1. No category

J Shoulder Elbow Surg (2014) 23, 182-188
www.elsevier.com/locate/ymse
Meta-analysis comparing single-row and double-row
repair techniques in the arthroscopic treatment of rotator
cuff tears
Caiqi Xu, MD, Jinzhong Zhao, MD*, Dingfeng Li, MD
Department of Arthroscopy Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
Background: Rotator cuff tears are among the most common shoulder injuries and can be a source of
persistent pain, disability, and decreased range of motion and strength. Our hypothesis was to conduct a
meta-analysis of recently published studies to compare the clinical results of a double-row technique
with the results of a single-row technique for different tear sizes.
Methods: A search was performed in the MEDLINE, EMBASE, and Ovid databases. All randomized and
quasi-randomized clinical trials that reported the outcome of single-row repair and double-row repair techniques were included in our meta-analysis. Two subgroups were set according to the tear size. The outcomes were the Constant score, American Shoulder and Elbow Surgeons (ASES) score, UCLA score,
re-tear rate, range of motion, and muscle strength.
Results: We included 9 studies in this meta-analysis, 5 of which were randomized prospective studies.
There was a statistically significant difference in favor of double-row repair for the overall ASES score,
re-tear rate, and internal rotation range of motion. In subgroup 2 (tear size > 30 mm in the anteroposterior
dimension), double-row techniques produced better outcomes than single-row techniques. There were no
statistically significant differences in the overall Constant score, UCLA score, external rotation and forward elevation range of motion, or muscle strength.
Conclusion: Double-row rotator cuff repair techniques have a significantly lower re-tear rate, higher ASES
score, and greater range of motion of internal rotation compared with single-row repair techniques. Especially in those rotator cuff tears with a size >30 mm, the double-row technique is recommended for repair.
Level of evidence: Level II, Meta-Analysis, Treatment Study.
Crown Copyright Ó 2014 Published by Elsevier Ltd on behalf of Neonatal Nurses Association. All rights
reserved.
Keywords: Double-row repair; single-row repair; rotator cuff tear; clinical outcomes; re-tear rate
Rotator cuff tears are among the most common shoulder
injuries and can be a source of persistent pain, disability,
and decreased range of motion (ROM) and strength.23
IRB: Not applicable.
*Reprint requests: Jinzhong Zhao, MD, Department of Arthroscopy
Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital,
600 Yishan Road, Shanghai 200233, China.
E-mail address: [email protected] (J. Zhao).
Improvements in surgical technique and instrumentation
have made arthroscopic rotator cuff surgery common.7
Currently, arthroscopic rotator cuff repair is becoming
increasingly popular, and significant research has been
performed to evaluate the different techniques and outcomes.24 The double-row technique of rotator cuff repair
can increase the tendon-bone contact area and creates a
more anatomic footprint.16,19 Although the single-row
technique of repairing the torn cuff tendons raises
1058-2746/$ - see front matter Crown Copyright Ó 2014 Published by Elsevier Ltd on behalf of Neonatal Nurses Association. All rights reserved.
http://dx.doi.org/10.1016/j.jse.2013.08.005
Meta-analysis comparing single-row and double-row repair
183
concerns about a lack of anatomic healing,11 it has been the
standard technique, producing acceptable clinical results.27
Our purpose was to conduct a meta-analysis of recently
published studies to compare the clinical results of a doublerow technique with the results of a single-row technique in
patients with rotator cuff tears of different sizes to help clinicians make medical decisions in different situations.
forward elevation (sagittal plane), and internal and external rotation (90 of abduction). In the studies,4,5,10,12,15,17,20 one medical
clinician who was unaware of surgery type or clinical results
conducted the ROM and muscle strength measurement.
Methods
Search strategy
A computer literature search was conducted with the search terms
‘‘single-row,’’ ‘‘double-row,’’ and ‘‘rotator cuff.’’ The following
databases were searched: MEDLINE (1950 to July 2012),
EMBASE (1980 to July 2012), and Ovid (1982 to July 2012). The
references of the retrieved articles were also screened for any
potential studies. When necessary, the authors of the studies were
contacted for further information.
Eligibility criteria
Type of studies
All randomized controlled clinical trials (level I and II studies)
that reported on the outcome of single-row versus double-row
techniques in the treatment of rotator cuff tear were included.
