Arthroscopic single-row versus double-row technique for repairing rotator cuff tears: a systematic review and meta-analysis

The High Resistance Loop (H-Loop) Technique for Arthroscopic Repair of Subscapularis

The subscapularis tendon is more challenging and riskier to repair than the posterior upper rotator cuff. The knotless anchor suture in subscapularis repair simplified the repair process and had an excellent postoperative effect. We describe a new knotless anchor stitching method, the H-Loop technique. The simplicity and efficiency of the technique make it particularly suitable for small subscapular tendon tears.

Changes in the Lateral Acromion Angle in Rotator Cuff Tear Patients with Acromioplasty

BACKGROUND

Arthroscopic surgery has been established as an efficacious intervention for the treatment of rotator cuff tears. The primary aim of this study was to analyze the modifications in the lateral acromial angle (LAA) subsequent to rotator cuff repair surgery using single-row rivet fixation and double-row rivet fixation techniques. Furthermore, we sought to investigate the influence of LAA on the prognosis of rotator cuff repair surgery.

METHOD

This observational study retrospectively enrolled 105 patients diagnosed with degenerative rotator cuff tears who underwent arthroscopic rotator cuff repair between 2016 and 2019. Following the exclusion of two patients with subscapularis or superior labrum anterior and posterior (SLAP) tears, as well as three patients who were lost to follow-up, a cohort of 100 patients was included for clinical and imaging evaluation. Among these individuals, 50 were assigned to the double-row repair group, whereas the remaining 50 comprised the single-row repair group. Bilateral shoulder magnetic resonance imaging (MRI) scans were conducted no less than 24 months post-surgery. Experienced arthroscopic surgeons, blinded to the LAA measurements, assessed the rotator interval (RI) using a control MRI. Functional assessment was performed using the University of California, Los Angeles (UCLA) quick disability of the shoulder and arm, shoulder and hand (qDASH) score. The Wilcoxon signed-rank test for dependent samples was employed to compare data between the pre- and post-intervention groups. Pearson correlation coefficients were calculated to evaluate the relationship between different parameters.

RESULTS

The study population consisted of 73 female patients and 27 male patients, with a mean age of 58.32 ± 5.29 years and a mean follow-up duration of 25.88 ± 8.11 months. Preoperatively, the mean LAA was 75.81° ± 11.28°, RI was 4.78 ± 0.62, UCLA score was 17.54 ± 2.44, and qDASH score was 2.45 ± 0.25. The average tear size was 8.95 ± 2.11 mm. A statistically significant difference in LAA was observed between the preoperative and postoperative measurements, with the double-row repair group exhibiting a greater LAA than the single-row repair group. Finally, a significant correlation was identified between LAA, RI, and qDASH scores after a 24-month follow-up period.

CONCLUSION

According to our findings, the utilization of double-row rivet fixation has a greater LAA angle than single-row rivet fixation. Moreover, this preservation of LAA is significantly associated with the functional recovery of the shoulder joint.

Arthroscopic rotator cuff repair using a single or double row technique: A meta-analysis of randomized clinical trial

PURPOSE

To compare the double row technique versus the single row technique for arthroscopic rotator cuff repair, in order to assess whether there are clinical differences.

METHODS

Systematic review of randomized clinical trials comparing the clinical results of the double-row technique versus the single-row technique in arthroscopic rotator cuff repair. Demographic, clinical, and surgical variables were analyzed, including functional scores, tendon healing rate, and re-tear rate.

RESULTS

Thirteen randomized clinical trials were selected. 437 patients in the single row group (50.7%) and 424 patients in the double row group (49.3%) were analyzed. No significant differences were found between the two groups in terms of age (P=.84), sex (P=.23) and loss to follow-up (P=.52). Significant differences were found for the better results of the double row technique at the UCLA level (P=.01). No significant differences were found on the Constant-Murley scale (P=.87) or on the ASES scale (P=.56). Similarly, there was a higher healing rate (P=.006) and less risk of rotator cuff re-tears with the double row technique (P=.006).

CONCLUSIONS

In rotator cuff repair, the double row technique was found to be superior to the single row technique in terms of better UCLA score, better tendon healing rate, and lower re-tear rate. No clinically significant differences were found on the Constant-Murley scale or on the ASES scale.

A network meta-analysis of arthroscopic rotator cuff repair

OBJECTIVE

Rotator cuff tear is a common shoulder injury that often leads to serious limitations in daily life. Herein, a network Meta-analysis using frequency theory was performed to evaluate the clinical outcomes of five rotator cuff repair techniques, including single-row repair, double-row repair, suture bridge repair, platelet-rich plasma therapy, and bone marrow stimulation, thus guiding clinical decision-making on rotator cuff repair.

METHODS

PubMed, EMbase, The Cochrane Library, and Web of Science were searched for randomized controlled trials and cohort studies comparing rotator cuff repair techniques published from inception to May 2022. Combined analysis and quality assessment were performed using software STATA15.1 and Review Manager5.3.

