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Single-Row Versus Double-Row Rotator Cuff Repair: The Controversy Continues

2011; Elsevier BV; Volume: 27; Issue: 7 Linguagem: Inglês

10.1016/j.arthro.2011.03.081

1526-3231

James H. Lubowitz, Matthew T. Provencher, Gary G. Poehling,

Cardiac Valve Diseases and Treatments

In this issue, among the many fine articles, readers will find a meta-analysis, “Single-row repair versus double-row repair of full-thickness rotator cuff tears,” by Prasathaporn, Kuptniratsaikul, and Kongrukgreatiyos of Chulalongkorn University in Bangkok.1Prasathaporn N. Kuptniratsaikul S. Kongrukgreatiyos K. Single-row repair versus double-row repair of full-thickness rotator cuff tears.Arthroscopy. 2011; 27: 978-985Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar The topic of single- versus double-row repair remains controversial in Arthroscopy and has engendered editorials,2Lubowitz J.H. Poehling G.G. Arthroscopic rotator cuff repair: Onward the row.Arthroscopy. 2007; 23 (editorial): 571-572Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 3Lubowitz J.H. Poehling G.G. Two on the fast track: Arthroscopic rotator cuff repair and subacromial decompression with coracoacromial ligament excision.Arthroscopy. 2009; 25 (editorial): 2-3Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 4Lubowitz J.H. Poehling G.G. Rotator cuff repair: Obviously.Arthroscopy. 2010; 26 (editorial): 293-294Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 5Lubowitz J.H. Poehling G.G. Controversy in Arthroscopy: Bring it on.Arthroscopy. 2010; 26 (editorial): 573-574Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 6Lubowitz J.H. Poehling G.G. Shoulder arthroscopy: Evolution of the revolution.Arthroscopy. 2009; 25 (editorial): 823-824Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar copious clinical7Brady P.C. Arrigoni P. Burkhart S.S. Evaluation of residual rotator cuff defects after in vivo single- versus double-row rotator cuff repairs.Arthroscopy. 2006; 22: 1070-1075Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 8Grasso 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. 2009; 25: 4-12Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar, 9Yamakado K. Katsuo S. Mizuno K. Arakawa H. Hayashi S. Medial-row failure after arthroscopic double-row rotator cuff repair.Arthroscopy. 2010; 26: 430-435Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 10Wall L.B. Keener J.D. Brophy R.H. Clinical outcomes of double-row versus single-row rotator cuff repairs.Arthroscopy. 2009; 25: 1312-1318Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 11Arrigoni P. Brady P.C. Burkhart S.S. The double-pulley technique for double-row rotator cuff repair.Arthroscopy. 2007; 23: 675.e1-675.e4Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 12Trantalis J.N. Boorman R.S. Pletsch K. Lo I.K.Y. Medial rotator cuff failure after arthroscopic double-row rotator cuff repair.Arthroscopy. 2008; 24: 727-731Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 13Lo I.K.Y. Burkhart S.S. Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff.Arthroscopy. 2003; 19: 1035-1042Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar, 14Sugaya H. Maeda K. Matsuki K. Moriishi J. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: Single-row versus dual-row fixation.Arthroscopy. 2005; 21: 1307-1316Abstract Full Text Full Text PDF PubMed Scopus (611) Google Scholar, 15Nho S.J. Ghodadra N. Provencher M.T. Reiff S. Romeo A.A. Anatomic reduction and next-generation fixation constructs for arthroscopic repair of crescent, L-shaped, and U-shaped rotator cuff tears.Arthroscopy. 2009; 25: 553-559Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 16Park M.C. ElAttrache N.S. Ahmad C.S. Tibone J.E. “Transosseous-equivalent” rotator cuff repair technique.Arthroscopy. 2006; 22: 1360.e1-1360.e5Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar, 17Toussaint B. Schnaser E. Lafosse L. Bahurel J. Gobezie R. A new approach to improving the tissue grip of the medial-row repair in the suture-bridge technique: The “modified lasso-loop stitch.”.Arthroscopy. 2009; 25: 691-695Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 18Kim K.-C. Rhee K.-J. Shin H.-D. Deformities associated with the suture-bridge technique for full-thickness rotator cuff tears.Arthroscopy. 2008; 24: 1251-1257Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 19Lafosse L. Baier G.P. Jost B. Footprint fixation for arthroscopic reconstruction in anterior shoulder instability: The Cassiopeia double-row technique.Arthroscopy. 2006; 22: 231.e1-231.e6Abstract Full Text Full Text PDF Scopus (33) Google Scholar, 20Pennington W.T. Gibbons D.J. Bartz B.A. et al.Comparative analysis of single-row versus double-row repair of rotator cuff tears.Arthroscopy. 