DOI: https://doi.org/10.21203/rs.2.15670/v1
Objective: The purpose of this study was to perform a meta-analysis of all available randomized controlled trials at 2-years minimum follow-up, to compare the clinical outcomes and radiological re-tear rates between single-row (SR) and double-row (DR) fixation.
Methods: PubMed, EMBASE, and Cochrane databases search were performed for meta-analysis. Randomized controlled trials at 2-years minimum follow-up which comparing clinical outcomes and radiological re-tear rates between single-row and double-row fixation for rotator cuff repair. Clinical outcomes included the American Shoulder and Elbow Surgeons score (ASES), University of California–Los Angeles score (UCLA), and Constant score; the radiological re-tear rate was assessed by Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA)or Ultrasonic (US). Two trained authors extracted data from all included articles, and if there are different opinions, the final decision would be made by the senior professor after reviewed the article.
Results: Six Level Ⅰ articles and two Level Ⅱ articles were included. In clinical outcomes, ASES, Constant score and forward flexion range of motion (ROM) showed no statistically significant difference between DR fixation and SR fixation technique at 2-years follow-up (P=0.61, P=0.19, P=0.17). UCLA score and internal rotation ROM were significantly better in DR group (P=0.005, P=0.001). DR repair showed less overall re-tear and partial re-tear rate and more intact rotator cuff than SR repair in radiological outcomes after 2-years follow-up (P=0.0002, P=0.02, P=0.0003).
Conclusion: The best current available evidence suggest that DR fixation technique have similar outcomes in ASES, Constant score and forward flexion ROM with SR fixation. However, DR group show higher UCLA score, greater internal rotation ROM and better radiological outcomes (include less overall re-tear and partial re-tear rate and more intact rotator cuff) than SR group after 2-years follow-up.
Level of Evidence: Level Ⅱ, meta-analysis
Rotator cuff tear is one of the most common shoulder injuries in clinical, which leads to shoulder weakness, pain and loss of range of motion. Robert Z et al.(42) presented a morbidity of full-thickness rotator cuff tear which 25% of individuals in their 60s and 50% of individuals in their 80s approximately. Meanwhile, Cadaver dissections(30) and radiological diagnosis (44) have found a prevalence of 17% and 23% rotator cuff tear, especially in the elderly.
Because of the advantages of less lesion, faster healing and comparable clinical outcomes, arthroscopic rotator cuff repair technique has been accepted by more and more people(3, 12, 34). Arthroscopic techniques for rotator cuff tear have evolved from formal single-row (SR) to double-row (DR) suture anchor and suture bridge technique. Lots of biomechanical researches(4, 22, 23, 38, 46) have revealed DR repair that increases the tendon-bone contact area, re-establish original rotator cuff footprint, and may decrease re-tear rate as well as increase function scores in clinical. Compared with SR fixation, however, DR didn’t show a significant difference in clinical and radiological outcomes(1, 19, 21). Numbers of meta-analysis(13, 32, 36, 37, 40, 41, 49–52) were done to compare DR and SR fixation method. However, the inclusion of no randomized controlled trials or level Ⅲ studies may be a potential source of heterogeneity in these articles(13, 36, 37, 50–52), which lead the analysis of DR and SR group to bias. Otherwise, other articles(32, 40, 41, 49) were analyzed in short-term follow-up, which didn’t give enough time for DR to reveal better clinical and radiological outcomes than SR repair.
Therefore, the purpose of this study was to perform a meta-analysis of all available randomized controlled trials at 2-years minimum follow-up, to compare the clinical outcomes and radiological re-tear rate between SR and DR repair technique. Our hypothesis was that DR repair technique would result in better clinical outcomes and radiological outcomes than SR repair.
This meta-analysis was started in October 1th 2018 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement(33).It has been registered in PROSPERO.The PubMed, EMBASE, and Cochrane database search was performed, only randomized controlled clinical trials at 2-years minimum follow-up comparing clinical outcomes and radiological re-tear rate between single-row and double-row fixation for rotator cuff tear were included. The latest date for this meta-analysis was November 1st, 2018. And the literature Search technique is shown in Figure 1. The corresponding authors were contacted immediately when additional information was needed.
Each study was evaluated by two trained reviewers (***, ***) for potential risk, including: selection bias, performance bias, detection bias, attrition bias, reporting bias or other bias. If the 2 reviewers have different opinions, a third author (***) participated in the discussion until consensus was achieved. And we evaluated the methodological quality of all included trails that meet the inclusion criteria by Consolidated Standards on Reporting Trials (CONSORT) checklist and scoring system(8).
Trained authors (***, ***) extracted data from all included articles, and if the views were different, the final decision would be made by the senior professor (***) after reviewed the article. The data in these papers included the year of publication, basic patient information, number of participants, initial rotator cuff tear size, surgical technique, rehabilitation program, complications, clinical outcomes and imaging results. Clinical outcomes were included preoperative and postoperative ASES score, Constant score and UCLA score. Imaging results were included the number of patients with intact, partial and complete rotator cuff re-tear, which was detected by MRA, MRI or US.
