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Arthroscopic Rotator Cuff Repair: Single or Double Row?

Andrew Titchener, Prashanth D’sa, Mark Gayden, Amol Tambe

Andrew Titchener, Prashanth D’sa, Mark Gayden, Amol Tambe, University Hospitals of Derby & Burton NHS Foundation Trust, DE22 3NE, United Kingdom

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Amol Tambe, University Hospitals of Derby & Burton NHS Foundation Trust, DE22 3NE, United Kingdom.
Email: amol.tambe1@nhs.net

Received: September 14, 2018
Revised: November 18, 2018
Accepted: October 20, 2018
Published online: February 28, 2019

ABSTRACT

Optimal treatment for rotator cuff tears remains a controversial topic with a wide variation in clinical practice. We aim to summarise the history of rotator cuff tear surgery and its’ evolution based upon biomechanical and clinical research with respect to the options available today. Arthroscopic repair of the rotator cuff tear has become the gold standard intervention in the last 3 decades and a multitude of options now exist. Considerable debate and discussion has centred on the ‘single row’ or ‘double row’ repair techniques. We will consider the relative merits of each technique in terms of their clinical, technical and financial implications. Rotator cuff pathology is an area that encompasses a wide range of clinical scenarios; hence it is not possible to be entirely prescriptive regarding a technique across the board. It is however important to be familiar with the merits, pitfalls and evidence relative to each in order to inform clinical practice. Furthermore, we believe a good shoulder arthroscopist should be proficient in both single and double row techniques and have an insight into the advantages and disadvantages of each in their own hands.

Key words: Rotator cuff; Rotator cuff tears; Arthroscopy; Single row; Double row

© 2019 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Tambe A. Arthroscopic Rotator Cuff Repair: Single or Double Row? International Journal of Orthopaedics 2019; 6(1): 996-1002 Available from: URL: http: //www.ghrnet.org/index.php/ijo/article/view/2413

INTRODUCTION

A variety of techniques have been described to repair the torn rotator cuff tendon and controversy exists around the superiority of single or double row constructs. While some surgeons will choose the technique that they consider best fits their case, others are strong advocates for one technique over the other. The water is further muddied as the optimal means of achieving tendon healing and consistently good clinical outcomes is not fully understood. Biomechanical studies may not necessarily translate into good long-term clinical outcomes and clinical studies are often inconclusive. Furthermore the risk of bias cannot be overlooked when dealing with rotator cuff tears that constitute a large volume and remain a high value field for implant companies. There are a multitude of different tear scenarios and a number of factors to consider when choosing between techniques. We aim to review the history of repair techniques and current practice, considering the posterosuperior cuff only, and to give our views on the indications for each technique.

HISTORY OF ROTATOR CUFF REPAIR

There are reports in the nineteenth century by Hüter and also by Müller of rotator cuff tendon repair in the context of dislocation and instability[1]. However the turn of the twentieth century saw the development and expansion of techniques to repair the rotator cuff. Perthes published a series of three cases[2] and in 1909 Codman published a report of two successfully performed supraspinatus repairs[3]. Further cases followed and in these early days trans-osseous suture fixation was considered the gold standard repair technique as other methods were obviously not available.

The development of arthroscopy revolutionised the diagnosis and treatment of cuff tears. Burman performed shoulder arthroscopy on cadavers in 1931[4] but without improvement in imaging equipment ‘arthroscopic only’ techniques for repair were not possible until later years. Because of the technological restrictions, progress was limited to open techniques. A method of proximal reattachment of the supraspinatus in cases of rotator cuff tears was reported by Mclaughlin in 1944[5] and in his renowned work of 1972, Neer defined impingement syndrome and it’s association with rotator cuff tears, describing a variety of techniques for their repair[6].

In 1990 Levy et al described a mini-open rotator cuff repair via a deltoid spilt preceded by an arthroscopic assessment of the joint and acromioplasty[7]. This was closely followed by preliminary reports from Snyder, and from Thal who published a technical note on arthroscopic repair[8]. All arthroscopic repairs were described initially using a single row of suture anchors. This offered the benefits of lower levels of post-operative pain and faster rehabilitation than open, transosseous repairs. The introduction of suture anchors facilitated the introduction of arthroscopic techniques; although widely used in open repair techniques their ease of use with arthroscopic portals was a game-changer for this method. A double row technique was introduced in 2003 by Lo and Burkhart[9] and thought to offer a better contact area for cuff healing. There continues to be discussion surrounding the relative merits of single versus double row repair which will be discussed further in this review. It is certainly true that arthroscopic repair using any technique has rapidly grown in popularity with a 600% increase in prevalence reported in America over the last decade[10] and all-arthroscopic repairs are the most common technique utilised in the UK[11].

