Purpose
To compare the biomechanical properties of the knotted versus knotless transosseous-equivalent
(TOE) techniques for rotator cuff repair (RCR).
Methods
A systematic review was performed according to the Preferred Reporting Items for Systematic
Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and the Cochrane
Library to identify studies that compared the biomechanical properties of knotted
and knotless TOE RCR techniques. The search phrase used was as follows: (Double Row)
AND (rotator cuff) AND (repair) AND (biomechanical). Evaluated properties included
ultimate load to failure, cyclic displacement, stiffness, footprint characteristics,
and failure mode.
Results
Eight studies met the inclusion criteria, including a total of 67 specimens in each
group. Of 6 studies reporting on ultimate load to failure, 4 found tendons repaired
with the knotted TOE technique to experience significantly higher ultimate load to
failure compared with knotless TOE repairs (knotted range, 323.5-549.0 N; knotless
range, 166.0-416.8 N; P < .05). Of 6 studies reporting on failure stiffness, 2 found knotted TOE repairs
to have significantly higher failure stiffness compared with knotless TOE repairs
(knotted range, 30.0-241.8 N/mm; knotless range, 28.0-182.5 N/mm; P < .05), whereas 1 study found significantly higher failure stiffness in knotless
TOE repairs compared with knotted TOE repairs (P = .039). Cyclic gap formation favored the knotted TOE group in 2 of 3 studies (knotted
range, 0.6-5.2 mm; knotless range, 0.4-9.1 mm; P < .05). The most common mode of failure in both groups was suture tendon tear.
Conclusions
On the basis of the included cadaveric studies, rotator cuff tendons repaired via
the knotted TOE technique display superior time-zero biomechanical properties, including
greater ultimate load to failure, compared with rotator cuffs repaired via the knotless
TOE technique. Suture tearing through the tendon remains a common failure method for
both techniques.
Clinical Relevance
The results of this systematic review provide helpful insight into the biomechanical
differences between 2 popular techniques for RCR. Although these results should be
carefully considered by surgeons who are using either of these techniques in the operating
room, they should not be mistaken for direct clinical applicability because cadaveric
studies may not directly correlate to clinical outcomes.
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Article info
Publication history
Published online: October 01, 2021
Accepted:
September 7,
2021
Received:
May 17,
2021
Footnotes
The authors report the following potential conflicts of interest or sources of funding: J.T.B. is board member of American Orthopaedic Society for Sports Medicine (AOSSM); is a consultant for DJ Orthopaedics, Sukla Medical, and Smith & Nephew; receives royalties from Shukla Medical; and receives research support from Stryker and Biomet, outside the submitted work. E.C.M. is a board member of AOSSM, International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS), Orthopedics Today, Orthopedics, and American Journal of Sports Medicine; is a consultant for Biomet; and receives royalties from Biomet, Elsevier, and Zimmer, outside the submitted work. A.F.V. is a board member of AOSSM and Video Journal of Sports Medicine; receives payment for lectures including service on speakers bureaus from Smith & Nephew, Vericel, and Arthrex; and receives research support from Arthrex, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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© 2021 by the Arthroscopy Association of North America