RESULTS

A total of 51 articles were finally included, including 27 randomized controlled trials and 24 cohort studies. Results from the network Meta-analysis showed that: (1) In terms of the American Shoulder and Elbow Surgeons score, platelet-rich plasma therapy, double-row repair, bone marrow stimulation, and single-row repair were significantly better than suture bridge repair. (2) In terms of Constant score, bone marrow stimulation was significantly better than double-row repair, single-row repair, and suture bridge repair. (3) In terms of visual analog scale score, platelet-rich plasma therapy was significantly better than double-row repair and suture bridge repair. (4) In terms of the Shoulder Rating Scale of the University of California at Los Angeles score, platelet-rich plasma therapy and double-row repair were relatively better but not significantly different from the other treatments. (5) In terms of the risk of re-tear, the re-tear rate of platelet-rich plasma therapy and double-row repair was significantly lower than that of single-row repair and suture bridge repair.

CONCLUSION

Based on the results of network Meta-analysis and surface under the cumulative ranking, platelet-rich plasma therapy, bone marrow stimulation, and double-row repair have good overall rehabilitation effects. It is recommended to choose appropriate repair techniques as per the actual clinical situation.

Comparison of Outcomes after Arthroscopic Rotator Cuff Repair between Elderly and Younger Patient Groups: A Systematic Review and Meta-Analysis of Comparative Studies

This study aimed to compare the outcomes of arthroscopic rotator cuff repair (ARCR) surgery between younger and older patients. We performed this systematic review and meta-analysis of cohort studies comparing outcomes between patients older than 65 to 70 years and a younger group following arthroscopic rotator cuff repair surgery. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and other sources for relevant studies up to 13 September 2022, and then assessed the quality of included studies using the Newcastle-Ottawa Scale (NOS). We used random-effects meta-analysis for data synthesis. The primary outcomes were pain and shoulder functions, while secondary outcomes included re-tear rate, shoulder range of motion (ROM), abduction muscle power, quality of life, and complications. Five non-randomized controlled trials, with 671 participants (197 older and 474 younger patients), were included. The quality of the studies was all fairly good, with NOS scores ≥ 7. The results showed no significant differences between the older and younger groups in terms of Constant score improvement, re-tear rate, or other outcomes such as pain level improvement, muscle power, and shoulder ROM. These findings suggest that ARCR surgery in older patients can achieve a non-inferior healing rate and shoulder function compared to younger patients.

Hybprinting for musculoskeletal tissue engineering

This review presents bioprinting methods, biomaterials, and printing strategies that may be used for composite tissue constructs for musculoskeletal applications. The printing methods discussed include those that are suitable for acellular and cellular components, and the biomaterials include soft and rigid components that are suitable for soft and/or hard tissues. We also present strategies that focus on the integration of cell-laden soft and acellular rigid components under a single printing platform. Given the structural and functional complexity of native musculoskeletal tissue, we envision that hybrid bioprinting, referred to as hybprinting, could provide unprecedented potential by combining different materials and bioprinting techniques to engineer and assemble modular tissues.

Rotator cuff repair with single row technique provides satisfying clinical results despite consistent MRI retear rate

BACKGROUND

The number of shoulder arthroscopies is steadily increasing to treat glenohumeral joint disorders, among which the rotator cuff tear is the most common. The prevalence of this condition ranges from 13% to 37% in the general population without considering the number of asymptomatic patients. The gold standard procedure for rotator cuff repair is still undefined. The purpose of this study is to evaluate a population who underwent a single row (SR) rotator cuff repair and correlate their clinical results with MRI findings.

MATERIALS AND METHODS

Sixty-seven consecutive rotator cuff procedures were retrospectively selected. All patients were diagnosed with a full-thickness rotator cuff tear and subsequently treated with an arthroscopic SR repair technique. Each patient was clinically assessed with the DASH questionnaire and the Constant-Murley Score to grade their satisfaction. Moreover, rotator cuff repair integrity was evaluated by MRI and graded using the Sugaya score.

RESULTS

Mean follow-up was 19.5 ± 5.7 months. The mean Constant score was 82.8 ± 13.0 points, with 55 patients reporting excellent results. No patient scored less than 30 points, which could be deemed as unsatisfying. Meanwhile, on the DASH questionnaire, 6.1% of our patients rated their clinical outcome as unsatisfying, whereas 75.8% rated their outcome as excellent. Postoperative MRI classified 45 patients (83.3%) as either Sugaya type I, II, or III, whereas 9 patients (16.7%) presented a Sugaya type IV consistent with a full-thickness cuff retear. Of these nine patients, five (55.6%) and three (33.3%) reported excellent results for the Constant score and DASH questionnaire, respectively. The Mann-Whitney test reported that the retear group had worse scores than the intact repaired cuff group for pain (8.3 ± 5.0 versus 13.1 ± 3.4), Constant Score (68.8 ± 18.5 versus 83.1 ± 11.6), and DASH (66.2 ± 22.1 versus 44.2 ± 14.9). Still, range of motion (ROM) differences were not significant, except for better forward flexion in the intact group (p < 0.039).

CONCLUSIONS

Both groups with intact repaired and retorn cuffs showed improvement in their condition, but unexpectedly, there is no significant  correlation between patient satisfaction and rotator cuff integrity.

LEVEL OF EVIDENCE

IV.