2010; 26: 1419-1426Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar and biomechanical21Lorbach O. Anagnostakos K. Vees J. Kohn D. Pape D. Three-dimensional evaluation of the cyclic loading behavior of different rotator cuff reconstructions.Arthroscopy. 2010; 26: S95-S105Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 22Barber F.A. Herbert M.A. Schroeder F.A. Aziz-Jacobo J. Mays M.M. Rapley J.H. Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs.Arthroscopy. 2010; 26: 316-323Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 23Burkhart S.S. Adams C.R. Burkhart S.S. Schoolfield J.D. A biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: The SwiveLock-FiberChain construct versus standard double-row repair.Arthroscopy. 2009; 25: 274-281Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 24Mahar A. Tamborlane J. Oka R. Esch J. Pedowitz R.A. Single-row suture anchor repair of the rotator cuff is biomechanically equivalent to double-row repair in a bovine model.Arthroscopy. 2007; 23: 1265-1270Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 25Spang J.T. Buchmann S. Brucker P.U. et al.A biomechanical comparison of 2 transosseous-equivalent double-row rotator cuff repair techniques using bioabsorbable anchors: Cyclic loading and failure behavior.Arthroscopy. 2009; 25: 872-879Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 26Pauly S. Kieser B. Schill A. Gerhardt C. Scheibel M. Biomechanical comparison of 4 double-row suture-bridging rotator cuff repair techniques using different medial-row configurations.Arthroscopy. 2010; 26: 1281-1288Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 27Leek B.T. Robertson C. Mahar A. Pedowitz R.A. Comparison of mechanical stability in double-row rotator cuff repairs between a knotless transtendon construct versus the addition of medial knots.Arthroscopy. 2010; 26: S127-S133Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 28Cole B.J. ElAttrache N.S. Anbari A. Arthroscopic rotator cuff repairs: An anatomic and biomechanical rationale for different suture-anchor repair configurations.Arthroscopy. 2007; 23: 662-669Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 29Peters K.S. Lam P.H. Murrell G.A.C. Repair of partial-thickness rotator cuff tears: A biomechanical analysis of footprint contact pressure and strength in an ovine model.Arthroscopy. 2010; 26: 877-884Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 30Barber F.A. Hapa O. Bynum J.A. Comparative testing by cyclic loading of rotator cuff suture anchors containing multiple high-strength sutures.Arthroscopy. 2010; 26: S134-S141Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 31Nelson C.O. Sileo M.J. Grossman M.G. Serra-Hsu F. Single-row modified mason-allen versus double-row arthroscopic rotator cuff repair: A biomechanical and surface area comparison.Arthroscopy. 2008; 24: 941-948Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar, 32Meier S.W. Meier J.D. The effect of double-row fixation on initial repair strength in rotator cuff repair: A biomechanical study.Arthroscopy. 2006; 22: 1168-1173Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar, 33Nho S.J. Yadav H. Pensak M. Dodson C.C. Good C.R. MacGillivray J.D. Biomechanical fixation in arthroscopic rotator cuff repair.Arthroscopy. 2007; 23: 94-102Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 34Mazzocca A.D. Bollier M.J. Obopilwe E. et al.Biomechanical evaluation of arthroscopic rotator cuff repairs over time.Arthroscopy. 2010; 26: 592-599Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 35Chu T. McDonald E. Tufaga M. Kandemir U. Buckley J. Ma C.B. Comparison of completely knotless and hybrid double-row fixation systems: A biomechanical study.Arthroscopy. 2011; 27: 479-485Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 36Wheeler D.J. Garabekyan T. Lugo R. et al.Biomechanical comparison of transosseous versus suture anchor repair of the subscapularis tendon.Arthroscopy. 2010; 26: 444-450Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar analyses, reviews,37Reardon D.J. Maffulli N. Clinical evidence shows no difference between single- and double-row repair for rotator cuff tears.Arthroscopy. 2007; 23: 670-673Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 38Nho S.J. Slabaugh M.A. Seroyer S.T. et al.Does the literature support double-row suture anchor fixation for arthroscopic rotator cuff repair? A systematic review comparing double-row and single-row suture anchor configuration.Arthroscopy. 2009; 25: 1319-1328Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 39Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar and passionate (and at times, some might say “heated”) letters to the editor.40Burks R. Study of rotator cuff repair techniques: We really are trying.Arthroscopy. 