Systematic review of 1252 rotator cuff repairs from 23 studies asking whether repair method or surgical approach affects structural retear rate on postoperative imaging. Results are stratified by tear size across four categories. The central question: does double-row fixation actually heal better, or just perform better on the bench?
The central clinical question this paper addresses is whether investing in double-row fixation (longer OR time, higher implant cost) actually results in a tendon that stays healed. Prior to this review, conflicting single-institution studies made it hard to draw a firm conclusion, and at least one Level 1 RCT had shown no clinical difference between single- and double-row repair.
The pooled data here are clear enough to drive a decision rule: for any tear larger than 1 cm, use double-row fixation when the tissue is mobile enough to reach the footprint. The benefit is largest in the 1–3 cm range (retear drops from 30% to 8%) and remains significant even for massive tears.
Two findings should change counseling: first, the repair method matters far more than the surgical approach, so an arthroscopic single-row repair is not equivalent to an arthroscopic double-row repair — don't conflate technique with access. Second, transosseous sutures and suture anchors are equivalent in healing; the historical transition to anchors did not improve structural outcomes.
The key limitation to flag with patients: double-row requires a mobile tear. If the cuff is retracted and stiff, the apparent healing advantage of double-row may partly reflect patient selection rather than technique alone.
Systematic review of 1252 rotator cuff repairs from 23 studies asking whether repair method or surgical approach affects structural retear rate on postoperative imaging. Results are stratified by tear size across four categories. The central question: does double-row fixation actually heal better, or just perform better on the bench?
The central clinical question this paper addresses is whether investing in double-row fixation (longer OR time, higher implant cost) actually results in a tendon that stays healed. Prior to this review, conflicting single-institution studies made it hard to draw a firm conclusion, and at least one Level 1 RCT had shown no clinical difference between single- and double-row repair.
The pooled data here are clear enough to drive a decision rule: for any tear larger than 1 cm, use double-row fixation when the tissue is mobile enough to reach the footprint. The benefit is largest in the 1–3 cm range (retear drops from 30% to 8%) and remains significant even for massive tears.
Two findings should change counseling: first, the repair method matters far more than the surgical approach, so an arthroscopic single-row repair is not equivalent to an arthroscopic double-row repair — don't conflate technique with access. Second, transosseous sutures and suture anchors are equivalent in healing; the historical transition to anchors did not improve structural outcomes.
The key limitation to flag with patients: double-row requires a mobile tear. If the cuff is retracted and stiff, the apparent healing advantage of double-row may partly reflect patient selection rather than technique alone.