Transosseous-Equivalent/Suture Bridge Arthroscopic Rotator Cuff Repair in Combination With Late Postoperative Mobilization Yield Optimal Outcomes and Retear Rate: A Network Meta-analysis of Randomized Controlled Trials


      The purpose of this study was to perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature in order to assess the evidence defining the optimal combination of surgical technique single-row repair (SRR), double-row repair (DRR), or transosseous-equivalent/suture bridge (TOE/SB) arthroscopic rotator cuff repair (ARCR) and postoperative rehabilitation (early or late) protocol for ARCR.


      The literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized SSR-early trials (RCTs) comparing SRR vs DRR vs TOE/SB ARCR techniques were included, as well as early vs late postoperative range of motion. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-score.


      Twenty-eight studies comprising 2,181 total shoulders met the inclusion criteria. TOE/SB-late (odds ratio [OR], 0.19; 95% confidence interval [CI], 0.08-0.46) and DRR-late (OR, 0.25; 95% CI, 0.12-0.52) were found to significantly reduce the rate of retear, with TOE/SB-late resulting in the highest P-score for the American Shoulder and Elbow Surgeons (P-score: 0.7911) score and retear rate (P-score: 0.8725). DRR-early did not result in any significant improvements over the SRR-early group, except in internal rotation. There was no significant difference in forward flexion between groups, with almost equivalent P-scores. Furthermore, TOE/SB-early and TOE/SB-late trended toward worsening external rotation compared with the control.


      The current study suggests that rotator cuff repair using the TOE/SB technique and late postoperative mobilization yields the highest functional outcomes and lowest retear rate in the arthroscopic management of symptomatic rotator cuff tears.