Reparo artroscópico da lesão de manguito rotador: Uma análise da função, força muscular e dor entre técnicas de fileira simples e fileira dupla

Objective  To evaluate the patients submitted to arthroscopic repair of the rotator cuff (RC), comparing the functional results, muscle strength, and pain obtained after single row (SR) and double row (DR) techniques.

Methods  Data were collected at the postoperative follow-up (minimum of 12 months) of 128 patients submitted to arthroscopic RC repair from 2011 to 2018. The clinical-functional variables were collected through the clinical examination, and the demographic, surgical and injury variables of the RC were collected from the electronic medical records. The results were compared between the SR and DR groups.

Results  The DR group showed higher anterior elevation strength when compared with the SR group (SF: 4.72 ± 2.73 kg versus DR: 5.90 ± 2.73 kg; p  = 0.017). The other variables of muscle strength, Constant-Murley Score, University of California at Los Angeles Shoulder Rating Scale (UCLA), and pain, were similar. Performing the stratification by size, in the analysis of small and medium injuries, no differences were found between the groups. However, in the analysis of large and extensive injuries, patients submitted to DR presented superiority of both muscle lifting strength (SF: 3.98 ± 2.24 kg versus DR: 6.39 ± 2.73 kg) and Constant score (SF: 81 ± 10 versus DR: 88 ± 7).

Conclusion  The use of the DR technique in arthroscopic RC repair allowed higher levels of muscle strength for anterior shoulder elevation when compared with the SF technique. Data stratification in large and extensive injuries showed superiority of anterior shoulder elevation muscle strength and of the Constant score in patients submitted to DR.

A comparison of simple and complex single-row versus transosseous-equivalent double-row repair techniques for full-thickness rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

Rotator cuff injuries have traditionally been managed by either single-row or double-row arthroscopic repair techniques. Complex single-row techniques have recently been proposed as a biomechanically stronger alternative treatment option. However, no rigorous meta-analysis has evaluated the effectiveness of complex single-row against double-row repair. This meta-analysis aims to evaluate clinical outcomes in patients with full-thickness rotator cuff injuries treated with both simple and complex single-row, as well as transosseous-equivalent (TOE) double-row procedures.

METHODS

An up-to-date literature search was performed using the predefined search strategy. All studies that met the inclusion criteria were assessed for methodological quality and included in the meta-analysis. Pain, functional scores, range of motion, and retear rate were all considered in the study.

CONCLUSION

The results of our meta-analysis suggest that there is no significant difference between complex single-row and TOE double-row procedures in any of the observed outcomes. At this point in time, the available comparative data between simple single-row and TOE double-row repair techniques are limited. Further high-quality studies are required to assess the clinical outcomes and cost-effectiveness of these different techniques.

Difference in the results of repair made with single or double rows according to the shape and size of the tear in arthroscopic rotator cuff surgery

The aim of this study was to evaluate the effect on the results of patients applied with arthroscopic full layer total layer rotator cuff repair made according to the shape and size of the tear.The study included a total of 120 patients applied with arthroscopic full layer rotator cuff repair as single or double row repair. The patients were separated into 3 groups of 40 according to the shape of the tear, as Group A (crescent type), Group B (U type), and Group C (L type).The mean age of the whole sample was 66.68 ± 6.86 years (range, 50-81 years). A statistically significant difference was determined between the groups in respect of constant murley (CM), American shoulder and elbow surgeons score (ASES), and University of California Los Angeles score (UCLA) scores (P < .05). The scores of Group A of all the scales were found to be higher than those of Group C (P < .05). In single row and double row repair of small and medium-sized tears of all shapes, no significant difference was determined in respect of the CM and UCLA scores (P > .05).No significant difference was determined between single and double row repair of crescent type tears of all sizes. In large U-shaped tears, the CM, ASES, and UCLA scores were determined to be high in double row repair.

Short-term outcomes following mini-open repair of chronic gluteus medius tendon tears using a double-row technique

Gluteal tendon tears represent a common but underreported cause of lateral hip pain and dysfunction. In case of conservative management failure, a surgical procedure must be performed to relieve patient symptoms. Current operative treatments, either open or endoscopic, have been however associated with different drawbacks which led to the introduction of the mini-open technique. The aim of this study was to evaluate and report the short-term outcomes of patients operated through the aforementioned surgical technique for gluteus medius (GM) chronic tears. We retrospectively analysed the records of 14 consecutive patients operated at the La Tour hospital by mini-open repair using a double-row technique for full-thickness GM chronic tears. Intra- and post-operative complications were recorded. The pre- and post-operative pain on visual analogue scale (pVAS), modified Harris Hip score (mHHS), abduction strength and gait dysfunction were assessed for all patients. Pre- and post-operative values were compared to evaluate whether improvements were statistically significant and clinically relevant. The study cohort comprised 13 women (93%) and 1 man (3%) aged 62.4 ± 18.0 at index surgery. No intra- or post-operative complications were noted. Compared to pre-operative values, patients reported a significant improvement in mHHS (59.1 ± 7.1 vs 92.7 ± 4.6) and pVAS (7.4 ± 1.0 vs 1.3 ± 1.3) at last follow-up. Patients exhibited a perfect improvement in muscle strength (3.6 ± 0.5 vs 5.0 ± 0.0), and the proportion of patients with a positive Trendelenburg sign decreased from 71% to 0%. Mini-open repair of chronic GM tendon tears using a double-row technique demonstrated excellent clinical and functional outcomes at short follow-up. Level of Evidence: IV.