The collected data were analyzed by using Revman software (version 5.1.4; Cochrane Collaboration, Nordic Cochrane Centre, Copenhagen, Denmark) for meta-analysis. Continuous variables (ASES score, Constant score, UCLA score and ROM) were assessed using the weighted mean difference (WMD). In addition, dichotomous outcomes were evaluated using odds ratio (OR). The associated 95% confidence intervals (CIs) were calculated for each included study, and P<0.05 were considered as a statistically significant difference. Q statistic and I2 statistic were performed to assess heterogeneity among the included studies. Considered no heterogeneity between articles when the I2 < 50% and P >0.10. A random-effects model could be used if there was statistical evidence of heterogeneity between articles. Otherwise, a fixed-effects model was considered.
The search strategy identified 2582 articles from PubMed, EMBASE, Cochrane database after removal of duplicates. The PRISMA checklist and flow diagram were showed in supplementary material 1 and 2. Only 18 articles were retained after reviewed the titles and abstracts. After further full text reviewed, we found that three articles (10, 35, 45) were less than 2-years follow up, four articles(2, 9, 26, 27) were not compared with single-row and double-row, one article(24) was compared the cost-effectiveness of single-row and double-row reconstruction, two articles(16, 47) were not randomized controlled trials. Therefore, only 8 studies(1, 11, 18, 19, 21, 28, 29, 31) were included in this meta-analysis (Figure 2).
There were 6 Level Ⅰ evidence(11, 18, 19, 21, 28, 29) and two Level Ⅱ evidence(1, 31) articles in this meta-analysis. All included studies were evaluated by Consolidated Standards on Reporting Trials (CONSORT) checklist and scoring system(8). According to the CONSORT checklist, these studies scored an excellent to good rating score (range 14–20) (Table 1)..
A total of 642 patients included in this study, 607 patients remained after 2-years follow-up, 308 with SR and 299 with DR. The key characteristics (include Mean Age, No. of patients, Tear size, Tear side, et al.) were listed in Table 2, details of the surgical technique, rehabilitation protocol and conclusion were summarized in Table 3. We considered less than 3 cm rotator cuff tear as a small tear, and 3 cm or bigger tear as a large tear. Only Ma et al.(31) and Carbonel et al.(11) stratified patients into small tears and large tears, Aydin et al.(1) excluded bigger than 3 cm rotator cuff tear participators. Two articles(21, 28) described the Global Fatty Degeneration Index (GFDI) of patients in pre-operation.
Five articles(1, 11, 21, 28, 29) used the Constant score to evaluate clinical outcomes, four(11, 28, 29, 31) used ASES score, UCLA score was investigated by five articles(11, 18, 19, 28, 31). Range of motion (ROM) was measured in four references(11, 18, 19, 28). Radiological outcomes were assessed by MRA, MRI or US in the six studies(11, 18, 19, 28, 29, 31) at 2-years follow-up. Strength also was recorded in four articles(11, 21, 29, 31), however, it was detected by different methods.
The meta-analysis of clinical function scores and ROM of the shoulder joint were showed in Figure 3–7. Only two articles(11, 31) divided patients into the small tear and large tear, therefore, we didn’t analyze the difference between the two subgroups. In addition, we didn’t evaluate the strength because of different measurement methods.
ASES score was reported in 4 articles(11, 28, 29, 31) at 2-years follow-up, included 179 participators in the DR group and 186 participators in SR group. This meta-analysis suggested no statistically significant difference between DR fixation and SR fixation (95%CI, –0.32 to 1.60) (Fig 3)..
The Constant score was investigated in 5 studies(1, 11, 21, 28, 29), with 222 patients for DR repair and 230 patients for SR repair. It was also shown no statistically significant difference between the two fixation techniques (95%CI, –1.70 to 1.00) (Fig 4)..
UCLA score was assessed in 5 references(11, 18, 19, 28, 31), contained 188 patients in DR group and 189 patients in SR group. It demonstrated that the difference between the two repair techniques was statistically significant (95%CI, 0.22 to 1.21) (Fig 5)..
ROM of the shoulder joint was measured in 4 articles(11, 18, 19, 28), included 162 patients in DR group and 162 patients in SR group. Franceschi et al.(18, 19) started measuring this motion with the elbow flexed to 90°, and the forearm flat on the chest, so we didn’t analyze the external rotation ROM. Koh et al.(28) used the sequence of thoracic spinal to measure internal rotation. Therefore, we didn’t include the article when we evaluated the internal rotation. The meta-analysis showed a statistically significant difference between DR and SR in internal rotation (95%CI, 0.73 to 2.97) (Fig 6).. However, there was no statistically significant difference between two groups in forward flexion (95%CI, –1.16 to 6.62) (Fig 7)..
