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Volume:4 Issue:8 Number:5 ISSN#:2563-559X
OE Original

Arthroscopic Single-row Versus Double-row Techniques for Rotator Cuff Tear: Powered by OE M.I.N.D.

Authored By: Yaping Chang, Steve Philips, Meng Zhu, Ayesha Siddiqua, Anna Miroshnychenko, Mohit Bhandari

Guest Contributor: Moin Khan, MD., MSc., FRCSC, Dip. Sport Med

August 31, 2021

How to Cite

OrthoEvidence. Arthroscopic Single-row Versus Double-row Techniques for Rotator Cuff Tear: Powered by OE M.I.N.D.. OE Original. 2021;4(8):5. Available from: https://myorthoevidence.com/Blog/Show/145

HIGHLIGHTS


- With the updated search by August 2021, OE M.I.N.D. contains data from 700 RCTs related to shoulder conditions with over 111,000 patients.

- For patients with rotator cuff tears, arthroscopic single-row repair was associated with shorter operative time compared to double-row repair technique. Double-row repair was associated with a small benefit in function, and decreased risk of retear when compared to single-row technique at 12 to 40 months’ follow-up. No significant difference was found in subgroup analysis comparing single-row technique to double-row suture bridge technique in outcomes of function, intact repair and retear.

- There was no significant difference between the single- and double-row repair techniques in pain at the longest follow-up.

Both single- and double-row repairs appear to be safe for treatment of rotator cuff tears. No serious adverse events were reported post surgery.

- In terms of arthroscopic repair for rotator cuff tears, a total of 21 studies were found to be currently ongoing around the world, aiming to recruit 104 patients based on data from clinicaltrials.gov.

- In most published studies related to arthroscopic repairs for rotator cuff tear, Constant Shoulder Score and a follow-up of 12 months are reported.



Rotator cuff tear is one of the most common causes of pain and dysfunction of the shoulder. Rotator cuff tears impact about 1 in 3 people over 60 years of age (Jain et al., 2014; Moosmayer et al., 2014). Arthroscopic rotator cuff repair is one of the most frequently performed orthopedic procedures in the United States, with over 270,000 procedures done annually (Jain et al., 2014).


The arthroscopic rotator cuff repair is a technique using suture anchors to restore the anatomy of the native rotator cuff tendon insertion or footprint in order to reduce pain and improve shoulder function. The most commonly used techniques for suture repair configuration are single row repair and double-row repair (Wall et al., 2009; Spiegl et al., 2016). In the single-row repair procedure, anchors are placed in a linear fashion from anterior to posterior on the greater tuberosity. In the double-row repair procedure, a linear row of anchors is placed medially at the articular margin, and a second row is placed along the lateral aspect of the rotator cuff footprint on the tuberosity. In a modified double-row repair procedure which is called the double-row suture bridge repair (also known as a transosseous-equivalent repair), the medial row suture limbs are linked to suture anchors on the lateral humeral cortex to create a suture bridge (Dines et al., 2010; Zafra et al., 2020).


Findings of controlled laboratory studies on cadaveric specimens and animal models are not consistent. Many studies have demonstrated improved footprint coverage of the rotator cuff with double row repair techniques as well as an increase in time zero repair strength and ultimate load to failure, and decreased footprint displacement and gap formation at the healing enthesis, compared to single-row repair for rotator cuff tears (Barbers et al., 2012; Baums et al., 2008, 2012). Some studies however have not found a difference in load to failure, maximum displacement at failure, stiffness, cyclic displacement and gap formation between the groups (Mazzocca et al., 2005; Esquivel et al., 2015). Evidence from patient studies is required to facilitate clinical application of the repair technique.


In this OE Original, we present analytics using OE M.I.N.D. that include a scoping review of published studies, meta-analysis results and quality of evidence, cumulative evidence synthesized by time and a profile of ongoing trials for single- versus double-row repair techniques for rotator cuff tear. All of the data were extracted from randomized controlled trials (RCTs) by experienced medical literature reviewers. OE M.I.N.D. updates the data on a daily basis, with new trials and data being constantly added. The results in this OE Original were based on analyses performed on August 20, 2021.



