Does the Use of Knotted Versus Knotless Transosseous Equivalent Rotator Cuff Repair Technique Influence the Incidence of Retears? A Systematic Review

Published:February 10, 2020DOI:


      To compare knotted and knotless transosseous equivalent (TOE) rotator cuff repair (RCR) techniques and evaluate their imaging-diagnosed retear rates.


      The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008 to 2019), EMBASE (2008 to 2019), and Medline (2008 to 2019) were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, with the following search terms: rotator cuff repair AND (knotless OR knotted) AND transosseous; rotator cuff repair AND (knotless OR knotted or transosseous); rotator cuff repair AND (“suture bridge” OR “suture bridging”). Data pertaining to demographic characteristics, surgical techniques, retears, and patient-reported outcomes were extracted from each study. Rates and locations of retear were reported using ranges, and risks of bias and heterogeneity for each study were assessed.


      A total of 7 studies (552 shoulders) were included. Patients had a weighted mean (± standard deviation) age of 60.5 ± 2.4 years with 27.8 ± 7.9-month follow-up. The incidence of retears ranged from 5.1% to 33.3% in patients treated with knotless TOE RCR, and the incidence for patients treated with knotted TOE RCR ranged from 7.5% to 25%. The incidence of type I retears ranged from 42.9% to 100% for patients treated with knotless TOE RCR and 20% to 100% for patients treated with knotted TOE RCR. The incidence of type II retears ranged from 0% to 57.1% in patients treated with knotless TOE RCR and 0% to 100% in patients treated with knotted TOE RCR.