Rotator Cuff Retears

» Regardless of recent advances in rotator cuff repair techniques, the rate of unhealed or recurrent rotator cuff tears remains high, with most recurrent rotator cuff tears occurring within the first 6 months after surgery. » Factors that can negatively affect tendon healing include older age, greater tear size, tendon retraction, and fatty infiltration. However, several clinical features that are often underestimated, including osteoporosis, diabetes, smoking, and hyperlipidemia, have proven to have an important influence on rotator cuff healing. » Recent meta-analyses that evaluated studies with Level-I and Level-II evidence have shown an overall increase in retear rates after single-row repair compared with double-row repair. However, to our knowledge, there are no Level-I clinical studies comparing different double-row configurations and, to date, no double-row repair technique has proven to be superior to the others. » The influence of postoperative rotator cuff healing on clinical outcomes is controversial. Although clinical differences may not be apparent in the short term, healed tendons have had better functional outcomes and greater strength in the midterm. » In general, a period of immobilization for 2 to 4 weeks, depending on tear size, is recommended. Graded supervised rehabilitation has proven to facilitate tendon healing without associated stiffness compared with early unprotected range of motion.

Arthroscopic Linked Triple Row Repair for Large and Massive Rotator Cuff Tears

Recently, many arthroscopic techniques have been described to improve the outcomes in rotator cuff repair of large and massive tears; these include conventional double-row, suture bridge, and triple-row techniques, in an effort to optimally reconstruct the rotator cuff footprint and improve fixation. This report describes a modified triple-row repair technique that links the double-row and suture-bridge techniques in one construct, merging the advantages of both to maximize the footprint contact area and contact pressure, which may lead to better healing and faster rehabilitation.

Holding on by a thread: the continuing story of rotator cuff tears

Rotator cuff tears are a common cause of shoulder pain. The incidence of these tears has increased significantly over the years, with the demands of an increasingly active elderly population. Therefore, a detailed understanding of rotator cuff tears will help doctors manage their patients' condition. This field has rapidly advanced over the past decade and this review provided an insight into the latest developments.

Histological evaluation of cellular response to a multifilament electrospun suture for tendon repair

BACKGROUND

Rotator cuff tendon repair in humans is a commonly performed procedure aimed at restoring the tendon-bone interface. Despite significant innovation of surgical techniques and suture anchor implants, only 60% of repairs heal successfully. One strategy to enhance repair is the use of bioactive sutures that provide the native tendon with biophysical cues for healing. We investigated the tissue response to a multifilament electrospun polydioxanone (PDO) suture in a sheep tendon injury model characterised by a natural history of failure of healing.

METHODOLOGY AND RESULTS

Eight skeletally mature English Mule sheep underwent repair with electrospun sutures. Monofilament sutures were used as a control. Three months after surgery, all tendon repairs healed, without systemic features of inflammation, signs of tumour or infection at necropsy. A mild local inflammatory reaction was seen. On histology the electrospun sutures were densely infiltrated with predominantly tendon fibroblast-like cells. In comparison, no cellular infiltration was observed in the control suture. Neovascularisation was observed within the electrospun suture, whilst none was seen in the control. Foreign body giant cells were rarely seen with either sutures.

CONCLUSION

This study demonstrates that a tissue response can be induced in tendon with a multifilament electrospun suture with no safety concerns.

Arthroscopic Rotator Cuff Repair: A Systematic Review of Overlapping Meta-Analyses

BACKGROUND

Rotator cuff tears are a common pathology, with an increasing number of repairs being performed arthroscopically. The purpose of this study was to systematically review the results in the current meta-analyses on arthroscopic rotator cuff repair, looking specifically at double-row repair compared with single-row repair, at whether platelet-rich plasma should be used adjunctively at the time of the surgical procedure, and at the effects of early-motion compared with late-motion rehabilitation postoperatively.

METHODS

MEDLINE, Embase, and the Cochrane Library were screened for meta-analyses on arthroscopic rotator cuff repair. The levels and quality of the evidence were assessed, and the clinical outcomes were evaluated. A significant result was defined as p < 0.05.

RESULTS

Twenty-four meta-analyses were identified, with 10 meta-analyses on double-row repair compared with single-row repair, 7 meta-analyses on platelet-rich plasma compared with a control, and 7 meta-analyses on early motion compared with late motion. Studies found a significant result in terms of reduced retear rates and/or increased tendon-healing rate for double-row repair (6 of 10 studies; p < 0.05), without a clinically important improvement in functional outcomes (0 of 10 studies). There was a favorable outcome when using platelet-rich plasma in small-to-medium tears in terms of a reduced rate of retear (4 of 4 studies; p < 0.05). However, in the 1 study in which platelet-rich plasma was stratified into pure platelet-rich plasma and platelet-rich fibrin matrix preparation, there was a significantly lower retear rate for tears of all sizes with platelet-rich plasma and not with platelet-rich fibrin (p < 0.05). Range of motion was shown to be significantly better with early motion (5 of 6 studies; p < 0.05) in the majority of the meta-analyses, without an increased risk of retear (6 of 6 studies; p > 0.05).