2. OE M.I.N.D. Meta Analyzer

--- Overview of the available evidence


Over 111,000 patients across 700 studies were reported for shoulder conditions. Of these, over 41,000 patients across 261 studies examined rotator cuff conditions. There are 159 treatments that were studied for rotator cuff tears, and 66 outcome measures were reported evaluating effectiveness and adverse events of arthroscopic single-row technique compared to double-row rotator cuff repair techniques (Figure 1).


Figure 1. Summary of research topic according to anatomical region, condition and treatment






2. OE M.I.N.D. Meta Analyzer --- Effectiveness of treatments


We identified 16 RCTs comparing effectiveness of single-row to double-row techniques for patients with rotator cuff tears. Of them, conventional double-row fixation was performed in 8 studies (Burks et al., 2009; Carbonel et al., 2012; Franceschi et al., 2007, 2016; Grasso et al., 2009; Koh et al., 2011; Lapner et al., 2012; Ma et al., 2012) and double-row suture bridge, i.e., transosseous-equivalent double-row fixation was performed in 8 studies (Aydin et al., 2010; Barber, 2016; Gartsman et al., 2013; Imam et al., 2020; Li et al., 2021; Nicholas et al., 2016; Yamakado, 2019; Zafra et al., 2020). All the included RCTs followed up patients for at least 1 year and the longest follow-up among these studies was 40 months (Li et al., 2021). The characteristics of the RCTs included in meta-analysis are presented in Table 1.



Table 1. Characteristics of RCTs included in meta-analysis

Author, Year

Country

Number of patients

Patients

Single-row details

Double-row details

Aydin et al., 2010

Turkey

68

Full-thickness small-to medium-sized tears (< 3 cm)

1 to 3 double-loaded Bio anchors; No. 2 Fiberwire sutures; tied using a locking, sliding knot with back-up half-hitches.

A suture bridge was created between medial and lateral rows by placing 1 or 2 anchors at articular margin of humeral head and 1 to 3 knotless anchors loaded with sutures from medial row over lateral edge of native tendon footprint.

Barber, 2016

The United States

40

Full-thickness rotator cuff tears

Triple-loaded Healix BR biocomposite suture anchors; a wedge created by folded platelet-rich plasma fibrin membrane was attached to a shuttling suture before the repair sutures were tied using sliding locking knots.

Suture-bridging technique: 1 or more double loaded Healix BR biocomposite suture anchors for medial row; a shuttling suture was used to pull the folded platelet-rich plasma fibrin membrane into position adjacent to the fixed medial row; 1 or 2 knotless lateral row anchors were placed for lateral row.

Burks et al., 2009

The United States

40

Full-thickness rotator cuff tears

Double-loaded Bio FT anchors; No. 2 Fiberwire sutures; tied using a locking, sliding knot with back-up half-hitches.

Double-loaded Bio FT anchors; medial row was established with a diamond pattern; lateral row was established in similar fashion to single-row group.

Carbonel et al., 2012

Spain

160

Full-thickness rotator cuff tears (>1 cm)

Double-loaded Bio-Corkscrew anchors; No. 2 FiberWire sutures; tied using a locking, sliding knot with backup half-hitches.

Double-loaded Bio-Corkscrew anchors; sutures were passed through the tendon in a mattress fashion; lateral row sutures were passed in a simple suture fashion; just 1 of the 2 sutures was passed through tendon.

Franceschi et al., 2007

Italy

60

Rotator cuff tears (>= 3 cm)

1 to 2 double-loaded Bio-Corkscrew anchors; No. 2 FiberWire sutures; both sutures were passed through the tendon in a mattress fashion.

2 to 4 double-loaded Bio-Corkscrew anchors; both sutures were passed through the tendon in a mattress fashion for medial row; lateral row sutures were passed in a simple suture fashion.

Franceschi et al., 2016

Italy

58

Rotator cuff tears

1 to 2 double-loaded Bio-Corkscrew anchors; No. 2 FiberWire sutures; both sutures were passed through the tendon in a mattress fashion.

2 to 4 double-loaded Bio-Corkscrew anchors; both sutures were passed through the tendon in a mattress fashion for medial row; lateral row sutures were passed in a simple suture fashion; just 1 suture was passed through tendon.