AVAILABLE TECHNIQUES TO REPAIR THE ROTATOR CUFF

Current accepted practice is that surgical treatment should be offered for symptomatic rotator cuff tears; repair of asymptomatic tears with the aim of preventing enlargement, development of atrophic change and cuff tear arthropathy is more controversial[12,13]. A biomechanically sound construct in a lower tension environment is sought to facilitate healing of the repair[14]. This can be achieved with a variety of techniques which may be open or arthroscopic and may include subacromial decompression. For partial thickness tears, options include in-situ repair or conversion to full thickness tear followed by repair[15,16]. For these reasons there are a number of possible confounding factors or sources of bias when seeking to compare between constituent parts of an operation such as the suture pattern utilised.

Trans-osseous bone tunnels were traditionally used for open rotator cuff repairs. This had the benefit of allowing for solid approximation of the tendon onto the footprint with an increased area for healing. However, this method also had the disadvantages of increased postoperative pain and decreased range of motion from violating the deltoid during the approach[14]. Advances in arthroscopic techniques allow for all-arthroscopic repair of most rotator cuff tears. This has added benefits including smaller skin incisions, avoiding deltoid detachment, decreased pain, decreased morbidity and an earlier return to normal mobility compared to open surgery[16, 17].

Methods of tendon-bone repair may utilise a range of sutures and deployment patterns with the main types as follows. Single row (SR) repair incorporates the use of a single row of anchors and uses sutures through the rotator cuff causing tendon compression onto the tuberosity with low tension. This method is simple, fast, cheaper, shorter learning curve, with a lower risk of injury to tendon margins and is easier to revise.

Double row (DR) repair incorporates medial- and lateral row anchors and includes traditional double row and suture bridge also known as transosseous-equivalent (TOE) techniques. TOE uses a medial row anchor as for a single row repair but these sutures are passed trans-tendinous, crossed, and secured over the footprint tissue to lateral row anchors. Biomechanical studies of these techniques have demonstrated increased mechanical strength and durability, greater restoration of the footprint anatomy, improved tendon to bone contact area and pressure, lesser gap formation and a watertight repair preventing synovial fluid ingress[18]; good clinical outcomes have also been reported[19]. Due to the greater tendon excursion required to cover the footprint, increased tendon stress can be complicated by creation of a medial re-tear, termed a type 2 failure at the musculotendinous junction; a scenario in which revision repair is very difficult or impossible[20]. Multiple sutures can also strangle and render the tendon avascular with possible deleterious effects on healing and multiple large area anchors may physically impede the surface available for tendon healing.

Suture technique

Simple comparisons between single and double row techniques are further compounded by the multiple suture configurations that may be utilised. The few clinical studies examining existing techniques frequently lack power and external validity. Techniques which can be employed include a simple interrupted or simple mattress suture, the ‘parachute technique’[21], the Mason Allen stitch including subsequent modifications such as the ‘Alex stitch’[22], the rip stop suture[23], the simple cinch, lasso, lasso-matress[24], or the Southern California Orthopaedic Institute (SCOI) technique popularised by Snyder[25] (Figures 1-3). Some of these techniques can also be converted to include a double row element.

Factors improving single row repairs

These can improve footprint contact with single row but not to the extent of double row repairs.

Knotless anchors and suture tapes may improve single row repair constructs.

Table 1 Factors improving single row repairs.
Biological factorsLess trauma to tendon margin
Less damage to tendon vascular zone
Enhanced biology
Crimson carpet
Less tendon strangulation
Mechanical factorsLow tension
Suture security avoiding pullout- Mason Alex stitch, Rip- stop suture or the looped / lasso repair, SCOI technique (Snyder)[25]
Deployment pattern such as parachute technique- tails from each anchor tied horizontally. Pulley either single or double.

Figure 1 Prepared footprint and cuff for medium size tear.

Figure 2 Two triple loaded anchors in single row repair.

Figure 3 Final ‘crimson duvet’ construct.