Radiographic outcomes were reported in 6 studies(11, 18, 19, 28, 29, 31). MRA, MRI or US were used to detect the re-tear rate. Five studies(11, 18, 19, 28, 31) divided overall rotator cuff re-tear into partial re-tear and complete re-tear. The specific differences were summarized in Figure 8–10.
The analysis of overall rotator cuff re-tear contained 217 patients in DR fixation and 221 patients in SR fixation. Fig 8 suggested a lower re-tear rate in DR group than SR group, which was statistically significant different (95%CI, 0.27 to 0.66). Meanwhile, Fig 9 implicated conspicuous difference in partial re-tear rate (95%CI, 0.27 to 0.66). Fig 10 shows DR group have more intact rotator cuff than SR after 2-years follow-up (95%CI, 1.53 to 4.12).
All included articles were randomized controlled trials, six Level Ⅰ evidence articles and two Level Ⅱ evidence articles. Two trained reviewers (***, ***) assessed the risk of bias for each study by using Revman software (version 5.1.4; Cochrane Collaboration, Nordic Cochrane Centre, Copenhagen, Denmark), and if they had different opinions, a senior professor made a final decision after reviewed the article. Figure 11 and Figure 12 show low risks among these studies.
However, there are also existing some factors of bias in this study. First, the tear size of each article was different. For example, Aydin et al.(1) only selected less than 3 cm rotator cuff tear participators in his research, Koh et al.(28) limited the inclusion criteria to 2–4 cm rotator cuff tear, and Franceschi et al.(18) contained less than 5 cm lesions. Second, the accompanying lesions of each article were different. Franceschi et al.(18) and Lapner et al.(29) included subscapularis lesion, but others were not or unclear. Grasso et al.(21), Aydin et al.(1) and Franceschi et al.(18) included long head of biceps tendon(LHBT) tear, while others didn’t. Third, just as shown in Table 3, the rehabilitation protocol was diverse. Moreover, the assessed methods of radiological outcomes were different. Three(18, 19, 31) used MRA, two(11, 28) used MRI, one(29) evaluated by both MRI or US.
Arthroscopic techniques become more and more common in shoulder lesion(14, 25), especially in rotator cuff injury. However, rotator cuff re-tear and shoulder stiffness are noteworthy after arthroscopic repair. The rate of rotator cuff re-tear after arthroscopic repair ranging from 30% to 94% was reported by Galatz LM et al.(20) and Boileau P et al.(7), and shoulder stiffness can be up to 15%(43, 48). What the surgeon can do to prevent rotator cuff re-tear and shoulder stiffness is to execute better rehabilitation protocol and stronger fixation method(18). Previous biomechanical trails(6, 22, 23, 38, 46) have demonstrated that DR increased the tendon-bone contact area, re-establish original rotator cuff footprint and provided quicker bone-tendon healing than SR group. Baums MH et al.(5, 6) suggested that DR rotator cuff repair increased the expression of type I and type III collagen and then provided faster tendon-bone healing than SR group in a sheep model. It means that DR fixation technique could promote rotator cuff healing and early motion. Through enrolled high risk of shoulder stiffness patients, Franceschi et al.(18) found than DR repair could lower the re-tear risk and maintain a low rate of shoulder stiffness after accelerated rehabilitation.
Eight randomized controlled trials were contained in this meta-analysis after strict selection, six(11, 18, 19, 21, 28, 29) level Ⅰ studies and two(1, 31) level Ⅱ. Although the differences between included studies existed, all included studies were assessed as having a good to excellent CONSORT rating score. It revealed that DR repair technique showed a statistically significant difference in less rotator cuff re-tear rate, greater ROM of internal rotation, and higher UCLA score after a 2-years minimum follow-up than SR group. In radiographic outcomes, DR group shows less overall re-tear and partial re-tear rate and more intact rotator cuff than SR group.
Five articles(1, 11, 21, 28, 29) applied the Constant score to evaluated shoulder function, four studies(11, 28, 29, 31) assessed by ASES score, and five(11, 18, 19, 28, 31) for UCLA score. There was statistically significant difference in UCLA score between DR and SR fixation technique. However, Constant score and ASES score weren’t. Four articles(11, 18, 19, 28) measured the ROM of shoulder joint. It showed a statistically significant difference between DR and SR in internal rotation, but no difference in forward flexion. We didn’t analyze the difference between the two subgroups because of onlytwo articles(11, 31) stratified patients into the small tear and large tear. When the meta-analysis contains only two articles, if the data is forcibly combined, it may lead to obvious bias and heterogeneity. Meanwhile, we didn’t analyze external rotation because the different measurement methods between these articles. Otherwise, it is worth noting that although there was no difference in the Constant score and forward flexion, the mean difference of 95% CI in Constant score and forward flexion tend to bigger than zero.