Gartsman et al., 2013

The United States

90

Full-thickness supraspinatus tears

2 double-loaded anchors; sutures were passed through the supraspinatus tendon in a simple fashion; tied using arthroscopic square knots.

Transosseous equivalent (suture bridge) technique. Medial row: 2 single-loaded anchors were placed; sutures were passed in a horizontal mattress fashion; tied using arthroscopic square knots. Lateral row: the 2 sutures from medial anchors were placed into lateral FootPrint anchors.

Grasso et al., 2009

Italy

80

Full-thickness rotator cuff tears (< 25 mm)

1 to 4 double-loaded, metal Corkscrew anchors; No. 2 FiberWire sutures; tied in a simple configuration with a sliding Duncan knot.

Tendon-to-bone repair with double-loaded Corkscrew anchors and side-to-side repair with No. 2 FiberWire sutures. Medial row: 1 or 2 anchors placed; sutures were tied in a mattress configuration with a non-sliding Revo knot. Lateral row: 1 to 3 anchors; just 1 suture was passed through tendon; tied using a Duncan loop secured with 3 alternating half-hitches.

Imam et al., 2020

Egypt

80

Full-thickness rotator cuff tears

2 double-loaded Corkscrew II anchors; No. 2 FiberWire sutures; tied using Duncan Loop knots.

Transosseous equivalent (suture bridge) technique: 2 double-loaded Corkscrew II anchors for medial row; sutures were then fixed with Bio-Corkscrew anchors laterally.

Koh et al., 2011

South Korea

71

Full-thickness 2- to 4-cm rotator cuff tears

2 double-loaded metal suture anchors Corkscrew anchors for the first 11 patients and Bio-Corkscrew anchors for the later patients; simple stitches

Double-row repair with 1 additional medial anchor. Double-loaded metal suture anchors Corkscrew anchors for the first 13 patients and Bio-Corkscrew anchors for the later patients; simple stitches for lateral row and mattress sutures for medial row.

Lapner et al., 2012

Canada

90

Full-thickness rotator cuff tears

1 to 2 double-loaded Metal Super Revo anchors or poly-L-lactic acid Duet anchors, No. 2 high-tensile-strength sutures; tied using a mattress or inverted-mattress fashion with sliding-locking knots and alternating half-hitches.

2 to 3 double-loaded anchors were used in the double-row group. Lateral row: same as single-row group. Medial row anchors were placed parallel to the sagittal axis of rotator cuff footprint, along bone-cartilage junction at medial aspect of footprint; tied using mattress sutures with sliding-locking knots and alternating half-hitches.

Li et al., 2021

China

68

Traumatic supraspinatus tears and adhesive capsulitis

The anchors were placed 5 mm from the cartilage margin; the rotator cuff was sutured and knotted.

Double-row suture bridge technique: anchors were inserted into the cartilage edge and the rotator cuff was sutured, knotted, and fixed. The proximal end of rotator cuff was fixed at the inner edge of the bone bed. The end of each knotted thread was inserted into the outer-row anchor.

Ma et al., 2012

Taiwan, China

53

Full-thickness medium to massive tear (>1 cm)

2 to 4 double-loaded metal anchors; No. 2 braided polyester Super Revo sutures; tied in a simple configuration with a sliding knot and backup half-hitches.

3 to 5 double-loaded anchors were used in the double-row group. Lateral row: same as single-row group. Medial row: 1 to 2 anchors were placed at articular margin of humeral head, both limbs of each suture passed through tendon in a horizontal mattress fashion with a non-sliding knot.

Nicholas et al., 2016

The United States

36

Full-thickness rotator cuff tears (>1 cm)

1 to 4 double-loaded Bio-Corkscrew anchors; No. 2 FiberWire sutures were passed through the cuff in a horizontal mattress configuration and tied using a Duncan loop knot.

Modified double-row suture bridge technique. Medial row: 2 double-loaded Bio-Corkscrew FT anchors; both limbs from each of the 2 sutures were passed through the tendon in a double mattress fashion. Lateral row: 2 SwiveLock anchors were interested; suture limbs were crossed to create suture bridges across the tendon.