CONCLUSIONS

The highest Level of Evidence and the highest-quality studies all supported the use of double-row repair, adjunctive platelet-rich plasma, and early-motion rehabilitation postoperatively in arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Repair of Rotator Cuff Tears in the Elderly: Does It Make Sense? A Systematic Review

BACKGROUND

The indications and outcomes for rotator cuff repair (RCR) among patients ≥70 years old are not widely reported. Many active patients in this age range desire a joint-preserving option, and several small series reported successful clinical outcomes after RCR among patients aged ≥70 years.

PURPOSE

To systematically review the literature on the outcomes of RCR among patients ≥70 years old.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed and Cochrane were used for the literature search. The quality of the included studies was evaluated according to the Coleman Methodology Score. Studies in English evaluating repair of full-thickness rotator cuff tears among patients aged ≥70 years were included.

RESULTS

Eleven studies were reviewed, including 680 patients (694 shoulders) who were treated with arthroscopic and/or open RCR with a mean follow-up of 24.2 months (range, 12-40.8 months). Forty patients were lost to follow-up, leaving 654 shoulders with outcome data. This age group demonstrated a significant increase in clinical and functional outcomes after RCR with high satisfaction. American Shoulder and Elbow Surgeons scores showed an improvement from 44.2 (range, 35.4-56) preoperatively to 87.9 (range, 84-90.3) postoperatively, while Constant scores improved from 41.7 (range, 22.6-53.6) to 70.8 (range, 58.6-76). Postoperative imaging evaluation was performed on 513 shoulders, revealing a retear rate of 27.1% (139 shoulders). There were 45 retears after open repair and 94 after arthroscopic repair. The difference in retear rate among patients receiving arthroscopic repairs was not significantly different than open repairs (P = .831). Pain according to a visual analog scale improved from 5.5 (range, 4.6-6.4) preoperatively to 1.3 (range, 0.5-2.3) postoperatively.

CONCLUSION

RCR among patients ≥70 years old shows high clinical success rates with good outcomes and overall excellent pain relief. Although patients in this age group have a high potential for retear or persistent defects on imaging studies, RCR offers a joint-preserving option with significant functional and clinical improvement for the appropriately indicated patient.

Current Concepts in Rotator Cuff Repair Techniques: Biomechanical, Functional, and Structural Outcomes

There is substantial evidence indicating that double-row (DR) repair restores more of the anatomic rotator cuff footprint and is biomechanically superior to single-row (SR) repair. Transosseous-equivalent (TOE) techniques have shown biomechanical advantages when compared with traditional DR, including increased contact at the rotator cuff footprint, higher pressure at the tendon-bone interface, and increased failure strength. Several meta-analyses of evidence level 1 and 2 studies have shown a lower rate of failed/incomplete healing when DR repair was compared with SR repair types. There is some limited evidence that TOE techniques improve healing rates in large and massive tears as compared with SR and DR. Overall, most level 1 and 2 studies have failed to prove a significant difference between SR and DR repairs in terms of clinical outcomes. However, most studies include only short-term follow-up, minimizing the impact that the higher rate of retears/failed healing seen with SR repairs can have in the long term. There are no high-quality clinical studies comparing different DR configurations, and there are currently not enough clinical data to determine the functional advantages of various DR technique modifications over one another. Although numerous biomechanical and clinical studies comparing different rotator cuff repair techniques have been published in the past decade, none has achieved universal acceptance. It is essential for the orthopaedic surgeon to know in detail the available literature to be able to apply the most appropriate and cost-effective technique in terms of healing and functional outcomes. This review provides a critical analysis of the comparative biomechanical and clinical studies among SR, DR, and TOE techniques reported in the literature in the past decade.

When deadman theory meets footprint decortication: a suture anchor biomechanical study

Background

The optimal insertion angle for suture anchor insertion has long been of great interest. Although greater tuberosity decortication is commonly performed during rotator cuff repair, the effect of decortication on the suture anchor insertion angle remains unclear. The purpose of this study was to compare the pullout strength of threaded suture anchors inserted at 45° and 90° in decorticated and non-decorticated synthetic bone models.

Methods

Two kinds of synthetic bones were used to simulate the decorticated and non-decorticated conditions, for which 40 metallic suture anchors were used. Anchors were inserted at 45° and 90° in both decorticated and non-decorticated models and tested under cyclic loading followed by load-to-failure testing. The number of completed cycles, ultimate failure load, and failure modes was recorded.

Results

In the decorticated model, the ultimate failure load of anchors inserted at 45° (67.5 ± 5.3 N) was significantly lower than that of anchors inserted at 90° (114.1 ± 9.8 N) (p <  0.001). In the non-decorticated model, the ultimate failure load of anchors inserted at 45° (591.8 ± 58 N) was also significantly lower than that of anchors inserted at 90° (724.9 ± 94 N) (p = 0.003). Due to the diverse failure modes in the non-decorticated model, specimens with a failure mode of suture anchor pullout were analyzed in greater detail, with results showing a significantly larger pullout strength for anchors inserted at 90° (781.6 ± 53 N) than anchors inserted at 45° (648.0 ± 43 N) (p = 0.025).