There were six studies(11, 18, 19, 28, 29, 31) reported the radiographic outcomes, and five studies(11, 18, 19, 28, 31) divided overall rotator cuff re-tear into partial re-tear and complete re-tear. This meta-analysis revealed a lower overall re-tear rate and partial re-tear rate and shown more intact rotator cuff in the DR group than SR group. This was similar to previous researches(13, 32, 41). It means that DR repair technique could provide better structural integrity, and then transfer to better clinical outcomes(41). However, in our study, only the result of UCLA score was statistically significant. The main reason may be that the number of patients is insufficient and the follow-up time is not long enough.
Lots of meta-analyses(13, 32, 36, 37, 40, 41, 49–52) were performed to compare the clinical and radiographic outcomes of DR and SR fixation method. However, most of articles(13, 36, 37, 50–52) included not only randomized controlled trials, but also no randomized controlled trials or level Ⅲ studies, which may be a potential source of heterogeneity and more or less lead the comparison between DR and SR group to bias. Otherwise, other articles(32, 40, 41, 49) were analyzed in short-term follow-up, which didn’t give enough time for DR to reveal better clinical and radiological outcomes than SR repair. Therefore, we design a meta-analysis which was based on the best current available evidence (only randomized controlled trials include) and longer follow-up (2-years minimum follow-up) to compare the outcomes between DR and SR fixation method.
There are several strengths in our study. At first, eight RCTs were included in this meta-analysis to compare the different clinical outcomes (including the Constant score, ASES score, UCLA score, ROM of the shoulder joint, re-tear rate) of DR with SR fixation. Second, we compared the clinical outcomes at 2-years minimum follow-up, which means DR group could show the medium-long term clinical outcomes in the treatment of rotator cuff tear. Third, we used the Revman software to evaluate the risk of bias in each included article, and used the CONSORT system to assess the quality of every article. It showed that all these studies had an excellent to good quality. In addition, when there were only two articles for subgroup analysis, we did not force to merge the data and avoid the possible heterogeneity.
There are still some limitations in this meta-analysis. First, only 8 studies were analyzed, included two level Ⅱ lesser-quality randomized controlled trials, which may be a potential source of bias. But all randomized controlled trials were included in this meta-analysis if met the eligibility criteria. Meanwhile, we evaluate the methodological quality of all included articles by CONSORT checklist and scoring system, and these studies scored an excellent to good rating score (range 14–20). Second, the details of each study were different, such as included criteria, tear size, fatty degeneration, operative techniques, rehabilitation protocols and radiological measurement methods. The heterogeneity of these articles was inevitable. Finally, only two references stratified patients into the small tear and large tear, therefore, we didn’t analyze the difference between the two subgroups. For the same reason, we didn’t assess the ROM of external rotation.
Therefore, normalized included criteria, operative techniques and assessment criteria should be established and applied. And high-quality randomized controlled trials should conduct to compare the clinical and radiological outcomes between DR and SR group, with longer follow-up and more standardized assessment criteria.
Based on the best current available evidence, this meta-analysis suggest that DR fixation technique have similar clinical outcome in ASES, Constant score and forward flexion ROM with SR fixation. However, DR group show higher UCLA score, greater ROM of internal rotation, less overall re-tear and partial re-tear rate and more intact rotator cuff than SR group after a 2-years minimum follow-up.
SR, single-row; DR, double-row; ASES, the American Shoulder and Elbow Surgeons score; UCLA, University of California–Los Angeles score; ROM, range of motion; RCT, randomized controlled trials; MRI, Magnetic Resonance Imaging; MRA, Magnetic Resonance Angiography; US, ultrasonic
Ethics approval and consent to participate: This article does not contain any studies with human participants or animals performed by any of the authors.
Consent for publication: Not applicable.
Availability of data and material: All data are fully available without restriction.
Competing interests: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
1.Aydin N, Kocaoglu B, Guven O. Single-row versus double-row arthroscopic rotator cuff repair in small- to medium-sized tears. Journal of Shoulder and Elbow Surgery 19 (5): 722–725, 2010.
2.Barber FA. Triple-Loaded Single-Row Versus Suture-Bridge Double-Row Rotator Cuff Tendon Repair With Platelet-Rich Plasma Fibrin Membrane: A Randomized Controlled Trial. Arthroscopy: The Journal of Arthroscopic & Related Surgery 32 (5): 753–761, 2016.
3.Barnes LA, Kim HM, Caldwell JM, Buza J, Ahmad CS, Bigliani LU, Levine WN. Satisfaction, function and repair integrity after arthroscopic versus mini-open rotator cuff repair. Bone & Joint Journal 99-B (2): 245, 2017.
4.Baums MH, Buchhorn GH, Spahn G, Poppendieck B, Schultz W, Klinger HM. Biomechanical characteristics of single-row repair in comparison to double-row repair with consideration of the suture configuration and suture material. Knee Surgery Sports Traumatology Arthroscopy 16 (11): 1052–1060, 2008.