Yamakado, 2019



Full-thickness, medium-sized (1- to 3-cm) supraspinatus tears

3-suture loaded titanium Healix Ti anchors were used in the medially based single-row group. No. 2 ultra-high-molecular-weight polyethylene sutures; tied using a simple stitch, mattress stitch, or cuff stitch with 7 half-hitches, avoiding a sliding knot.

Two-suture loaded anchors were used in the suture bridge repair. Medial row: 1 to 2 anchors were placed at the articular margin of humeral head, both limbs of each suture passed through tendon in a mattress fashion and were tied with 7 half-hitches, avoiding a sliding knot. Lateral row: suture limbs were brought into 2 lateral push-in VersaLok anchors, each anchor was fixed lateral to footprint.

Zafra et al., 2020

Spain

50

Partial-thickness (exceeding 50%) articular-sided rotator cuff tears

2 Healix Transtend anchors were placed.

4 anchors were used in the double-row suture bridge group. Anterior procedure: same as single-row group. Lateral row: after knotting, medial anchor sutures were fixed with a lateral row Healix Advance Knotless anchor using the suture bridge technique.




2.1 Operative time


In the comparison of arthroscopic single- versus double-row techniques for the outcome of operative time, a total of 342 patients from 5 studies published between 2007 to 2020 are included in the analysis. Four studies favour the single-row technique and 1 study shows no difference between the two techniques. The overall effect demonstrates shorter operative time with single-row over double-row technique [mean difference (MD), 29.14 minutes shorter; 95% confidence interval (CI), 24.36 minutes shorter to 33.92 minutes shorter]. The certainty of the evidence by GRADE assessment was rated as moderate due to serious risk of bias (Figure 2).


The subgroup analysis by different types of double-row fixation demonstrates shorter operative time with single-row technique over the conventional double-row fixation (189 patients from 3 RCTs; MD, 18.2 minutes shorter; 95% CI, 11.7 minutes shorter to 24.69 minutes shorter), with low certainty of evidence. Similarly, the operative time with single-row technique is significantly shorter than that of double-row suture bridge fixation (153 patients from 2 studies; MD, 42.08 minutes shorter; 95% CI, 35.02 minutes shorter to 49.14 minutes shorter) with moderate certainty of evidence (Figure 2).


Figure 2. Forest plot of operative time

Notes: ROB = risk of bias; red circle with a cross mark = high risk of bias; yellow circle with an exclamation mark = have some concerns.





2.2 Function (0 to 100, a higher score indicates better recovery)


All the included studies reported one or more of the following functional outcomes during 12 to 40 months’ follow-up: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Constant Shoulder Score, UCLA Shoulder Rating Scale, and Disability of Arm and Shoulder (DASH) score. We normalized these function measures on a 0 to 100 scale and meta-analyzed the values at the longest follow-up to assess patient recovery.


In the comparison of single- versus double-row rotator cuff repair for the outcome of function at follow-up between 12 and 40 months, a total of 1051 patients from 15 studies published between 2007 to 2021 are included in the analysis. The overall effect demonstrates that double-row technique results in a significant improvement in function with patients experiencing, on average, a 0.97 (95% CI, 0.21 to 1.74) point improvement. The effect and 95% CI do not exceed the recommended minimally important difference (MID) of 21.9 points on the 0 to 100 ASES score (Gagnier et al., 2018). The certainty of the evidence was rated as low due to serious risk of bias and imprecision (Figure 3).


In the comparison of single-row versus conventional double-row technique for the outcome of function, a total of 612 patients from 8 studies are included in the analysis. The overall effect demonstrates that double-row rotator cuff repair results in a significant improvement in function with patients experiencing, on average, a 1.34 (95% CI, 0.45 to 2.22) point improvement. The certainty of the evidence was low (Figure 3).


In the comparison of single- versus double-row suture bridge repair for the outcome of function, a total of 439 patients from 7 studies are included in the analysis. There was no significant difference in function between the two groups. The certainty of evidence was low (Figure 3).





Figure 3. Forest plot of function on a 0-100 scale



Notes: MID = minimally important difference; ROB = risk of bias; red circle with a cross mark = high risk of bias; yellow circle with an exclamation mark = have some concerns.