      Level of Evidence

      Level I, meta-analysis of Level I studies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jain N.B.
        • Higgins L.D.
        • Losina E.
        • Collins J.
        • Blazar P.E.
        • Katz J.N.
        Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States.
        BMC Musculoskelet Disord. 2014; 15: 4
        • 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
        • Neyton L.
        • Godeneche A.
        • Nove-Josserand L.
        • Carrillon Y.
        • Clechet J.
        • Hardy M.B.
        Arthroscopic suture-bridge repair for small to medium size supraspinatus tear: Healing rate and retear pattern.
        Arthroscopy. 2013; 29: 10-17
        • Galatz L.M.
        • Ball C.M.
        • Teefey S.A.
        • Middleton W.D.
        • Yamaguchi K.
        The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears.
        J Bone Joint Surg Am. 2004; 86: 219-224
        • Arndt J.
        • Clavert P.
        • Mielcarek P.
        • Bouchaib J.
        • Meyer N.
        • Kempf J.F.
        Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: A prospective randomized study.
        Orthop Traumatol Surg Res. 2012; 98: S131-S138
        • Cuff D.J.
        • Pupello D.R.
        Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol.
        J Shoulder Elbow Surg. 2012; 21: 1450-1455
        • Parsons B.O.
        • Gruson K.I.
        • Chen D.D.
        • Harrison A.K.
        • Gladstone J.
        • Flatow E.L.
        Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness?.
        J Shoulder Elbow Surg. 2010; 19: 1034-1039
        • Saltzman B.M.
        • Zuke W.A.
        • Go B.
        • et al.
        Does early motion lead to a higher failure rate or better outcomes after arthroscopic rotator cuff repair? A systematic review of overlapping meta-analyses.
        J Shoulder Elbow Surg. 2017; 26: 1681-1691
        • Howick J.
        • Chalmers I.
        • Glasziou P.
        • et al.
        The Oxford Levels of Evidence 2. Oxford Centre for Evidence-Based Medicine.
        (Accessed May 9, 2020)
        • Higgins J.P.T.
        • Altman D.G.
        • Gotzsche P.C.
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343 (d5928-d5928)
        • Aydin N.
        • Kocaoglu B.
        • Guven O.
        Single-row versus double-row arthroscopic rotator cuff repair in small- to medium-sized tears.
        J Shoulder Elbow Surg. 2010; 19: 722-725
        • Burks R.T.
        • Crim J.
        • Brown N.
        • Fink B.
        • Greis P.E.
        A prospective randomized clinical trial comparing arthroscopic single- and double-row rotator cuff repair: Magnetic resonance imaging and early clinical evaluation.
        Am J Sports Med. 2009; 37: 674-682
        • Carbonel I.
        • Martinez A.A.
        • Calvo A.
        • Ripalda J.
        • Herrera A.
        Single-row versus double-row arthroscopic repair in the treatment of rotator cuff tears: A prospective randomized clinical study.
        Int Orthop. 2012; 36: 1877-1883
        • Düzgün I.
        • Baltacı G.
        • Atay O.A.
        Comparison of slow and accelerated rehabilitation protocol after arthroscopic rotator cuff repair: Pain and functional activity.
        Acta Orthop Traumatol Turc. 2011; 45: 23-33
        • Franceschi F.
        • Ruzzini L.
        • Longo U.G.
        • et al.
        Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for rotator cuff tears: A randomized controlled trial.
        Am J Sports Med. 2007; 35: 1254-1260
        • Franceschi F.
        • Papalia R.
        • Franceschetti E.
        • et al.
        Double-row repair lowers the retear risk after accelerated rehabilitation.
        Am J Sports Med. 2016; 44: 948-956
        • Gartsman G.M.
        • Drake G.
        • Edwards T.B.
        • et al.
        Ultrasound evaluation of arthroscopic full-thickness supraspinatus rotator cuff repair: Single-row versus double-row suture bridge (transosseous equivalent) fixation. Results of a prospective, randomized study.
        J Shoulder Elbow Surg. 2013; 22: 1480-1487
        • Grasso 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: 4-12
        • Hantes M.E.
        • Ono Y.
        • Raoulis V.A.
        • et al.
        Arthroscopic single-row versus double-row suture bridge technique for rotator cuff tears in patients younger than 55 years: A prospective comparative study.
        Am J Sports Med. 2018; 46: 116-121
        • Heuberer P.R.
        • Pauzenberger L.
        • Gruber M.S.
        • et al.
        Delaminated rotator cuff tears showed lower short-term retear rates after arthroscopic double-layer repair versus bursal layer-only repair: A randomized controlled trial.
        Am J Sports Med. 2020; 48: 689-696
        • Jenssen K.K.
        • Lundgreen K.
        • Madsen J.E.
        • Kvakestad R.
        • Pripp A.H.
        • Dimmen S.
        No functional difference between three and six weeks of immobilization after arthroscopic rotator cuff repair: A prospective randomized controlled non-inferiority trial.
        Arthroscopy. 2018; 34: 2765-2774
        • Keener J.D.
        • Galatz L.M.
        • Stobbs-Cucchi G.
        • Patton R.
        • Yamaguchi K.
        Rehabilitation following arthroscopic rotator cuff repair: A prospective randomized trial of immobilization compared with early motion.
        J Bone Joint Surg Am. 2014; 96: 11-19
        • Koh K.H.
        • Kang K.C.
        • Lim T.K.
        • Shon M.S.
        • Yoo J.C.
        Prospective randomized clinical trial of single- versus double-row suture anchor repair in 2- to 4-cm rotator cuff tears: Clinical and magnetic resonance imaging results.
        Arthroscopy. 2011; 27: 453-462
        • Koh K.H.
        • Lim T.K.
        • Shon M.S.
        • Park Y.E.
        • Lee S.W.
        • Yoo J.C.
        Effect of immobilization without passive exercise after rotator cuff repair: Randomized clinical trial comparing four and eight weeks of immobilization.
        J Bone Joint Surg Am. 2014; 96: e44
        • Kim K.C.
        • Shin H.D.
        • Cha S.M.
        • Lee W.Y.
        Comparison of repair integrity and functional outcomes for 3 arthroscopic suture bridge rotator cuff repair techniques.
        Am J Sports Med. 2013; 41: 271-277
        • Lapner P.L.
        • Sabri E.
        • Rakhra K.
        • et al.
        A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair.
        J Bone Joint Surg Am. 2012; 94: 1249-1257
        • Lee B.G.
        • Cho N.S.
        • Rhee Y.G.
        Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: Aggressive versus limited early passive exercises.