5.Baums MH, Miosge N, Spahn G, Schultz W, Buchhorn GH, Lakemeier S, Klinger HM. Biomechanical, Cell Biological and Magnetic Resonance Imaging (MRI)-Morphological Results Comparing Single- and Double-Row Repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery 29 (10): e94, 2013.
6.Baums MH, Schminke B, Posmyk A, Miosge N, Klinger HM, Lakemeier S. Effect of single- and double-row rotator cuff repair at the tendon-to-bone interface: preliminary results using an in vivo sheep model. Archives of Orthopaedic and Trauma Surgery 135 (1): 111–118, 2015.
7.Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am 87 (6): 1229–40, 2005.
8.Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med 148 (4): 295–309, 2008.
9.Boyer P, Bouthors C, Delcourt T, Stewart O, Hamida F, Mylle G, Massin P. Arthroscopic double-row cuff repair with suture-bridging: a structural and functional comparison of two techniques. Knee Surgery, Sports Traumatology, Arthroscopy 23 (2): 478–486, 2015.
10.Burks RT, Crim J, Brown N, Fink B, Greis PE. A Prospective Randomized Clinical Trial Comparing Arthroscopic Single-and Double-Row Rotator Cuff Repair. The American Journal of Sports Medicine 37 (4): 674–682, 2009.
11.Carbonel I, Martinez AA, Calvo A, Ripalda J, Herrera A. Single-row versus double-row arthroscopic repair in the treatment of rotator cuff tears: a prospective randomized clinical study. International Orthopaedics 36 (9): 1877–1883, 2012.
12.Carr A, Cooper C, Campbell MK, Rees J, Moser J, Beard DJ, Fitzpatrick R, Gray A, Dawson J, Murphy J, Bruhn H, Cooper D, Ramsay C. Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial. Bone Joint J 99-B (1): 107–115, 2017.
13.Chen M, Xu W, Dong Q, Huang Q, Xie Z, Mao Y. Outcomes of single-row versus double-row arthroscopic rotator cuff repair: a systematic review and meta-analysis of current evidence. Arthroscopy 29 (8): 1437–49, 2013.
14.Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am 94 (3): 227–33, 2012.
15.Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res (214): 160–4, 1987.
16.Denard PJ, Jiwani AZ, Lädermann A, Burkhart SS. Long-Term Outcome of Arthroscopic Massive Rotator Cuff Repair: The Importance of Double-Row Fixation. Arthroscopy: The Journal of Arthroscopic & Related Surgery 28 (7): 909–915, 2012.
17.Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am 68 (8): 1136–44, 1986.
18.Franceschi F, Papalia R, Franceschetti E, Palumbo A, Del Buono A, Paciotti M, Maffulli N, Denaro V. Double-Row Repair Lowers the Retear Risk After Accelerated Rehabilitation. The American Journal of Sports Medicine 44 (4): 948–956, 2016.
19.Franceschi F, Ruzzini L, Longo UG, Martina FM, Beomonte Zobel B, Maffulli N, Denaro V. Equivalent Clinical Results of Arthroscopic Single-Row and Double-Row Suture Anchor Repair for Rotator Cuff Tears. The American Journal of Sports Medicine 35 (8): 1254–1260, 2007.
20.Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 86-A (2): 219–24, 2004.
21.Grasso A, Milano G, Salvatore M, Falcone G, Deriu L, Fabbriciani C. Single-Row Versus Double-Row Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Study. Arthroscopy: The Journal of Arthroscopic & Related Surgery 25 (1): 4–12, 2009.
22.Grimberg J, Diop A, Kalra K, Charousset C, Duranthon LD, Maurel N. In vitro biomechanical comparison of three different types of single- and double-row arthroscopic rotator cuff repairs: Analysis of continuous bone-tendon contact pressure and surface during different simulated joint positions. Journal of Shoulder & Elbow Surgery 19 (2): 236–243, 2010.
23.Hohmann E, Konig A, Kat CJ, Glatt V, Tetsworth K, Keough N. Single- versus double-row repair for full-thickness rotator cuff tears using suture anchors. A systematic review and meta-analysis of basic biomechanical studies. Eur J Orthop Surg Traumatol 28 (5): 859–868, 2018.
24.Huang AL, Thavorn K, van Katwyk S, MacDonald P, Lapner P. Double-Row Arthroscopic Rotator Cuff Repair Is More Cost-Effective Than Single-Row Repair. J Bone Joint Surg Am 99 (20): 1730–1736, 2017.
25.Iyengar JJ, Samagh SP, Schairer W, Singh G, Valone FR, Feeley BT. Current trends in rotator cuff repair: surgical technique, setting, and cost. Arthroscopy 30 (3): 284–8, 2014.
26.Kim KC, Shin HD, Lee WY, Han SC. Repair Integrity and Functional Outcome After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine 40 (2): 294–299, 2012.