2.3 Pain score (0 to 100, a higher score indicates worse pain)


Five studies including 366 patients reported Visual analogue scale (VAS) of pain at follow-up of 12 to 40 months. There was no significant difference in pain between single- and double-row repair techniques for all the studies (MD, 0.08; 95% CI, -2.56 to 2.71 points), or subgroup analysis by either conventional or suture bridge techniques of double-row repair. We rated the certainty of evidence as low due to risk of bias and imprecision (Figure 4).


Figure 4. Forest plot of pain on 0-100 score




2.4 Incidence of intact repair (Healing of tear)


In the comparison of single- versus double-row rotator cuff repair for the outcome of intact repair at the longest follow-up (12 to 33 months), a total of 554 patients from 8 studies published between 2007 to 2019 are included in the analysis. Two studies favour double-row repair and 6 studies show no difference between the two techniques. The overall effect demonstrates that the probability of intact repair (healing of tear) is significantly higher with double-row than with single-row technique [relative risk (RR), 1.57; 95% CI, 1.15 to 2.15], with moderate certainty of evidence (Figure 5).


The subgroup analysis by different types of double-row fixation demonstrates higher probability of intact repair with conventional double-row over the single-row technique (332 patients from 5 RCTs; RR, 1.51; 95% CI, 1.07 to 2.14), with moderate certainty of evidence (Figure 5).


On the contrary, there was no significant difference in incidence of intact repair between single-row and double-row suture bridge fixations (222 patients from 3 RCTs; RR, 1.78; 95% CI, 0.89 to 3.55), with low certainty of evidence (Figure 5).


Figure 5. Forest plot of intact repair (Healing of tear)


One RCT reported subgroup outcome of intact repair by tear size that the intact repair rates in single-row and conventional double-row groups at a mean follow-up of 33 months were 82.2% versus 94.1% (p value, 0.61) among patients with a tear size < 3 cm, and 12.5% and 44.4% (p value, 0.29) among patients with a tear size > 3 cm (Ma et al., 2012).





2.5 Incidence of adverse events (General complications)


Of the 10 studies that reported outcome of adverse events, no complications such as vascular or neurological injuries and and anchor pull-out were observed in both groups (Aydin et al., 2010; Burks et al., 2009; Franceschi et al., 2007, 2016; Lapner et al., 2012; Li et al., 2021; Ma et al., 2012; Yamakado, 2019). Postoperative adhesive capsulitis was reported in one study (1 patient in single-row and 2 patients in double-row suture bridge group, Zafra et al., 2020). Postoperative superficial infections were reported in one study (1 patient in single-row and 1 patient in double-row suture bridge group, Imam et al., 2020).


Low certainty evidence shows no significant difference in adverse events between single- and double-row techniques for all the studies (RR, 0.85; 95% CI, 0.29 to 2.49), or subgroup analysis by either conventional or suture bridge techniques of double-row repair. (Figure 6).


Figure 6. Forest plot of adverse events (General complications)




2.6 Incidence of retear (Rerupture)


In the comparison of single- versus double-row rotator cuff repair for the outcome of retear at the longest follow-up (12 to 40 months), a total of 504 patients from 8 studies published between 2009 to 2021 are included in the analysis. Two studies favour double-row repair and 6 studies show no difference between the two techniques. The overall effect demonstrates that the risk of retear is significantly higher with single-row than with double-row technique [RR, 1.87; 95% CI, 1.16 to 3.01], with moderate certainty of evidence (Figure 7).


The subgroup analysis by different types of double-row fixation demonstrates higher risk of retear with single-row over the conventional double-row technique (169 patients from 3 RCTs; RR, 2.03; 95% CI, 1.12 to 3.71), with moderate certainty of evidence (Figure 7).


No significant difference was found in incidence of retear between single-row and double-row suture bridge fixations (335 patients from 5 RCTs; RR, 1.68; 95% CI, 0.78 to 3.62), with low certainty of evidence (Figure 7).


Figure 7. Forest plot of incidence of retear






We present a summary of the six outcome measures at the longest follow-up in Table 2.