Nonrandomized comparative clinical studies (level III evidence)
were excluded. Reviews, case series, expert opinions, and editorial
pieces (level IV and V studies) were also excluded. Studies that
reported only nonclinical outcome measures or were in vitro and
animal studies were also excluded.
Type of subjects
Studies enrolling human subjects of all ages with rotator cuff tears
that were unilaterally or bilaterally undergoing arthroscopic rotator cuff repair were eligible for inclusion. We excluded trials or
studies of patients with congenital deformities, patients with other
systemic diseases (like cardiovascular disease and neurologic
disorders), and animals or cadavers.
Type of interventions
The experimental intervention was a double-row repair technique.
All repair techniques were included. The control intervention was a
single-row repair technique. Studies comparing the double-row
technique with another intervention but not with the single-row
technique were excluded. Studies comparing the double-row technique with another intervention and with the single-row technique
were included if the groups could be analyzed separately.
Types of outcome measures
The outcomes included the UCLA (University of California, Los
Angeles) score,8 ASES (American Shoulder and Elbow Surgeons)
score,25 Constant score,6 ROM of the shoulder (including internal
and external rotation, flexion and abduction, and forward elevation), muscle strength, and re-tear rate. A standard universal
goniometer was used for measurement of ROM. In the study
conducted by Franceschi et al,10 an examining couch was used to
obtain the measurement of ROM at 90 of abduction in the
scapular plane (approximately 15 anterior to the coronal plane),
Subgroups
The included subjects were divided into 2 groups according to the
tear size described in the original articles. The small and mediumsize tear (subgroup 1) was defined as a tear <30 mm evaluated by
magnetic resonance imaging (MRI) in the anteroposterior
dimension preoperatively; the large or massive-size tear (subgroup
2) was defined as a tear >30 mm. In each subgroup, all clinical
outcomes were integrated and compared.
Study selection
From the titles and abstracts, two independent reviewers selected
relevant studies for full review. For inclusion in the analysis, two
reviewers (C.X. and D.L.) analyzed the full articles using the
previously mentioned criteria independently. The reviewers were
not blinded to the author of the studies or the journal in which the
studies were published.
Data collection and statistical methods
The data were extracted by two authors (C.X. and D.L.) independently, and the data were analyzed for a meta-analysis. The data
were pooled, and a meta-analysis was performed by the use of
RevMan software (Review Manager Version 5.1.6, Copenhagen:
The Nordic Cochrane Centre, The Cochrane Collaboration, 2011).
Continuous data (UCLA, ASES, and Constant scores and
ROM) were reported as standardized mean differences. Dichotomous data (re-tear rate) were reported as risk ratios by the use of a
random or fixed effect model. Heterogeneity was assessed by use
of I2. An I2 of less than 60% was the cutoff for homogeneity of the
data, justifying pooling. A fixed effects model was applied when
the included studies were assessed to be homogeneous; a randomized effect model was applied when they were heterogeneous.
Results
Study selection
The electronic search produced the following hits: 103
from MEDLINE, 114 from EMBASE, and 133 from Ovid.
After the removal of duplicates and exclusion by a first
screening based on the titles and eligibility criteria, 150
records remained. Of these, 104 were excluded on the basis
of their abstracts and exclusion criteria, and 37 were
excluded on the basis of the eligibility criteria. Nine
studies1,3-5,10,12,15,17,20 were included in the meta-analysis.
Study characteristics
A total of 651 subjects were included in 9 studies (Table I);