2010; 26 (letter): 1013-1015Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 41Park M.C. Ahmad C.S. ElAttrache N.S. Lee T.Q. Regarding biomechanical advantages of triple-loaded suture anchors.Arthroscopy. 2010; 26 (letter): 873-874Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 42Barber F.A. Aziz-Jacobo J. Rapley J.H. Herbert M.A. Schroeder F.A. Mays M.M. Authors' reply.Arthroscopy. 2010; 26 (letter): 874-876Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 43Burkhart S.S. Cole B.J. Authors' reply.Arthroscopy. 2010; 26 (letter): 1015-1017Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 44Maffulli N. Franceschi F. Longo U.G. Ruzzini L. Denaro V. Clinical evidence for suture anchor repair of rotator cuff tears does add up: Some just do not want to see it.Arthroscopy. 2010; 26 (letter): 1568-1569Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 45Cole B.J. Burkhart S.S. Authors' reply.Arthroscopy. 2010; 26 (letter): 1569-1570Abstract Full Text Full Text PDF Scopus (1) Google Scholar The meta-analysis by Prasathaporn et al.1Prasathaporn N. Kuptniratsaikul S. Kongrukgreatiyos K. Single-row repair versus double-row repair of full-thickness rotator cuff tears.Arthroscopy. 2011; 27: 978-985Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar continues the controversy. Purists assert that meta-analyses should include only scientific articles of Level I evidence for quantitative analysis and statistical synthesis.46Lubowitz J.H. Poehling G.G. Arthroscopy: The future.Arthroscopy. 2007; 23: 453-454Abstract Full Text Full Text PDF Scopus (13) Google Scholar Readers should note that Prasathaporn et al. include 3 Level I evidence studies (randomized controlled trials) and 2 Level II evidence studies (nonrandomized, prospective comparative studies); thus, some could consider this a systematic review rather than a true meta-analysis. Regardless of the semantics, Prasathaporn et al. report clear Level II evidence. Next, all studies have limitations. All research takes place at a specific point in time, and review articles are no exception. Readers should carefully note the inclusion and exclusion criteria that Prasathaporn et al. applied, and specifically note that the authors searched for and included articles published before September 2009. As Burks recently noted in his very original letter,40Burks R. Study of rotator cuff repair techniques: We really are trying.Arthroscopy. 2010; 26 (letter): 1013-1015Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar “In the rapidly moving field of orthopaedics, … we surgeons have already moved on.” In other words, since September 2009, additional clinical trials have been conducted, surgical techniques have evolved, and it is possible that as a result of this evolution, study conclusions published today, while accurate, may be different from what we may find in the future. Prasathaporn et al. meticulously note additional limitations of their systematic review: few studies and small numbers of patients are included. While meta-analytic methods combine patients from various studies to increase statistical power, when a study concludes that there is “no statistically significant difference between groups,” readers must ask, “Might there be beta error?” In other words, would inclusion of larger numbers of patients result in a statistical difference? Additional limitations of Prasathaporn et al. are common to most systematic reviews and meta-analyses. These limitations result from heterogeneity among the reported studies. The included studies differ in study design, surgical technique, reported outcome measures, and time to follow-up. All studies, even those of the highest quality and levels of evidence, have bias, and some study bias may be unavoidable. Nevertheless, Prasathaporn et al. confirm the conclusions (spoiler alert) of previously published reviews37Reardon D.J. Maffulli N. Clinical evidence shows no difference between single- and double-row repair for rotator cuff tears.Arthroscopy. 2007; 23: 670-673Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 38Nho S.J. Slabaugh M.A. Seroyer S.T. et al.Does the literature support double-row suture anchor fixation for arthroscopic rotator cuff repair? A systematic review comparing double-row and single-row suture anchor configuration.Arthroscopy. 2009; 25: 1319-1328Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar: “Despite the fact that double-row repair shows a significantly high rate of tendon healing and more external rotation than does single-row repair, there is no significantly improved shoulder function, muscle strength, forward flexion, internal rotation, patient satisfaction, or return to work.”1Prasathaporn N. Kuptniratsaikul S. Kongrukgreatiyos K. Single-row repair versus double-row repair of full-thickness rotator cuff tears.Arthroscopy. 