Complex cuff repair may not be justified

Repairing rotator cuff tears with a double-row configuration of suture anchors takes longer and costs more than performing single-row repair, but does the more complex technique—which maximizes contact area—offer specific advantages? Not according to the results of a Canadian multicenter trial presented on Wednesday by Peter L.C. Lapner, MD, FRCSC.

Fig. 1 Arthroscopic images of single-row (A) and double-row (B) suture anchor rotator cuff repair.

(Reproduced from Dines JS, Bedi A, ElAttrache NS, Dines DM: Single-row versus double-row rotator cuff repair: Techniques and outcomes. J Am Acad Orthop Surg 2010;18(2):83-93.)

“No statistically significant differences in primary or secondary outcomes after rotator cuff surgery were identified between double-row and single-row techniques,” said Dr. Lapner. “Given the added time needed to complete the procedure and the added cost of additional implants, this trial does not provide justification for use of the more complex repair technique.”

Conducting the study
The double-blind, randomized control trial included 90 patients who underwent arthroscopic rotator cuff repair for tears of any size at two orthopaedic surgery facilities from June 2006 to June 2010. After diagnostic arthroscopy confirmed that the tear was repairable, patients were randomized to undergo either single-row or double-row repair performed by one of two fellowship-trained shoulder surgeons.

“The target population was men and women of any age with a diagnosis by clinical criteria (including imaging) of full-thickness tears of the rotator cuff,” said Dr. Lapner. Baseline demographic data—age, sex, affected side, and cuff tear size—did not differ between the two groups.

All study participants had pain and functional disability for at least 6 months. At least 6 months of conservative treatment, including activity modification, administration of analgesic or anti-inflammatory medication, and/or physiotherapy, had been unsuccessful. Exclusion criteria included subluxation of the humeral head, rendering the rotator cuff tear unable to be repaired; significant shoulder comorbidities, such as Bankart lesions; active workers’ compensation claims; active joint or system infection; significant muscle paralysis; and several other factors.

“Our primary objective was to compare the Western Ontario Rotator Cuff, or WORC, score at 24 months,” explained Dr. Lapner. Secondary objectives included measuring anatomic outcomes as determined by magnetic resonance imaging (MRI) or ultrasound as well as Constant and American Shoulder and Elbow Surgeons (ASES) scores.

According to a sample size calculation, 84 patients provided 80 percent power, with a 50 percent effect size, which was sufficient to detect a statistical difference between the groups.

Analyzing outcomes
When researchers compared WORC, ASES, Constant, and strength scores between single-row and double-row groups, they found no statistical differences at any time points (baseline, 3, 6, 12, and 24 months).

Within each group, patients experienced statistically significant improvements from baseline to all time points in all clinical outcome scores (p < 0.0001). Four patients needed further surgery (three patients in the double-row group and one patient in the single-row group) and had a repeat arthroscopic cuff repair within 24-months of the previous rotator cuff repair.

“When we used ultrasound or magnetic resonance imaging to analyze healing rates at 12 months postoperatively, we found a mean of 65 percent tendon healing in the single-row group, and a mean of 77 percent tendon healing in the double-row group.” These results, however, were not statistically significant (p = 0.255), emphasized Dr. Lapner.

“In summary,” he said, “we found that double-row repair does not yield better functional outcomes than single-row repair. The healing rates were higher with double-row repair, but further studies are necessary to clarify this finding.”

He added that “the results of this study are in agreement with other randomized clinical trials on the subject,” emphasizing that “the results of the trial do not support the use of double-row fixation for repair of the rotator cuff by arthroscopic methods.”

Dr. Lapner’s coauthors for “A Multicenter, Randomized Control Trial Comparing Single Row with Double Row Fixation in Arthroscopic Cuff Repair” are Kimberly Bell, BA; Jeff Leiter, MSc; Sheila McRae, MSc; and Peter Benjamin MacDonald, MD.

Disclosure information: Dr. Lapner, Ms. Bell, Mr. Leiter, and Ms. McRae—no conflicts; Dr. MacDonald—CONMED Linvatec.

Prepared by Jennie McKee, staff writer for AAOS Now.