5 studies were randomized prospective trials (evidence
184
Table I
C. Xu et al.
Characteristics of included studies
Aydin1 (2010)
Burks3 (2009)
Carbonel4 (2012)
Charousset5 (2007)
Franceschi10 (2007)
Grasso12 (2009)
Koh15 (2011)
Ma17 (2012)
Park20 (2008)
Age (years)
Sex (M/F)
No. of
patients
No. of suture
anchors
Follow-up period
(months)
Evidence
level
SR, 59 (40-69)
DR, 57 (36-67)
SR, 56 (43-74)
DR, 57 (41-81)
SR, 55.79 6.3
DR, 55.21 5.0
SR, 58 (32-74)
DR, 60 (37-62)
SR, 63.5 (43-76)
DR, 59.6 (45-80)
SR, 58.3 10.3
DR, 55.2 6.5
SR, 61.6 8.8
DR, 61.1 9.1
SR, 60.8 (47-80)
DR, 61.6 (40-72)
SR, 57 (39-78)
DR, 54.4 (28-76)
Not reported
SR, 34
DR, 34
SR, 20
DR, 20
SR, 80
DR, 80
SR, 35
DR, 31
SR, 26
DR, 26
SR, 37
DR, 35
SR, 31
DR, 31
SR, 27
DR, 26
SR, 40
DR, 38
SR, 1-3
DR, 1-3
SR, 2.25
DR, 3.2
SR, 1.83 (1-3)
DR, 2.99 (2-4)
SR, 1-4
DR, 2-4
SR, 1.9 (1-2)
DR, 2.3 (2-4)
SR, 1-2
DR, 2-5
Not reported
12
II
12
I
24
I
28.7 (24-40)
II
22.5 (18-25)
I
24.8 (22.4-26.2)
I
SR, 31.0 6.2
DR, 32.8 6.4
SR, 33.3 (24-42)
DR, 33.5 (24-42)
25.1 (22-30)
I
Not reported
SR, 35/45
DR, 33/47
SR, 15/20
DR, 16/15
SR, 12/14
DR, 16/10
SR, 16/21
DR, 18/17
SR, 9/22
DR, 11/20
SR, 15/12
DR, 14/12
SR, 20/20
DR, 22/16
SR, 2.37 (2-4)
DR, 3.38 (3-5)
SR, 1-3
DR, 2-6
II
II
SR, single row; DR, double row.
Table II
Reporting of tear size and outcomes per included study
Tear size
Aydin1
(2010)
Burks3
(2009)
Carbonel4
(2012)
Charousset5
(2007)
Franceschi10
(2007)
Grasso12
(2009)
Koh15 (2011)
Ma17 (2012)
Park20 (2008)
UCLA
score
Constant
score
ASES
score
Retear
rate
Range of motion and muscle strength
Internal
rotation
External
rotation
O
O
(Nm)
O
(degree)
O
(Nm)
O
(degree)
O
(degree)
O
(degree)
Elevation
Flexion
Abduction
O
(degree)
O
(degree)
O
NR
NR
O
O
O
10-30 mm
30-50 mm
NR
O
O
O
>30 mm
O
O
O
O
O
(degree)
O
NR
20-40 mm
O
<30
>30
<30
>30
O
mm
mm
mm
mm
O
O
O
(lb)
O
O
O
O
O
O
(degree)
O
(SSI)
O
(degree)
O
(kg)
O
(SSI)
O
(degree)
O
(kg)
O
(SSI)
NR, not reported; UCLA, University of California, Los Angeles; ASES, American Shoulder and Elbow Surgeons; SSI, Shoulder Strength Index; N.m, newtonmetres.
level I), and the other 4 were evidence level II studies. The
mean age of the subjects in the included studies was between 55.2 and 63.5 years. The mean follow-up time
ranged from 12 to 42 months. The reported outcomes
varied among the included studies (Table II).
Shoulder outcome scores
Constant score
The Constant scores at the final follow-up were reported in
7 studies,1,3-5,12,15,20 2 of which divided all subjects into 2
Meta-analysis comparing single-row and double-row repair
185
Figure 1 Forest plots of overall functional outcomes and re-tear rate. (A) Mean difference and 95% CIs of Constant score. (B) Mean
difference and 95% CIs of UCLA score. (C) Mean difference and 95% CIs of ASES score. (D) Risk ratio and 95% CIs of re-tear rate. IV,
inverse variance statistical method; M-H, Mantel-Haenszel statistical method.
Figure 2 Forest plots of functional outcomes in two subgroups. (A) Mean difference and 95% CIs of Constant score in subgroup 1. (B)
Mean difference and 95% CIs of Constant score in subgroup 2. (C) Mean difference and 95% CIs of UCLA score in subgroup 1. (D) Mean
difference and 95% CIs of UCLA score in subgroup 2. (E) Mean difference and 95% CIs of ASES score in subgroup 1. (F) Mean difference
and 95% CIs of ASES score in subgroup 2. IV, inverse variance statistical method.
subgroups according to tear size.4,20 This meta-analysis did
not show statistically significant differences between the
single-row technique and the double-row technique, with a
mean difference of 0.31 (95% CI, 2.71 to 2.09) (Fig. 1,
A). The same outcomes were shown in the integration of the
subgroups (subgroup 1: mean difference, 0.23; 95% CI,
1.78 to 1.31; subgroup 2: mean difference, 2.41; 95%
CI, 1.95 to 6.76) (Fig. 2, A, B).