STRUCTURAL OUTCOMES AFTER ROTATOR CUFF REPAIR

Intuitively, the aim of a rotator cuff repair is to achieve healing of the tendon back to its anatomic position in order to permit resolution of pain and improvement in function. As discussed, historically the initial open repair techniques were mainly trans-osseous, and the initial arthroscopic repairs were single row repairs for reasons of simplicity and efficiency. The principle aim of a double row, trans-osseous or trans-osseous-equivalent repair is to recreate the ‘anatomic footprint’ that is thought to promote healing and recovery of function. Biomechanical studies have suggested that a double row repair results in a greater contact area of tendon to tuberosity, increased stiffness, decreased gap formation and an increased load to failure and cyclic load to failure[26-31].

The influence of healing of the macroscopic tendon structure on outcomes is not fully understood. Some studies have shown that early re-tears post-surgery were associated with inferior clinical outcomes[32]. The UK rotator cUFF (UKUFF) trial found that tendons which healed had a better clinical outcome than those which did not, however the technique utilised in the UKUFF Trial was left to the surgeon’s preference and included both single and double row procedures[33]. Numerous studies have shown a higher re-tear rate after single row repair[34-36], but have generally failed to subsequently show a correlation with clinical outcomes.

Rotator cuff tears come in a variety of forms however with a diverse range of factors in each individual likely to influence outcome including not only the physical aspects of the injury such as tear size and location, but also the chronicity, muscular degeneration and biological factors or comorbidities. A single ‘one-size-fits-all’ repair strategy may therefore not be appropriate for all scenarios and studies investigating the effect of a single technique may fail to identify a superior technique as a result. Tears are not uncommonly retracted to some degree due to the unopposed pull of the muscle, this is especially the case with larger degenerate tears which often have intrinsic contractures and surrounding adhesions. Critics of an anatomic repair in this scenario point to the desire for a low-tension repair to promote healing and advocate a single row. Furthermore, excessive tension on an anatomic repair can lead to a more medial failure at the musculotendinous junction of the tendon, a so-called type II failure, which is difficult or impossible to salvage due to the difficulty of obtaining a meaningful repair in the remaining muscle tissue.

Size of the tear as an independent factor that increases re-tear rates after cuff repair has been reported by many authors. Duquin et al performed a systematic review including 1252 repairs from 23 studies. They found that double row techniques gave significantly lower re-tear rates for tears greater than 1cm, but failed to find an effect below 1cm[37].

Trans-osseous equivalent techniques, where the medial row sutures are passed over the ‘footprint’ tendon to lateral row anchors have been purported to improve tendon contact area and pressure, increasing cyclic load to failure in biomechanical models[38].

Due to practical limitations the follow-up for series of cuff repair is often relatively short and the influence of sustaining a re-tear on the subsequent development of cuff tear arthropathy is unclear. Some commentators would use this as a rationale to advocate the lower re-tear rate albeit equivalent short term clinical outcomes of a double row repair.

CLINICAL OUTCOMES AFTER SINGLE AND DOUBLE ROW ROTATOR CUFF REPAIR

The efficacy of rotator cuff repair can be difficult to determine as the natural history of the condition without surgical treatment is some degree of improvement at least in the short term[39]. While there are a number of level I and II studies comparing single vs double row repair, these often fail to show conclusively a clinical difference in outcome between the techniques, regardless of the structural outcomes[40-43]. Of the few level I studies showing an improvement in clinical outcomes with double row repairs, there does appear to be an effect of initial tear size. Carbonel et al stratified their results and identified improvements in both objective and subjective (ASES and UCLA) scores in tears of 3-5cm at final 2 year follow up[44]. In this study tears of 1-3cm repaired via double row were also superior in terms of range of motion and internal/external rotation strength. Double row repairs were also found to be clinically superior in larger tears in studies by Park et al[45] and Ma et al[42]. Studies which fail to sub-stratify their study groups in this way may miss this effect.

However meta-analyses of level I randomised clinical trials have failed to show a significant difference when tears of all sizes are included[18]. Various commentators suggest that this may be because these studies are underpowered to detect this difference resulting in a type II error[46]. There may also be a bias due to relatively short follow up times. In their meta-analysis, Millett et al found a significant increase in imaging-diagnosed re-tear rates after a single row repair, which did not correlate with a decline in outcome scores[18], a result replicated by other reviews[37,47].

RETEARS – WHAT FACTORS PREDICT?

Post rotator cuff surgical re-tear rates of 11 to 57% have been reported in the literature[48]. As previously discussed, the correlation between re-tears post-surgery and subsequent clinical outcomes is variable. It would seem naïve however to ignore studies such as the UKUFF trial[33] and other studies which have shown better clinical outcomes in tendons which heal than those which do not[32]. A healed repair should therefore be the surgical aim in most circumstances.