        Arthroscopy. 2012; 28: 34-42
        • Ma H.L.
        • Chiang E.R.
        • Wu H.T.
        • et al.
        Clinical outcome and imaging of arthroscopic single-row and double-row rotator cuff repair: A prospective randomized trial.
        Arthroscopy. 2012; 28: 16-24
        • Ma H.H.
        • Chen K.H.
        • Chiang E.R.
        • Chou T.A.
        • Ma H.L.
        Does arthroscopic suture-spanning augmentation of single-row repair reduce the retear rate of massive rotator cuff tear?.
        Am J Sports Med. 2019; 47: 1420-1426
        • Nicholas S.J.
        • Lee S.J.
        • Mullaney M.J.
        • et al.
        Functional outcomes after double-row versus single-row rotator cuff repair: A prospective randomized trial.
        Orthop J Sports Med. 2016; 4 (2325967116667398)
        • Park J.Y.
        • Lhee S.H.
        • Choi J.H.
        • Park H.K.
        • Yu J.W.
        • Seo J.B.
        Comparison of the clinical outcomes of single- and double-row repairs in rotator cuff tears.
        Am J Sports Med. 2008; 36: 1310-1316
        • Randelli P.
        • Stoppani C.A.
        • Zaolino C.
        • Menon A.
        • Randelli F.
        • Cabitza P.
        Advantages of arthroscopic rotator cuff repair with a transosseous suture technique: A prospective randomized controlled trial.
        Am J Sports Med. 2017; 45: 2000-2009
        • Sheps D.M.
        • Silveira A.
        • Beaupre L.
        • et al.
        Early active motion versus sling immobilization after arthroscopic rotator cuff repair: A randomized controlled trial.
        Arthroscopy. 2019; 35: 749-760.e742
        • Tirefort J.
        • Schwitzguebel A.J.
        • Collin P.
        • Nowak A.
        • Plomb-Holmes C.
        • Lädermann A.
        Postoperative mobilization after superior rotator cuff repair: Sling versus no sling: A randomized prospective study.
        J Bone Joint Surg Am. 2019; 101: 494-503
        • Yamakado K.
        A Prospective randomized trial comparing suture bridge and medially based single-row rotator cuff repair in medium-sized supraspinatus tears.
        Arthroscopy. 2019; 35: 2803-2813
        • Zafra M.
        • Uceda P.
        • Muñoz-Luna F.
        • Muñoz-López R.C.
        • Font P.
        Arthroscopic repair of partial-thickness articular surface rotator cuff tears: Single-row transtendon technique versus double-row suture bridge (transosseous equivalent) fixation: Results from a prospective randomized study.
        Arch Orthop Trauma Surg. 2020; 140: 1065-1071
        • Sugaya H.
        • Maeda K.
        • Matsuki K.
        • Moriishi J.
        Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: A prospective outcome study.
        J Bone Joint Surg Am. 2007; 89: 953-960
        • Meier 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: 1168-1173
        • Lo I.K.
        • Burkhart S.S.
        Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff.
        Arthroscopy. 2003; 19: 1035-1042
        • Burkhart S.S.
        • Cole B.J.
        Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.
        Arthroscopy. 2010; 26: 677-680
        • Park Y.B.
        • Park Y.E.
        • Koh K.H.
        • Lim T.K.
        • Shon M.S.
        • Yoo J.C.
        Subscapularis tendon repair using suture bridge technique.
        Arthrosc Tech. 2015; 4: e133-e137
        • 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
        • Fei W.
        • Guo W.
        A biomechanical and histological comparison of the suture bridge and conventional double-row techniques of the repair of full-thickness rotator cuff tears in a rabbit model.
        BMC Musculoskelet Disord. 2015; 16: 148
        • Nassos J.T.
        • ElAttrache N.S.
        • Angel M.J.
        • Tibone J.E.
        • Limpisvasti O.
        • Lee T.Q.
        A watertight construct in arthroscopic rotator cuff repair.
        J Shoulder Elbow Surg. 2012; 21: 589-596
        • 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
        • Mihata T.
        • Watanabe C.
        • Fukunishi K.
        • et al.
        Functional and structural outcomes of single-row versus double-row versus combined double-row and suture-bridge repair for rotator cuff tears.
        Am J Sports Med. 2011; 39: 2091-2098
        • Hatta T.
        • Giambini H.
        • Hooke A.W.
        • et al.
        Comparison of passive stiffness changes in the supraspinatus muscle after double-row and knotless transosseous-equivalent rotator cuff repair techniques: A cadaveric study.
        Arthroscopy. 2016; 32: 1973-1981
        • Franceschi F.
        • Papalia R.
        • Palumbo A.
        • Vasta S.
        • Maffulli N.
        • Denaro V.
        Management of postoperative shoulder stiffness.
        Sports Med Arthrosc Rev. 2011; 19: 420-427
        • Cofield R.H.
        Arthroscopy of the shoulder.
        Mayo Clin Proc. 1983; 58: 501-508
        • Neer II, C.S.
        • Craig E.V.
        • Fukuda H.
        Cuff-tear arthropathy.
        J Bone Joint Surg Am. 1983; 65: 1232-1244
        • Sonnabend D.H.
        • Howlett C.R.
        • Young A.A.
        Histological evaluation of repair of the rotator cuff in a primate model.
        J Bone Joint Surg Br. 2010; 92: 586-594
        • Prasathaporn N.
        • Kuptniratsaikul S.
        • Kongrukgreatiyos K.
        Single-row repair versus double-row repair of full-thickness rotator cuff tears.
        Arthroscopy. 2011; 27: 978-985
        • Boileau P.
        • Brassart N.
        • Watkinson D.J.
        • Carles M.
        • Hatzidakis A.M.
        • Krishnan S.G.
        Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal?.
        J Bone Joint Surg Am. 2005; 87: 1229-1240
        • Gazielly D.F.
        • Gleyze P.
        • Montagnon C.
        Functional and anatomical results after rotator cuff repair.
        Clin Orthop Relat Res. 1994; 304: 43-53
        • Harryman II, D.T.
        • Mack L.A.
        • Wang K.Y.
        • Jackins S.E.
        • Richardson M.L.
        • Matsen III, F.A.
        Repairs of the rotator cuff: Correlation of functional results with integrity of the cuff.
        J Bone Joint Surg Am. 1991; 73: 982-989
        • O'Holleran J.D.
        • Kocher M.S.
        • Horan M.P.
        • Briggs K.K.
        • Hawkins R.J.
        Determinants of patient satisfaction with outcome after rotator cuff surgery.
        J Bone Joint Surg Am. 2005; 87: 121-126
        • Tashjian R.Z.
        • Bradley M.P.
        • Tocci S.
        • Rey J.
        • Henn R.F.
        • Green A.
        Factors influencing patient satisfaction after rotator cuff repair.
        J Shoulder Elbow Surg. 2007; 16: 752-758