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Orthop J Sports Med. 2019 May 16;7(5):2325967119842881. doi: 10.1177/2325967119842881. eCollection 2019 May.

Does Medial-Row Fixation Technique Affect the Retear Rate and Functional Outcomes After Double-Row Transosseous-Equivalent Rotator Cuff Repair?

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Hospital for Special Surgery, New York, New York, USA.
Department of Orthopedic Surgery, NYU Langone Medical Center, New York, New York, USA.
Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA.



Double-row transosseous-equivalent (TOE) rotator cuff repair techniques have been widely accepted because of their superior biomechanical properties when compared with arthroscopic single-row repair. Concerns regarding repair overtensioning with medial-row knot tying have led to increased interest in knotless repair techniques; however, there is a paucity of clinical data to guide the choice of technique.


Arthroscopic TOE repair techniques using knotless medial-row fixation will demonstrate lower retear rates and greater improvements in the Constant score relative to conventional knot-tying TOE techniques.

Study Design:

Systematic review; Level of evidence, 4.


A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Inclusion criteria were English-language studies that examined repair integrity or Constant scores after arthroscopic rotator cuff repair with TOE techniques. Two investigators independently screened results for relevant articles. Data regarding the study design, surgical technique, retear rate, and Constant shoulder score were extracted from eligible studies. A quality assessment of all articles was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.


The systematic review identified a total of 32 studies (level of evidence, 1-4) that met inclusion and exclusion criteria. Of the 32 studies, 5 reported on knotless TOE techniques, 25 reported on knot-tying TOE techniques, and 2 reported on both. In the knotless group, retear rates ranged from 6% to 36%, and Constant scores ranged from 38-65 (preoperative) to 73-83 (postoperative). In the knot-tying group, retear rates ranged from 0% to 48%, and Constant scores ranged from 42-64 (preoperative) to 55-96 (postoperative).


Despite several theoretical advantages of knotless TOE repair, both knotless and knot-tying techniques reported considerable improvement in functional outcomes after rotator cuff repair. Although tendon failure rates showed a downward trend in knotless studies, additional prospective studies are warranted to better understand the role of medial-row fixation on tendon repair integrity and postoperative clinical outcomes.


arthroscopic; knot; knotless; meta-analysis; shoulder; surgical techniques; systematic review

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: P.D.F. has received educational support from Smith & Nephew and hospitality payments from Medical Device Business Services. M.J.A. has received educational support and speaking fees from Arthrex and has received hospitality payments from DePuy and Gotham Surgical. K.J.J. has received educational support from Arthrex, honoraria from the Musculoskeletal Transplant Foundation, and hospitality payments from Aesculap and Micromed. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

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