27.Ko S, Lee C, Friedman D, Park K, Warner JJP. Arthroscopic Single-Row Supraspinatus Tendon Repair With a Modified Mattress Locking Stitch: A Prospective, Randomized Controlled Comparison With a Simple Stitch. Arthroscopy: The Journal of Arthroscopic & Related Surgery 24 (9): 1005–1012, 2008.
28.Koh KH, Kang KC, Lim TK, Shon MS, Yoo JC. Prospective Randomized Clinical Trial of Single- Versus Double-Row Suture Anchor Repair in 2- to 4-cm Rotator Cuff Tears: Clinical and Magnetic Resonance Imaging Results. Arthroscopy: The Journal of Arthroscopic & Related Surgery 27 (4): 453–462, 2011.
29.Lapner PL, Sabri E, Rakhra K, McRae S, Leiter J, Bell K, MacDonald P. A Multicenter Randomized Controlled Trial Comparing Single-Row with Double-Row Fixation in Arthroscopic Rotator Cuff Repair. The Journal of Bone and Joint Surgery-American Volume 94 (14): 1249–1257, 2012.
30.Lehman C, Cuomo F, Kummer FJ, Zuckerman JD. The incidence of full thickness rotator cuff tears in a large cadaveric population. Bull Hosp Jt Dis 54 (1): 30–1, 1995.
31.Ma H, Chiang E, Wu HH, Hung S, Wang S, Liu C, Chen T. Clinical Outcome and Imaging of Arthroscopic Single-Row and Double-Row Rotator Cuff Repair: A Prospective Randomized Trial. Arthroscopy: The Journal of Arthroscopic & Related Surgery 28 (1): 16–24, 2012.
32.Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl UJ. Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-analysis of level I randomized clinical trials. J Shoulder Elbow Surg 23 (4): 586–97, 2014.
33.Moher D, Liberati A, Tetzlaff J, Altman DG, The PG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLOS Medicine 6 (7): e1000097, 2009.
34.Mohtadi NG, Hollinshead RM, Sasyniuk TM, Fletcher JA, Chan DS, Li FX. A randomized clinical trial comparing open to arthroscopic acromioplasty with mini-open rotator cuff repair for full-thickness rotator cuff tears: disease-specific quality of life outcome at an average 2-year follow-up. American Journal of Sports Medicine 36 (6): 1043–1051, 2008.
35.Nicholas SJ, Lee SJ, Mullaney MJ, Tyler TF, Fukunaga T, Johnson CD, McHugh MP. Functional Outcomes After Double-Row Versus Single-Row Rotator Cuff Repair. Orthopaedic Journal of Sports Medicine 4 (10): 232596711666739, 2016.
36.Perser K, Godfrey D, Bisson L. Meta-analysis of Clinical and Radiographic Outcomes After Arthroscopic Single-Row Versus Double-Row Rotator Cuff Repair. Sports Health 3 (3): 268–74, 2011.
37.Prasathaporn N, Kuptniratsaikul S, Kongrukgreatiyos K. Single-Row Repair Versus Double-Row Repair of Full-Thickness Rotator Cuff Tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery 27 (7): 978–985, 2011.
38.Quigley RJ, Gupta A, Oh JH, Chung KC, Mcgarry MH, Gupta R, Tibone JE, Lee TQ. Biomechanical comparison of single-row, double-row, and transosseous-equivalent repair techniques after healing in an animal rotator cuff tear model. Journal of Orthopaedic Research 31 (8): 1254–1260, 2013.
39.Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, Iannotti JP, Mow VC, Sidles JA, Zuckerman JD. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 3 (6): 347–52, 1994.
40.Sheibani-Rad S, Giveans MR, Arnoczky SP, Bedi A. Arthroscopic single-row versus double-row rotator cuff repair: a meta-analysis of the randomized clinical trials. Arthroscopy 29 (2): 343–8, 2013.
41.Sobhy MH, Khater AH, Hassan MR, El SO. Do functional outcomes and cuff integrity correlate after single- versus double-row rotator cuff repair? A systematic review and meta-analysis study. Eur J Orthop Surg Traumatol 28 (4): 593–605, 2018.
42.Tashjian RZ. Epidemiology, Natural History, and Indications for Treatment of Rotator Cuff Tears. Clinics in Sports Medicine 31 (4): 589–604, 2012.
43.Tauro JC. Stiffness and rotator cuff tears: incidence, arthroscopic findings, and treatment results. Arthroscopy 22 (6): 581–6, 2006.
44.Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 8 (4): 296–9, 1999.
45.Wade R, Salgar S. Clinico-radiological evaluation of retear rate in arthroscopic double row versus single row repair technique in full thickness rotator cuff tear. Journal of Orthopaedics 14 (2): 313–318, 2017.
46.Wall LB, Keener JD, Brophy RH. Double-row vs single-row rotator cuff repair: a review of the biomechanical evidence. J Shoulder Elbow Surg 18 (6): 933–941, 2009.