Conclusion

Regardless of decortication, the pullout strength of anchors inserted at 90° was greater than those inserted at 45°. The clinical relevance is that inserting suture anchors at 90° is recommended due to the significantly larger ultimate failure load in both decorticated and non-decorticated bones.

Tear characteristics and surgeon influence repair technique and suture anchor use in repair of superior-posterior rotator cuff tendon tears

BACKGROUND

The factors that associate with surgical decisions about repair technique and the number of suture anchors used in rotator cuff repair have not been previously investigated. This study investigated the extent to which patient, surgeon, and surgical factors associate with performing single-row vs. double-row repair technique and ultimately with the number of suture anchors used.

METHODS

Our institution's prospective surgical cohort was queried for patients undergoing suture anchor repair of superior-posterior rotator cuff tendon tears between February 2015 and August 2017. Exclusion criteria were patients with isolated subscapularis tears, tears that were not repaired, repairs without suture anchors, repairs involving graft augmentation, and repairs by surgeons with fewer than 10 cases. Multivariable statistical modeling was used to investigate associations between patient and surgical factors and the choice of repair technique and number of suture anchors used.

RESULTS

A total of 925 cases performed by 13 surgeons met inclusion criteria. Tear type (full thickness), tear size (medium, large, and massive), a greater number of torn tendons, repair type (arthroscopic), and surgeon were significantly associated with performing a double-row over a single-row repair. Tear size, a greater number of torn tendons, double-row repair technique, and surgeon were significantly associated with a greater number of anchors used for repair.

CONCLUSIONS

Our findings suggest that in the absence of data to conclusively support a clinical benefit of one repair technique over another, surgeons' training, experience, and inherent practice patterns become the primary factors that define their surgical methods.

Arthroscopic double-row rotator cuff repair: a comprehensive review of the literature

Rotator cuff repairs seek to achieve adequate tendon fixation and to secure the fixation during the process of biological healing. Currently, arthroscopic rotator cuff repair has become the gold standard. One of the earliest defined techniques is single-row repair but the inadequacy of single-row repair to precisely restore the anatomical footprint as well as the significant rates of retear especially in large tears have led surgeons to seek other techniques. Double-row repair techniques, which have been developed in response to these concerns, have various modifications like the number and placement of anchors and suture configurations.

When the literature is reviewed, it is possible to say that double-row repairs demonstrate superior biomechanical properties. In regard to retear rates, both double row and transosseous equivalent (TOE) techniques have also yielded more favorable outcomes compared to single-row repair. But the clinical results are conflicting and more studies have to be conducted. However, it is more probable that superior structural integrity will yield better structural and functional results in the long run. TOE repair technique is regarded as promising in terms of better biomechanics and healing since it provides better footprint contact. Knotless TOE structures are believed to reduce impingement on the medial side of tendons and thus aid in tendon nutrition; however, there are not enough studies about its effectiveness.

It is important to optimize the costs without endangering the treatment of the patients. We believe that the arthroscopic TOE repair technique will yield superior results in regard to both repair integrity and functionality, especially with tears larger than 3 cm. Although defining the pattern of the tear is one of the most important guiding steps when selecting the repair technique, the surgeon should not forget to evaluate every patient individually for tendon healing capacity and functional expectations.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Do functional outcomes and cuff integrity correlate after single- versus double-row rotator cuff repair? A systematic review and meta-analysis study

PURPOSE

The purpose of this study is to perform a systematic review and meta-analysis of all available level I prospective randomized controlled trials comparing arthroscopic single-row (SR) with double-row (DR) rotator cuff repairs by both clinical outcomes and radiological re-tear rates.

METHODS

PubMed, EMBASE, Google Scholar, and Cochrane databases search was done for level I RCTs comparing clinical and radiological outcomes after SR versus DR rotator cuff repair. Clinical outcomes included UCLA, ASES, Constant, WORC, and SANE scores; structural outcomes included MRI, MRA, or US.

RESULTS

Seven level I studies were included (5 mid-term and 2 short-term). Postoperative ASES, Constant, WORC, and SANE scores showed nonsignificant slightly better function of DR groups. Only, UCLA score showed significantly better scores with DR repair (p = 0.007). Full-thickness re-tear incidence was reported in 15/174 (8.6%) in DR group and 20/175 (11.4%) in SR group (p = 0.44). Partial-thickness re-tear rate was reported in 18/174 patients (10.3%) in DR group and 41/175 patients (23.4%) in SR group (p = 0.009).

CONCLUSION

Within the domain of level I mid-term and short-term studies, DR repair showed significant better UCLA score only. (ASES, Constant, WORC, and SANE scores showed no significance.) This may correlate weakly with the significant lower partial-thickness re-tear rates of DR repairs. In contrary, long-term level III studies showed a direct correlation of both functional outcomes and cuff structural integrity, with significant superiority of DR over SR repair techniques.

LEVEL OF EVIDENCE

Level 1, systematic review and meta-analysis.