Table 2. Summary and certainty of the evidence

Outcome

All studies

Single- vs. conventional double-row technique

Single- vs. double-row suture bridge technique

Operative time

Favours Single-row

(Moderate certainty)

Favours Single-row

(Low certainty)

Favours Single-row

(Moderate certainty)

Function

Favours Double-row

(Low certainty)

Favours Double-row

(Low certainty)

No difference

(Low certainty)

Pain

No difference

(Low certainty)

No difference

(Low certainty)

No difference

(Low certainty)

Intact repair

Favours Double-row

(Moderate certainty)

Favours Double-row

(Moderate certainty)

No difference

(Low certainty)

Adverse events

No difference

(Low certainty)

No difference

(Low certainty)

No difference

(Low certainty)

Retear

Favours Double-row

(Moderate certainty)

Favours Double-row

(Moderate certainty)

No difference

(Low certainty)





3. OE M.I.N.D. Forecaster --- Sequential meta-analysis


The trends in treatment effects over time show that, when new RCTs are reported and more patients are included in the analysis, precision of effects increases for all the outcomes at their longest follow-up (narrower 95% CI over time) (Figures 8, 9).


Figure 8 shows that operative time of single-row technique was shorter than double-row technique, at first with 95% CI of difference from 11 to 35 minutes shorter based on studies published in 2007 and over time the 95% CI difference was from 24 to 34 minutes shorter based on all the studies published up to 2020.


For function, the overall effect started with the first reported study published in 2007 favouring double-row repair technique, with patients experiencing, on average, a 5.14 point (95% CI, 1.9 to 8.38) greater improvement. There was no significant difference in effects between 2010 and 2015. After examining all of the evidence over time, the final effect favoured double-row technique, with patients experiencing, on average, a 0.97 point (95% CI, 0.21 to 1.74) greater improvement in function. Throughout all the publication years, when a statistical significance between the two techniques was demonstrated, the effect had never exceeded the MID (Figure 8).


There is no significant difference between single- and double-row techniques in terms of pain and this finding has remained consistent since 2011 (Figure 8).



Figure 8. Sequential meta-analysis result for operative time, function and pain


For intact repair and retear rate, there was no significant difference between single- and double-row techniques in the first few years with evidence from the published trials. The overall effects were in favour of double-row repair and the effects were small (lower boundary of 95% CI is close to the no difference threshold of 1 for relative risks) over time (Figure 9).


There is no significant difference between single- and double-row techniques in terms of adverse events (general complications) and this finding has remained consistent since 2008 (Figure 9).


Figure 9. Sequential meta-analysis result for intact repair, adverse events

and incidence of retear





4. OE M.I.N.D Ongoing trials report


In terms of arthroscopic repair for rotator cuff tear, a total of 21 studies were found to be currently ongoing around the world, aiming to recruit 104 patients. Near half of the ongoing studies (10 of 21 studies, 47.6%) are being conducted in Canada. Thirteen of them (61.9%) are interventional studies and 8 of them (38.1%) are observational studies (Figure 10).


Figure 10. Ongoing trials of arthroscopic repair for rotator cuff repair








5. OE M.I.N.D. Research Planning Tool


The OE M.I.N.D. Research Planning Tool provides us with an overview of characteristics of prior RCTs. For studies investigating effects of arthroscopic repairs for rotator cuff tear, the most frequently reported characteristics include: patient demographics, age (90.9% studies reported age); follow-up time point, 12 months (40.9% studies reported outcomes at 12 months’ follow-up); studies conducted at a single center (95.5%); Constant Shoulder Score (54.5%); and the country, Italy (22.7%) (Figure 11).


Figure 11. The most frequently reported characteristics of studies investigating effects of arthroscopic repairs for rotator cuff tear




Discussion


In this OE Original, we identified 16 RCTs that compared the efficacy of arthroscopic single-row versus double-row techniques for patients with rotator cuff tears. In our meta-analysis, moderate quality of evidence showed that the single-row technique was associated with shorter operative time compared to double-row fixation. It is important to note however that various forms of double row fixation exists and certain knotless transosseous equivalent configurations significantly decrease operative time. Low quality of evidence showed that double-row was superior to single-row in functional outcome (ASES, Constant Shoulder Score, UCLA Shoulder Rating Scale or DASH) at the longest follow-up. When we look at the subgroup analysis, the statistical difference was only demonstrated in comparison between single- and conventional double-row repair and the 95% CI of the effect size did not exceed the recommended MID (Gagnier et al., 2018). No significant difference was detected between single- and double-row suture bridge technique in functional outcome. There was no significant difference between the two techniques in pain at the longest follow-up.