2011; 27: 978-985Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar The conclusions stated above must be considered in the context of the limitations, and in the context of the passionate and, some might say contentious, letters.40Burks R. Study of rotator cuff repair techniques: We really are trying.Arthroscopy. 2010; 26 (letter): 1013-1015Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 41Park M.C. Ahmad C.S. ElAttrache N.S. Lee T.Q. Regarding biomechanical advantages of triple-loaded suture anchors.Arthroscopy. 2010; 26 (letter): 873-874Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 42Barber F.A. Aziz-Jacobo J. Rapley J.H. Herbert M.A. Schroeder F.A. Mays M.M. Authors' reply.Arthroscopy. 2010; 26 (letter): 874-876Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 43Burkhart S.S. Cole B.J. Authors' reply.Arthroscopy. 2010; 26 (letter): 1015-1017Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 44Maffulli N. Franceschi F. Longo U.G. Ruzzini L. Denaro V. Clinical evidence for suture anchor repair of rotator cuff tears does add up: Some just do not want to see it.Arthroscopy. 2010; 26 (letter): 1568-1569Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 45Cole B.J. Burkhart S.S. Authors' reply.Arthroscopy. 2010; 26 (letter): 1569-1570Abstract Full Text Full Text PDF Scopus (1) Google Scholar According to Burkhart and Cole,39Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar “second-generation double-row repair techniques that use bridging sutures to link the 2 rows of suture anchors together in a self-reinforcing manner, are producing superior clinical and biomechanical results.” Burkhart and Cole presented Level V evidence and made a compelling argument that future research, using state-of-the-art double-row techniques, will confirm that double-row rotator cuff tear is superior. According to Burks' most memorable letter40Burks R. Study of rotator cuff repair techniques: We really are trying.Arthroscopy. 2010; 26 (letter): 1013-1015Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar: “I do not believe that there is always a one-size-fits-all approach for every situation. I have to disagree with Burkhart and Cole, and I do not think we should apologize for techniques that work and happen to be less expensive and may be easier to do as well. We need to use our best assessment of the patient, tear pattern, tissue and bone quality, and so on, and do the repair that is considered to be best in that situation. Undoubtedly, there are times when different approaches might seem to be the most appropriate in a given case. I wish we spent more time discussing enhancing biology, improving rehabilitation, and evaluating outcomes uniformly and seeing their impact on quality of health at this point. Let's encourage science, promote even better studies, and better help our patients, displacing our opinions from the discussion. The healthy debate, for example, on single-bundle versus double-bundle anterior cruciate ligament reconstruction has studies that support both sides. Only over time can we gain a balance of what is probably true for most surgeries done by most surgeons. As I like to say, though, this is all just one man's humble opinion.” And as for your Editors? We still say: Controversy in Arthroscopy? Bring it on.5Lubowitz J.H. Poehling G.G. Controversy in Arthroscopy: Bring it on.Arthroscopy. 2010; 26 (editorial): 573-574Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar We recommend that readers review the cited letters, study the strong work by Prasathaporn et al., considering its many strengths as well as its limitations, and reach their own educated and considered opinions. We continue to encourage researchers to pursue adequately powered, comparative studies of the highest levels of evidence, so that some day controversy might be supplanted by consensus. In the interim, we continue to encourage letters to the editor, with our usual rejoinder, well worth repeating: Controversy … Bring It On. Can We Detect a Clinical Difference?ArthroscopyVol. 27Issue 12PreviewI read with interest the article by Prasathaporn et al.1 and the accompanying editorial2 in the July 2011 issue of Arthroscopy, having recently published a nearly identical meta-analysis of single- versus double-row rotator cuff repairs that reached essentially identical conclusions regarding clinical and imaging results.3 I completely agree with the point that we may still be failing to detect a clinical difference between these repair methods because of a β error, and, for that reason, my co-investigators and I included a power analysis to determine the sample size necessary to detect a desired effect using the standard deviations found in the same 5 studies included by Prasathaporn et al. Full-Text PDF