Numerous factors have been implicated in the failure of cuff repairs. The UKUFF trial in 2017 reported an overall healing failure rate of 43% at 1-year post surgery. Via logistic regression only age and massive tears were identified as independent predictors[49].

Le et al examined 1000 rotator cuff repairs for factors predictive of re-tears in single row repairs[48]. Patient age, tear size, extent of fatty infiltration, muscle atrophy and amount of retraction at the time of surgery were identified to be the most important predictors of outcome; other factors with significant but weaker correlation with re-tears were preoperative supraspinatus weakness, a positive drop arm sign, a higher level of sporting activity at presentation, history of a shoulder dislocation, and history of a contralateral shoulder problem. Rashid et al investigated the effect of age and tear size on cuff healing post-surgery and found both to be independent risk factors for an adverse outcome[49].

COST IMPLICATIONS OF SINGLE ROW VS OTHER TECHNIQUES

In this age of extant resources it is important to consider the cost implications when considering the merits of different surgical techniques. Rotator cuff repair in general has been shown to be cost effective when compared with other common healthcare interventions[50] particularly if the patient is referred immediately as early surgery can facilitate an early return to work[51]. Mather et al found a net societal cost benefit for rotator cuff repair in patients under the age of 61 and an increase in QALYs across all age groups[52].

Huang et al[53] found that in the Canadian health system a double row technique was more costly but also more clinically cost effective than a single row technique, with an incremental cost effectiveness ratio between the techniques of $26,666 per QUALY gained. Subgroup analysis in this paper further suggested that double row is particularly cost effective when considering tears of over 3 cm.

With respect to tear size, a cost analysis of single vs double row techniques in the US system found that the increased cost associated with the double row technique would need to result in one fewer revision in every 17 primary cases in order to obtain cost neutrality in tears < 1 cm, and one fewer in every four primary cases in tears over 5cm[54]. Genuario et al reported that in their decision analytical model double row repair was not cost effective for any size of tear. However, they went on to define limits; if the increased cost of a double row technique was less than $287 for a small or moderate tear or $352 for large or massive tears then double row techniques could become cost effective[55].

Cost will also depend on the preferences and skill of the surgeon in terms of theatre time utilisation and the number of anchors used. Chalmers et al[56] found that factors significantly increasing the direct cost of a cuff repair were single vs double row, size of tear, increased number of anchors and increasing ASA grade. The price of the anchors used will also clearly affect the overall cost of any procedure and introduce a significant variability into this area when considering costs[57].

Procurement price differences within and between countries can heavily bias the results of investigative studies. In this context it is relevant to apply the cost discussion to countries that have seen a rapid increase in arthroscopic shoulder surgery in recent years where a large proportion of procedures undertaken are patient funded. In this scenario a double row repair almost doubles the implant related cost that is passed on to the patient. The surgeon will have to use the current evidence and their own experience and expertise judiciously so as not to disadvantage their patients.

Conclusion; So when should we use a single row technique?

We would contend that it is impossible to be completely prescriptive and advocate a particular technique for every scenario. We believe a good shoulder arthroscopist should be proficient in both single and double row techniques and have an insight into the advantages and disadvantages of each in their own hands.

There are however some general principles that provide guidance in this minefield. The biomechanical literature suggests that double row repair offers the advantage of high fixation strength and decreased gap formation with greater footprint coverage and pressure than single row repairs, and this should be borne in mind. However these properties do not necessarily confer improved clinical outcomes and studies are often confounded by a number of factors including the variation in the number of anchors used. While not entirely conclusive, for larger tears the clinical literature is more supportive of a double row technique, for smaller tears a single row technique will likely suffice. In some situations a double row repair may be planned, but may require intraoperative conversion to a single row repair due to difficulties such as limited excursion of the tendon in a stiff retracted tear. In this circumstance it is important not to cause collateral tendon damage or to pre-dispose to a type II failure by over-zealously tightening in a double row repair, when a large body of evidence would support a single row technique. We also acknowledge that there are schools of thought amongst eminent and experienced surgeons who achieve excellent results through a single row technique and so see no need to change their practice. Early in an arthroscopist’s career they may offer a simpler approach which is easier and quicker to learn and reproduce; increased complexity increases operative time incurring increased financial costs as well as risking morbidity. Increased numbers of anchors are also a financial consideration and many may find this unjustifiable in the context of equivocal evidence.

In summary, there are a multitude of factors at play and single row repair techniques do lend themselves well to a number of situations. We consider each individual case on its merits and will use both single and double row techniques in our practice.

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Peer Reviewer: Maurice Balke

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