UCLA score
The UCLA score was documented in 5 studies,3,4,10,15,17 and
3 of them4,10,17 had subgroups. Although the double-row
186
C. Xu et al.
Figure 3 Forest plots of overall ROM and muscle strength. (A) Mean difference and 95% CIs of internal rotation ROM. (B) Mean
difference and 95% CIs of external rotation ROM. (C) Mean difference and 95% CIs of forward elevation ROM. (D) Mean difference and
95% CIs of abduction muscle strength. (E) Mean difference and 95% CIs of internal rotation muscle strength. (F) Mean difference and 95%
CIs of external rotation muscle strength. IV, inverse variance statistical method.
group had a higher score than that of the single-row group, no
statistically significant difference was identified (mean difference, 0.64; 95% CI, 0.22 to 1.50) (Fig. 1, B). The same
outcome was shown in subgroup 1 (tear size < 30 mm), with
mean difference of 0.54 (95% CI, 2.98 to 1.90) (Fig. 2, C).
However, in subgroup 2 (tear size > 30 mm), this study
favored double-row techniques, which had a statistically
significant difference compared with single-row techniques
(mean difference, 1.48; 95% CI, 0.44 to 2.51) (Fig. 2, D).
ASES score
Five studies3,4,15,17,20 compared the ASES score at the final
follow-up. This meta-analysis showed that the double-row
repair group had a statistically significant functional
elevation compared with the single-row repair group, with a
mean difference of 1.22 (95% CI, 0.39 to 2.05) (Fig. 1, C).
In the subgroups comparison, the same result was found in
subgroup 2 (tear size > 30 mm),4,17,20 with a mean difference of 2.08 (95% CI, 0.84 to 3.32) (Fig. 2, F); nevertheless, in subgroup 1 (tear size < 30 mm), the 2 repair
techniques had no statistically significant difference (mean
difference, 1.09; 95% CI, 0.94 to 3.11) (Fig. 2, E).
MRI (anteroposterior tear dimension) was used to evaluate the tear after operations. Several radiographic manifestations indicated that the re-tear happened after
operation, including fat saturation, tendon torn away from
reattachment site, and incomplete coverage of footprint.
The pooled results showed an incidence of 30 of 126
(23.8%) in the double-row repair group and 53 of 132
(40.2%) in the single-row repair group (risk ratio, 0.59;
95% CI, 0.41 to 0.86), which was a statistically significant
difference (Fig. 1, D).
Range of motion
Three studies4,10,15 described the range of internal rotation,
external rotation, and forward elevation. Our analysis
showed a statistically significant difference in internal rotation with double-row repair (mean difference, 1.64; 95% CI,
1.00 to 2.29), but no statistically significant differences in
external rotation (mean difference, 0.76; 95% CI, 0.31 to
1.83) or forward elevation (mean difference, 0.25; 95% CI,
13.08 to 13.58) were detected (Fig. 3, A-C).
Muscle strength
Re-tear rate
3,5,10,15,17
Five studies
reported the re-tear rate of the rotator
cuff postoperatively. Coronal T1-weighted or T2-weighted
Four studies3,12,17,20 documented the muscle strength of
abduction, internal rotation, and external rotation preoperatively and postoperatively with different measurement
Meta-analysis comparing single-row and double-row repair
187
methods. Therefore, we used the standardized mean differences to compare these scales by measuring the same
outcome. No statistically significant differences were
shown in the abduction strength (mean difference, 0.08;
95% CI, 0.38 to 0.54), internal rotation strength (mean
difference, 0.04; 95% CI, 0.40 to 0.32), or external
rotation strength (mean difference, 0.20; 95% CI, 0.50
to 0.11) between the groups (Fig. 3, D-F).
have a significantly lower re-tear rate compared with
single-row repair techniques, which may be mainly due to a
higher and tighter contact of the tendon-bone interface and
lower gap formation. Rotator cuff repair aims to provide
tendon fixation secure enough to hold the repaired tendons
in place until biologic healing is established. Several factors
may be implicated in failure of rotator cuff repairs,
including suture or knot failure, inadequate tendon-to-bone
fixation, and lack of tendon-to-bone healing. In addition,
follow-up time is an important aspect for evaluation of
these results, but it is a fact about which there is no clear
consensus.