Arthroscopic fixation of pediatric tibial eminence fractures using suture anchors: a mid-term follow-up

PURPOSE

The aim of this study was to follow a group of skeletally immature patients who received arthroscopy-assisted fixation of the displaced tibial eminence fractures with suture anchors and evaluate the clinical results.

METHODS

Twenty-one pediatric patients with displaced tibial eminence fractures were enrolled in this retrospectively study. They received arthroscopy-assisted reduction and fixation using suture anchors. All cases were followed up for 40-47 months with a mean of 43.4 months. Follow-up examinations included radiographic assessment, Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) rating scale and KT-1000 test.

RESULT

Twenty patients were available for our final evaluations. They improved significantly at the final follow-up compared with preoperative examinational results with respect to the results of radiographic assessment, Lysholm score, Tegner score, IKDC rating scale and KT-1000 test.

CONCLUSION

Arthroscopy-assisted reduction and fixation of the displaced tibial eminence fractures using suture anchors is a simple and reliable technique and is suitable for skeletally immature patients.

[Rotator cuff repair: single- vs double-row. Clinical and biomechanical results]

BACKGROUND

The goal of rotator cuff repair is a high initial mechanical stability as a requirement for adequate biological recovery of the tendon-to-bone complex. Notwithstanding the significant increase in publications concerning the topic of rotator cuff repair, there are still controversies regarding surgical technique.

OBJECTIVES

The aim of this work is to present an overview of the recently published results of biomechanical and clinical studies on rotator cuff repair using single- and double-row techniques.

MATERIALS AND METHODS

The review is based on a selective literature research of PubMed, Embase, and the Cochrane Database on the subject of the clinical and biomechanical results of single- and double-row repair.

RESULTS

In general, neither the biomechanical nor the clinical evidence can recommend the use of a double-row concept for the treatment for every rotator cuff tear. Only tears of more than 3 cm seem to benefit from better results on both imaging and in clinical outcome studies compared with the use of single-row techniques.

CONCLUSIONS

Despite a significant increase in publications on the surgical treatment of rotator cuff tears in recent years, the clinical results were not significantly improved in the literature so far. Unique information and algorithms, from which the optimal treatment of this entity can be derived, are still inadequate. Because of the cost-effectiveness and the currently vague evidence, the double-row techniques cannot be generally recommended for the repair of all rotator cuff tears.

Arthroscopic Rotator Cuff Repair: Double-Row Transosseous Equivalent Suture Bridge Technique

Following a failed course of conservative management, arthroscopic rotator cuff repair (ARCR) has become the gold standard treatment for patients presenting with symptomatic rotator cuff (RC) tears. Traditionally, the single-row repair technique was used. Although most patients enjoy good to excellent clinical outcomes, structural healing to bone remains problematic. As a result, orthopaedic surgeons have sought to improve outcomes with various technological and technical advancements. One such possible advancement is the double-row technique. We present a method for repairing an RC tear using double-row suture anchors in a transosseous equivalent suture bridge technique. The double-row technique is believed to more effectively re-create the anatomic footprint of the tendon, as well as increase tendon to bone surface area, and apposition for healing. However, it requires longer operating times and is costlier. This report highlights this technique for ARCR in an adult by using a double-row transosseous equivalent suture bridge.

Functional Outcomes After Double-Row Versus Single-Row Rotator Cuff Repair: A Prospective Randomized Trial

Background:

The functional benefits of double-row (DR) versus single-row (SR) rotator cuff repair are not clearly established.

Purpose:

To examine the effect of DR versus SR rotator cuff repair on functional outcomes and strength recovery in patients with full-thickness tears.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

Forty-nine patients were randomized to DR or SR repairs; 36 patients (13 women, 23 men; mean age, 62 ± 7 years; 20 SR, 16 DR) were assessed at a mean 2.2 ± 1.6 years after surgery (range, 1-7 years; tear size: 17 medium, 13 large, 9 massive). The following data were recorded prior to surgery and at follow-up: Penn shoulder score, American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) results; range of motion (ROM) for shoulder flexion, external rotation (ER) at 0° and 90° of abduction, and internal rotation (IR) at 90° of abduction; and shoulder strength (Lafayette manual muscle tester) in empty- and full-can tests, abduction, and ER at 0° of abduction. Treatment (SR vs DR) × time (pre- vs postoperative) mixed-model analysis of variance was used to assess the effect of rotator cuff repair.

Results:

Rotator cuff repair markedly improved Penn, ASES, and SST scores (P < .001), with similar improvement between SR and DR repairs (treatment × time, P = .38-.10) and excellent scores at follow-up (DR vs SR: Penn, 91 ± 11 vs 92 ± 11 [P = .73]; ASES, 87 ± 12 vs 92 ± 12 [P = .21]; SST, 11.4 ± 1.0 vs 11.3 ± 1.0 [P = .76]). Patients with DR repairs lost ER ROM at 0° of abduction (preoperative to final follow-up, 7° ± 10° loss [P = .013]). ER ROM did not significantly change with SR repair (5° ± 14° gain, P = .16; treatment by time, P = .008). This effect was not apparent for ER ROM at 90° of abduction (treatment × time, P = .26). IR ROM improved from preoperative to final follow-up (P < .01; SR, 17° ± 27°; DR, 7° ± 21°; treatment × time, P = .23). Rotator cuff repair markedly improved strength in empty-can (54%), full-can (66%), abduction (47%), and ER (54%) strength (all P < .001), with no difference between SR and DR repairs (P = .23-.75). All clinical tests with the exception of the lift-off test were normalized at follow-up (P < .05).