47.Wang S. Single-Versus Double-Row Arthroscopic Rotator Cuff Repair in Massive Tears. Medical Science Monitor 21: 1556–1561, 2015.
48.Warner JJ, Greis PE. The treatment of stiffness of the shoulder after repair of the rotator cuff. Instr Course Lect 47: 67–75, 1998.
49.Xu C, Zhao J, Li D. Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears. J Shoulder Elbow Surg 23 (2): 182–8, 2014.
50.Yang JJ, Robbins M, Reilly J, Maerz T, Anderson K. The Clinical Effect of a Rotator Cuff Retear: A Meta-analysis of Arthroscopic Single-Row and Double-Row Repairs. Am J Sports Med 45 (3): 733–741, 2017.
51.Ying ZM, Lin T, Yan SG. Arthroscopic single-row versus double-row technique for repairing rotator cuff tears: a systematic review and meta-analysis. Orthop Surg 6 (4): 300–12, 2014.
52.Zhang Q, Ge H, Zhou J, Yuan C, Chen K, Cheng B. Single-row or double-row fixation technique for full-thickness rotator cuff tears: a meta-analysis. PLoS One 8 (7): e68515, 2013.
Table 1: CONSORT checklist and scoring system of all included articles
Checklist Items |
Franceschi 2007 |
Grasso 2009 |
Aydin 2010 |
Koh 2011 |
Carbonel 2012 |
Lapner 2012 |
Ma 2012 |
Franceschi 2016 |
Title and abstract |
1 |
1 |
0 |
1 |
1 |
1 |
1 |
1 |
Introduction and background |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Methods |
|
|
|
|
|
|
|
|
Participation |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Intervention |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Objectives |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Outcomes |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Samples size |
0 |
1 |
0 |
1 |
0 |
1 |
0 |
0 |
Random sequence generation |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Allocation |
1 |
1 |
1 |
0 |
1 |
1 |
1 |
1 |
Implementation |
0 |
1 |
1 |
0 |
1 |
1 |
0 |
0 |
Blinding |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Statistical methods |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Results |
|
|
|
|
|
|
|
|
Participant flow |
1 |
0 |
1 |
1 |
0 |
1 |
0 |
1 |
Implementation of intervention |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Recruitment |
1 |
0 |
0 |
0 |
1 |
1 |
0 |
1 |
Baseline data |
1 |
1 |
0 |
1 |
1 |
1 |
1 |
1 |
Numbers analyzed |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Outcomes and estimation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Ancillary analyzed |
0 |
1 |
0 |
0 |
1 |
1 |
1 |
0 |
Adverse events |
1 |
0 |
1 |
0 |
0 |
1 |
1 |
1 |
Discussion |
|
|
|
|
|
|
|
|
Interpretation |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Generalizability |
1 |
0 |
0 |
1 |
0 |
1 |
1 |
1 |
Overall evidence |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
1 |
Total score |
17 |
16 |
14 |
15 |
16 |
20 |
16 |
17 |
Table 2: Characteristics of per included study; NR, not reported;
|
IF |
Mean Age |
No. of Last follow-up patients |
Tear side |
Tear size(mm) |
Mean Follow-up |
Clinical outcome measures |
Radiographic outcome measures |
||||
|
Male |
Female |
Total |
L |
R |
Coronal |
Sagittal |
|||||
Francesco 2007 |
6.05 |
SR:63.5 DR:59.6 |
SR:12 DR:16 |
SR:14 DR:10 |
SR:26 DR:26 |
NR |
NR |
NR |
NR |
At least 24 M |
UCLA, ROM |
MRA |
Grasso 2009 |
4.33 |
SR:58.3 DR:55.2 |
SR:16 DR:18 |
SR:21 DR:17 |
SR:37 DR:35 |
SR:10 DR:6 |
SR:27 DR:29 |
NR |
NR |
24.8±1.4 M |
Constant, DASH, Work-DASH, Strength |
NR |
Aydin 2010 |
2.85 |
SR:59.0 DR:57.0 |
SR:NR DR:NR |
SR:NR DR:NR |
SR:NR DR:NR |
NR |
NR |
<30 |
<30 |
36M (24-40) |
Constant |
NR |
Koh 2011 |
4.33 |
SR:61.6 DR:61.6 |
SR:9 DR:11 |
SR:22 DR:20 |
SR:31 DR:31 |
SR:1 DR:2 |
SR:30 DR:29 |
SR:21.0 DR:20.8 |
SR:17.2 DR:17.5 |
SR:31.0M (24-44) DR:32.8M (24-42) |
VAS, ASES, Constant, UCLA, ROM, Satisfaction |
