant difference in small-medium tears (2 studies: p=0.66), although scores in large-massive tears were significantly higher with double-row repair (3 studies: MD 1.48 [95%CI 0.44, 2.51]; p=0.005).
  • ASES scores were pooled among 5 studies, indicating significantly higher scores with double-row repair (MD 1.22 [95%CI 0.39, 2.05]; p=0.004). The difference in small-medium tears was not significant (3 studies: p=0.29), whereas the difference in large-massive tears was significantly in favour of double-row repair (3 studies: MD 2.08 [95%CI 0.84, 3.32]; p=0.001).
  • Pooled re-tear rates (5 studies) were 30/126 following double-row repair (23.8%) and 53/132 after single-row repair (40.2%). The difference between groups was statistically significant (RR 0.59 [95%CI 0.41, 0.86]; P=0.006).
  • A significant difference in favour of double-row repair was observed in pooling of 2 studies for range of internal rotation (p<0.00001), although no difference was observed among 3 studies which reported data on range of external rotation (p=0.16) and 2 studies which reported data on range of forward elevation (p=0.97).
  • There were no significant differences between double-row and single-row observed in the analyses of abduction muscle strength (p=0.73), external rotation muscle strength (p=0.81), and internal rotation muscle strength (p=0.21).

What should I remember most?

Double-row arthroscopic repair of torn rotator cuff tendons was associated with a significantly lower re-tear rate, improved ASES score, and greater internal rotation. Large to massive tears additionally benefited from double-row repair, with improved UCLA scores. Constant score, range of motion in external rotation and forward elevation, and muscle strength were similar between double-row and single-row repair.

How will this affect the care of my patients?

The results of this analysis highlight the potential benefits of double-row repair in the treatment of rotator cuff tears, particularly those above 30mm. Objective analyses using MRI findings should be considered to further investigate any differences in treatment effects between double- and single-row repairs.

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