      The incidence and location of retears after knotless and knotted TOE RCR appear to be similar.
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        • Chona D.V.
        • Lakomkin N.
        • Lott A.
        • et al.
        The timing of retears after arthroscopic rotator cuff repair.
        J Shoulder Elbow Surg. 2017; 26: 2054-2059
        • Yang Jr., J.
        • Robbins M.
        • Reilly J.
        • Maerz T.
        • Anderson K.
        The clinical effect of a rotator cuff retear: A Meta-analysis of arthroscopic single-row and double-row repairs.
        Am J Sports Med. 2017; 45: 733-741
        • McElvany M.D.
        • McGoldrick E.
        • Gee A.O.
        • Neradilek M.B.
        • Matsen 3rd, F.A.
        Rotator cuff repair: Published evidence on factors associated with repair integrity and clinical outcome.
        Am J Sports Med. 2015; 43: 491-500
        • Park M.C.
        • Elattrache N.S.
        • Ahmad C.S.
        • Tibone J.E.
        “Transosseous-equivalent” rotator cuff repair technique.
        Arthroscopy. 2006; 22 (1360.e1361-1365)
        • Park M.C.
        • ElAttrache N.S.
        • Tibone J.E.
        • Ahmad C.S.
        • Jun B.J.
        • Lee T.Q.
        Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique.
        J Shoulder Elbow Surg. 2007; 16: 461-468
        • Park M.C.
        • Tibone J.E.
        • ElAttrache N.S.
        • Ahmad C.S.
        • Jun B.J.
        • Lee T.Q.
        Part II: Biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique.
        J Shoulder Elbow Surg. 2007; 16: 469-476
        • Hein J.
        • Reilly J.M.
        • Chae J.
        • Maerz T.
        • Anderson K.
        Retear rates after arthroscopic single-row, double-row, and suture bridge rotator cuff repair at a minimum of 1 year of imaging follow-up: A systematic review.
        Arthroscopy. 2015; 31: 2274-2281
        • Cho N.S.
        • Yi J.W.
        • Lee B.G.
        • Rhee Y.G.
        Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique.
        Am J Sports Med. 2010; 38: 664-671
        • Kaplan K.
        • ElAttrache N.S.
        • Vazquez O.
        • Chen Y.J.
        • Lee T.
        Knotless rotator cuff repair in an external rotation model: The importance of medial-row horizontal mattress sutures.
        Arthroscopy. 2011; 27: 471-478
        • Vaishnav S.
        • Millett P.J.
        Arthroscopic rotator cuff repair: Scientific rationale, surgical technique, and early clinical and functional results of a knotless self-reinforcing double-row rotator cuff repair system.
        J Shoulder Elbow Surg. 2010; 19: 83-90
        • Barber F.A.
        • Drew O.R.
        A biomechanical comparison of tendon-bone interface motion and cyclic loading between single-row, triple-loaded cuff repairs and double-row, suture-tape cuff repairs using biocomposite anchors.
        Arthroscopy. 2012; 28: 1197-1205
        • Burkhart 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: 274-281
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
        • Harris J.D.
        • Quatman C.E.
        • Manring M.M.
        • Siston R.A.
        • Flanigan D.C.
        How to write a systematic review.
        Am J Sports Med. 2014; 42: 2761-2768
        • Davidson J.
        • Burkhart S.S.
        The geometric classification of rotator cuff tears: A system linking tear pattern to treatment and prognosis.
        Arthroscopy. 2010; 26: 417-424
        • Patte D.
        Classification of rotator cuff lesions.
        Clin Orthop Relat Res. 1990; : 81-86
        • Wright J.G.
        • Swiontkowski M.F.
        • Heckman J.D.
        Introducing levels of evidence to the journal.
        J Bone Joint Surg Am. 2003; 85: 1-3
        • Stuck A.E.
        • Rubenstein L.Z.
        • Wieland D.
        Bias in meta-analysis detected by a simple, graphical test. Asymmetry detected in funnel plot was probably due to true heterogeneity.
        BMJ. 1998; 316 (author reply 470-461): 469
        • Galbraith R.F.
        A note on graphical presentation of estimated odds ratios from several clinical trials.
        Stat Med. 1988; 7: 889-894
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Boyer P.
        • Bouthors C.
        • Delcourt T.
        • et al.
        Arthroscopic double-row cuff repair with suture-bridging: A structural and functional comparison of two techniques.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 478-486
        • Honda H.
        • Gotoh M.
        • Mitsui Y.
        • et al.
        Clinical and structural outcomes after arthroscopic rotator cuff repair: A comparison between suture bridge techniques with or without medial knot tying.
        J Orthop Surg Res. 2018; 13: 297
        • Kim K.C.
        • Shin H.D.
        • Lee W.Y.
        • Yeon K.W.
        • Han S.C.
        Clinical outcomes and repair integrity of arthroscopic rotator cuff repair using suture-bridge technique with or without medial tying: Prospective comparative study.
        J Orthop Surg Res. 2018; 13: 212
        • Hug K.
        • Gerhardt C.
        • Haneveld H.
        • Scheibel M.
        Arthroscopic knotless-anchor rotator cuff repair: A clinical and radiological evaluation.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 2628-2634
        • Lee S.H.
        • Kim J.W.
        • Kim T.K.
        • et al.
        Is the arthroscopic suture bridge technique suitable for full-thickness rotator cuff tears of any size?.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2138-2146
        • Rhee Y.G.
        • Cho N.S.
        • Parke C.S.
        Arthroscopic rotator cuff repair using modified Mason-Allen medial row stitch: Knotless versus knot-tying suture bridge technique.
        Am J Sports Med. 2012; 40: 2440-2447
        • Millett P.J.
        • Espinoza C.
        • Horan M.P.
        • et al.
        Predictors of outcomes after arthroscopic transosseous equivalent rotator cuff repair in 155 cases: A propensity score weighted analysis of knotted and knotless self-reinforcing repair techniques at a minimum of 2 years.
        Arch Orthop Trauma Surg. 2017; 137: 1399-1408
        • Trantalis J.N.
        • Boorman R.S.
        • Pletsch K.
        • Lo I.K.
        Medial rotator cuff failure after arthroscopic double-row rotator cuff repair.
        Arthroscopy. 2008; 24: 727-731
        • Mazzocca A.D.
        • Millett P.J.
        • Guanche C.A.
        • Santangelo S.A.
        • Arciero R.A.
        Arthroscopic single-row versus double-row suture anchor rotator cuff repair.
        Am J Sports Med. 2005; 33: 1861-1868
        • Bedeir Y.H.
        • Schumaier A.P.
        • Abu-Sheasha G.
        • Grawe B.M.
        Type 2 retear after arthroscopic single-row, double-row and suture bridge rotator cuff repair: A systematic review.
        Eur J Orthop Surg Traumatol. 2019; 29: 373-382