Double-row repair showed a significantly greater internal rotation ROM, but no significant difference was
detected for forward flexion or external rotation. However,
a small mean difference in external rotation may not indicate any clinically significant difference.
Different methods of muscle strength measurement were
documented in each of 4 studies. Burks et al3 described
muscle strength with the Lafayette manual muscle test
system (model 01163; Lafayette Instrument, Lafayette, IN,
USA). Grasso et al12 used a digital dynamometer (in
pounds). Park et al20 used the Shoulder Strength Index to
compare muscle strength. Ma et al17 favored a myometer
(in kilograms; Mecmesin, Nottingham, UK). No significant
differences were detected in the abduction, internal rotation, or external rotation muscle strength between the repair
techniques.
This meta-analysis has some limitations. Only 9 studies
were analyzed, and low numbers of patients were selected
for inclusion. There were differences in the study designs,
surgical techniques, outcome measurement methods, and
follow-up times to outcome evaluation. Although this metaanalysis showed a difference between single-row and
double-row repair in patient-reported outcomes, we were
unable to detect differences for radiologic findings (e.g.,
MRI follow-up postoperatively). Lack of common objective outcome measurements and different follow-up periods
(from 12 months to 24 months) were also a limitation to
this meta-analysis. Several muscle strength measurement
techniques were available and reviewed by the authors,
which was a limitation to the present analysis. In the future,
we recommend more sufficiently powered randomized
studies comparing single-row and double-row repair with
standardized measurement techniques, follow-up periods,
and repair procedures focused on clinical findings.
Discussion
The goals of rotator cuff repair are to achieve an initial fixation strength, to minimize the gap formation, to maintain the
mechanical stability, and to optimize the biologic tendonbone healing.24 Many surgical techniques have been developed to achieve these goals. Among them, transosseous
repairs are proven to have the highest load resistance and the
lowest gap formation.13 Double-row rotator cuff repairs,
using a ‘‘transosseous-equivalent technique,’’ have been
designed to achieve an initial fixation strength that is comparable to that of open or mini-open transosseous repair.
Several biomechanical studies comparing single-row and
double-row repair show an increased load to failure,
improved contact at the tendon-bone interface, and decreased
gap formation2,9,14,16,18,21,22,26 with double repairs.
Although the number of included studies was small,
these 9 studies were assessed as having a moderate to high
level of evidence. All 5 randomized controlled trials3,4,10,12,15 had an adequate allocation concealment technique. A variety of tear shapes, tear sizes, and gradings of
the tear size were noted in some studies. It is difficult to
avoid performance bias because of the other pathologic
processes seen in the shoulder. All studies followed up the
patients for at least a 12-month period.
Seven studies1,3-5,12,15,20 preferred the Constant score to
assess shoulder function. This meta-analysis shows no
significant clinical outcome difference for the repair techniques, even within the subgroups and using the UCLA
score,3,4,10,15,17 which is similar to the results of many
previous studies. However, with use of the ASES
score,3,4,15,17,20 the double-row techniques show advantages
over the single-row techniques. Moreover, in subgroup 2
(tear size > 30 mm), double-row repairs have a statistically
significant improved functional outcome in their UCLA and
ASES scores. Although the Constant score showed no
significant difference between single-row and double-row
rotator cuff repair, the functional score can still be widely
used in clinical assessment after shoulder surgery.
There are 5 studies3,5,10,15,17 describing the postoperative tendon repair integrity. One study, by Charousset
et al,5 used computed tomographic arthrography in combination with MRI examination to determine the tendon
integrity, but the others used MRI evaluation. A re-tear is
defined as a partial-thickness or full-thickness tear postoperatively. In this analysis, double-row repair techniques
Conclusion
Despite the fact that double-row rotator cuff repair
techniques have a significantly lower re-tear rate, higher
ASES score, and greater ROM of internal rotation, there
is no difference in the improvement in the Constant
score, UCLA score, ROM of forward elevation and
188
external rotation, or muscle strength. Larger tears
(>30 mm) show statistically significant improved
functional outcomes with double-row repairs.
Acknowledgment
To Dr. Ignacio Carbonel, Hospital Universitario Miguel
Servet, Zaragoza, Spain, for his extraordinary work and
generosity of providing original data to us for this metaanalysis.
C. Xu et al.
11.
12.
13.
14.
15.
Disclaimer
The authors, their immediate families, and any research
foundation 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.
16.
17.
18.
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