In terms of healing (intact repair rate) and the incidence of retear, moderate quality of evidence showed results favouring double-row technique when all the studies were included in meta-analysis as well as in subgroup analysis comparing single-row versus conventional double-row techniques. There was no difference between single- and double-row suture bridge techniques in intact repair rate and incidence of retear at the longest follow-up. No serious postoperative adverse events were reported after single-row or double-row fixations in all the eligible RCTs.


Three RCTs reported subgroup outcomes by tear sizes of < 3 cm and > 3 cm (Carbonel et al., 2012; Imam et al., 2020; Ma et al., 2012). In one study, intact repair rates in single-row and conventional double-row groups at a mean follow-up of 33 months were 82.2% versus 94.1% (p value, 0.61) among patients with a tear size < 3 cm, and 12.5% and 44.4% (p value, 0.29) among patients with a tear size > 3 cm (Ma et al., 2012). The same study reported greater effects in shoulder strength with conventional double-row technique compared to single-row technique in patients tear size > 3 cm than in patients with tear size < 3 cm (Ma et al., 2012). One study reported 1 patient with tear size > 3 cm had retear at 12 months follow-up occurring in single-row group, versus 0 retear in double-row suture bridge group (statistical analysis result was not reported) (Imam et al., 2020). No other subgroup effects by tear size were reported in the included studies.


Previously published systematic reviews investigating patient outcomes of arthroscopic single- versus double-row rotator cuff repairs showed that double-row technique was associated with higher healing rates by magnetic resonance imaging (MRI) or other forms of imaging examinations but no significant differences were found between the single- and double-row techniques in terms of function, pain and quality of life (Wall et al., 2009; Spiegl et al., 2016). The findings in this OE Original are consistent with such results.


One of the major concerns during the evidence quality assessment was the imprecision issue. We rated down one level of GRADE assessment for imprecision regarding both outcomes of function and pain. Although the CIs of the function outcome for all the studies and subgroup analysis of single-row versus conventional double-row repair techniques excluded the no effect line, their CIs crossed the recommended MID values and clinical decisions would differ if the upper boundary versus the lower boundary of the CIs represented the true effect, for patients to achieve a minimally important improvement (Guyatt et al., 2011a). For all the outcomes, we also rated down one level of GRADE assessment for serious risk of bias due to lack of blinding to investigators and participants (Guyatt et al., 2011b).


Due to the limitation of available information, we were not able to perform a subgroup analysis by tear characteristics for incidence of retear, which may significantly influence retear rates and impact of single and double row repairs (Imam et al., 2020).


Additional future research with larger sample sizes and with at least 1 year follow-up is needed to comprehensively evaluate the clinical outcomes and by subgroups of different severities of tear, and verify the findings of the current meta-analysis results.


Bottom line


Meta-analysis of 16 RCTs showed that for patients with rotator cuff tears, single-row technique was associated with shorter operative time compared to double-row fixation. Double-row technique was associated with a small benefit with respect to function as well as improved healing (intact repair rate) and decreased incidence of retear when compared to single-row fixation. There was no significant difference between the single- and double-row repair techniques in pain at the longest follow-up. No serious adverse events were reported after both procedures.




Related ACE Reports:

https://myorthoevidence.com/AceReports/Report/20

https://myorthoevidence.com/AceReports/Report/313

https://myorthoevidence.com/AceReports/Report/849

https://myorthoevidence.com/AceReports/Report/2720

https://myorthoevidence.com/AceReports/Report/3288

https://myorthoevidence.com/AceReports/Report/3692

https://myorthoevidence.com/AceReports/Report/5769

https://myorthoevidence.com/AceReports/Report/8939

https://myorthoevidence.com/AceReports/Report/9024

https://myorthoevidence.com/AceReports/Report/12356





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