Conclusion:

Outcomes were not different between SR or DR repair, with generally excellent outcomes for both groups. Rotator cuff repair and subsequent rehabilitation markedly improved shoulder strength.

Triple-Row Modification of the Suture-Bridge Technique for Arthroscopic Rotator Cuff Repair

Recent advances to improve outcomes in rotator cuff repair include using arthroscopic double-row suture-bridge techniques in an effort to reconstruct the rotator cuff footprint and improve fixation. However, when using this technique for larger tears, it can be difficult to get the lateral portion of the rotator cuff into an anatomic position. This report describes a triple-row modification of the suture-bridge technique that results in significantly more footprint contact area and contact pressure compared with the double-row and standard suture-bridge techniques. Maximizing the rotator cuff footprint contact area exposes more of the tendon to bone and may improve the healing potential.

Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial

BACKGROUND

Platelet-rich plasma (PRP) has the potential to improve tendon-bone healing. The evidence is still controversial as to whether PRP application after repair of medium-sized to large cuff tears leads to superior structural and clinical outcome, especially after single-row repair.

METHODS

In a randomized study, 102 patients (PRP group, 52 patients; control group, 50 patients) with medium-sized and large degenerative posterosuperior tears were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with clinical scores (visual analog scale score, Constant-Murley score, University of California-Los Angeles score, and American Shoulder and Elbow Surgeons score) and ultrasound to assess retear and vascularity pattern of the cuff.

RESULTS

Visual analog scale scores were significantly lower in the PRP group than in controls at 1 month, 3 months, and 6 months but not later. Constant-Murley scores were significantly better in the PRP group compared with controls at 12 and 24 months, whereas University of California-Los Angeles scores were significantly higher in the PRP group at 6 and 12 months (P < .05). The American Shoulder and Elbow Surgeons score in both groups was comparable at all the times. At 24 months, retear in the PRP group (n = 2; 3.8%) was significantly lower than in the control group (n = 10; 20%; P = .01). The retear difference was significant only for large tears (PRP:control group, 1:6; P = .03). Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively (P < .05) and in peribursal tissue until 12 months.

CONCLUSION

Application of moderately concentrated PRP improves clinical and structural outcome in large cuff tears. PRP also enhances vascularity around the repair site in the early phase.

Summary of Meta-Analyses Dealing with Single-Row versus Double-Row Repair Techniques for Rotator Cuff Tears

Background:

Several meta-analyses of randomized clinical trials have been performed to analyze whether double-row (DR) rotator cuff repair (RCR) provides superior clinical outcomes and structural healing compared to single-row (SR) repair. The purpose of this study was to sum up the results of meta-analysis comparing SR and DR repair with respect on clinical outcomes and re-tear rates.

Methods:

A literature search was undertaken to identify all meta-analyses dealing with randomized controlled trials comparing clinical und structural outcomes after SR versus DR RCR.

Results:

Eight meta-analyses met the eligibility criteria: two including Level I studies only, five including both Level I and Level II studies, and one including additional Level III studies. Four meta-analyses found no differences between SR and DR RCR for patient outcomes, whereas four favored DR RCR for tears greater than 3 cm. Two meta-analyses found no structural healing differences between SR and DR RCR, whereas six found DR repair to be superior for tears greater than 3 cm tears.

Conclusion:

No clinical differences are seen between single-row and double-row repair for small and medium rotator cuff tears after a short-term follow-up period with a higher re-tear rate following single-row repairs. There seems to be a trend to superior results with double-row repair in large to massive tear sizes.

Effect of Additional Sutures per Suture Anchor in Arthroscopic Bankart Repair: A Review of Single-loaded Versus Double-loaded Suture Anchors

PURPOSE

To directly compare single-loaded suture anchors (SSA) with double-loaded suture anchors (DSA) to help surgeons optimize the operative technique, time, and cost of Bankart repairs.

METHODS

A literature review was performed using the PubMed and SCOPUS databases. Studies that directly compared SSA and DSA for Bankart repairs, or indirectly compared them by collecting relevant data despite a different objective, were included.

RESULTS

A total of two studies were included, both of which were cadaveric laboratory studies. A total of 28 shoulders were tested. Tests conducted include loading to failure and cyclic loading. One study found SSA to be biomechanically equivalent to DSA, and one found DSA to be superior.

CONCLUSIONS

Based on limited cadaveric study, DSA are at least equivalent biomechanically to SSA, and may be superior. By using DSA, surgeons create repair constructs that are as strong as, or stronger than, those made with SSA, but with fewer anchors. This reduces the amount of holes drilled and implants placed in the glenoid, while also minimizing cost.

CLINICAL RELEVANCE

Quantifying the benefit of additional sutures in a suture anchor can help optimize the quality of repair, time, and cost in arthroscopic shoulder repair.