MRI |
Carbonel 2012 |
2.38 |
SR:55.79 DR:55.21 |
SR:35 DR:33 |
SR:45 DR:47 |
SR:80 DR:80 |
NR |
NR |
NR |
NR |
At least 24 M |
ASES, UCLA, Constant, SSI, ROM |
MRI |
Lapner 2012 |
4.33 |
SR:56.0 DR:57.8 |
SR:35 DR:29 |
SR:13 DR:13 |
SR:48 DR:42 |
SR:11 DR:13 |
SR:37 DR:29 |
SR:21.4 DR:23.8 |
SR:18.9 DR:18.9 |
At least 24 M |
ASES. WORC. Constant Strength |
MRI, US |
Ma 2012 |
4.58 |
SR:60.8 DR:61.6 |
SR:15 DR:12 |
SR:12 DR:14 |
SR:27 DR:26 |
SR:11 DR:8 |
SR:16 DR:18 |
NR |
NR |
SR:33.3M (24-42) DR:33.5M (24-42) |
ASES, UCLA, Strength |
MRA |
Franceschi 2016 |
6.06 |
SR:61.8 DR:58.9 |
SR:12 DR:15 |
SR:18 DR:10 |
SR:30 DR:25 |
SR:7 DR:5 |
SR:18 DR:20 |
<50 |
Unclear |
At least 24 M |
UCLA, ROM |
MRA |
Table 3: Reporting to details No. of anchors, Concomitant procedures, rehabilitation protocol and conclusion per included study; *SSc, subscapularis; # LHBT, long head of biceps tendon; GFDI, Global Fatty Degeneration Index
|
No. of patients |
Mean No. of anchors |
SSc* lesion |
GFDI |
LHBT# lesion |
Concomitant procedures |
Rehabilitation protocol |
Conclusion |
Francesco 2007 |
SR:26 DR:26 |
SR:1.9(1-2) DR:2.3(2-4) |
Unclear |
Unclear |
Unclear |
Unclear |
Abduction Sling: 6 weeks; Passive exercise: first day; Overhead stretching and active exercise: 6weeks; Srengthening:10-12 weeks |
No differences between SR and DR in clinical or radiographic outcomes |
Grasso 2009 |
SR:37 DR:35 |
Unclear |
Exclude |
SR:1.9 DR:1.9 |
Include |
Subacromial decompression; LHBT: shaving or tenodesis or tenotomy |
Sling: 3 weeks; Passive-active exercise:4-8weeks; Srengthening exercise: 9 weeks behinds; |
No differences between SR and DR in clinical outcomes |
Aydin 2010 |
SR:NA DR:NA |
Unclear |
Exclude; |
Unclear |
Include |
Subacromial decompression; |
Abduction Sling; Passive forward flexion: first day; Active assisted exercise:4-6weeks; Full active exercise: 6-8 weeks |
No differences between SR and DR in clinical outcomes |
Koh 2011 |
SR:31 DR:31 |
SR:2 DR:3 |
Exclude |
SR:1.2 DR:1.2 |
Unclear |
Subacromial decompression; |
Abduction brace: 3 weeks, Passive exercise: after 4 weeks; Active exercise: full ROM gained; Strengthening exercises; 3 mouths |
No differences between SR and DR in clinical or radiographic outcomes |
Carbonel 2012 |
SR:80 DR:80 |
SR:1.83(1-3) DR:2.99(2-4) |
Unclear |
Unclear |
Unclear |
Subacromial decompression; |
Abduction Sling, Passive exercise: frist week; Active exercise:4-6 weeks; Full active ROM,6-8 weeks; Strengthening exercises,10-12 weeks |
DR show significant difference in clinical outcomes compared with SR, especially in over 30-mm tears. No MRI differences were observed. |
Lapner 2012 |
SR:48 DR:42 |
SR:1(1-2) DR:2(2-3) |
Include |
Unclear |
Unclear |
Unclear |
Pendulum exercises: first day; Active-assisted exercises 6weeks; Active exercises:6-12weeks; Strengthening exercises,12 weeks |
DR get greater healing rates than SR. No differences between SR and DR in clinical outcomes |
Ma 2012 |
SR:27 DR:26 |
SR:2.37(2-4) DR:3.38(3-5) |
Exclude |
Unclear |
Unclear |
Subacromial decompression |
Sling:frist week; Active exercises(<3cm):6 weeks; Active exercises (>3cm): 8 weeks; Strengthening exercises(<3cm):8 weeks; Strengthening exercises(>3cm): 10 weeks; |
DR get greater shoulder strength than SR in over 30-mm tears. No MRA differences were observed. |
Franceschi 2016 |
SR:30 DR:25 |
SR:1.8(1-2) DR:2.4(2-4) |
Include |
Unclear |
Include |
LHBT lesion: tenotomy |
Abduction Sling:4 weeks; Closed chain passive exercises: before 6 weeks; Overhead stretching:6 weeks; Strengthening exercises:10-12 weeks. |
DR repair of the RC could lower the risk of re-tears while maintaining a low rate of stiffness. |