Types of Retears After Knot-tying and Knotless Suture Bridge Rotator Cuff Repair: A Systematic Review and Meta-analysis

Abstract

Background:

In conventional double-row repair for rotator cuff tears, tying the medial row of anchor sutures can strangulate the tendon. The knotless medial row technique has been recommended to improve vascularity and reduce retear rates. The researchers divided the retear pattern into 2 categories: type 1 (failure at the tendon-bone interface) and type 2 (failure at the musculotendinous junction with healed footprint).

Purpose:

To compare studies on knot-tying versus knotless double-row repair for rotator cuff tears according to retear type and clinical and radiological outcomes.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A search of the PubMed, Embase, Scopus, and Cochrane databases was performed following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included were studies that directly compared the knot-tying and knotless double-row techniques and provided postoperative patient-reported outcomes and retear rates. The Methodology Index for Non-Randomized Studies (MINORS) criteria were used for methodological quality assessment of the included studies. Odds ratios (ORs) were calculated for dichotomous outcomes, and mean differences (MDs) were calculated for continuous outcomes.

Results:

Included were 12 studies (n = 1411 shoulders); 1 study had level 1 evidence, 3 studies had level 2 evidence, and 8 studies had level 3 evidence. The MINORS score ranged from 15 to 19, indicating that the methodology was fair to good. There was no statistically significant difference in retear rate between techniques (OR, 0.99; 95% CI, 0.67-1.47; P = .96); however, more type 1 retears were seen in the knotless technique (OR, 0.42; 95% CI, 0.23-0.77; P = .005), and more type 2 retears were seen in the knot-tying technique (OR, 3.15; 95% CI, 1.70-5.83; P = .0003). Higher postoperative Constant scores were seen in the knot-tying technique (MD, 1.28; 95% CI, 0.03-2.53; P = .04); however, there were no significant differences between techniques regarding other postoperative outcomes.

Conclusion:

There was no significant difference in overall retear rates between the knotless and knot-tying techniques, and both techniques demonstrated similar clinical outcomes. However, type 2 retear rates were significantly greater after knot-tying repair, and type 1 retear rates were significantly greater after knotless repair.

Keywords

systematic review rotator cuff double-row repair suture bridge knotless knot-tying knotted clinical outcome retear failure

Although single-row repair for rotator cuff tears has produced favorable clinical outcomes, the retear rate is high.^2,4,8 The double-row repair technique was developed to help decrease the retear rate.²¹ The goals of double-row repair are to increase fixation strength, decrease gap formation under cyclic loading, and improve the restoration of the anatomic footprint of the humeral head.^1,17,25,26 A meta-analysis by Prasathaporn et al²¹ concluded that double-row rotator cuff repair can increase tendon healing, enabling patients to have greater external rotation and a significantly higher rate of tendon healing compared with single-row repair.

Cho et al⁶ divided the rotator cuff retear pattern on postoperative magnetic resonance imaging into 2 categories: type 1 (failure at the tendon-bone interface) and type 2 (failure at the musculotendinous junction with healed footprint). In conventional double-row repair, knot-tying of the medial row of anchor sutures can strangulate the tendon⁵ and impair vascular inflow, resulting in a type 2 retear. Recently, the knotless medial row technique has been recommended to improve vascularity and prevent type 2 failure.²⁷ A systematic review of biomechanical factors (ultimate load, stiffness, gap formation, and contact area) reported that when medial knots are tied in double-row repairs, they perform significantly better than knotless medial row repairs.¹⁸

Many studies have compared clinical and radiological outcomes between the knot-tying and knotless double-row repair techniques for rotator cuff tears.^¶ A meta-analysis by Kunze et al¹⁵ concluded that clinical outcomes, retear rates, and location of retears after knot-tying versus knotless double-row repairs were not significantly different. Recent retrospective comparative studies confirmed no retear rate differences between both techniques.^9,28,29 However, a recent prospective randomized controlled trial comparing clinical and radiological outcomes between knot-tying and knotless medial row techniques found type 2 failure rates to be significantly higher when using the knot-tying medial row technique.²³

The purpose of the present study was to compare studies on knot-tying versus knotless double-row repair of rotator cuff tears according to retear type and clinical and radiological outcomes.

Methods

Literature Search and Study Eligibility

A systematic literature search was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement²⁰ by 2 authors (N.P., N.T.), who queried the PubMed, Embase, Scopus, and Cochrane databases for studies involving arthroscopic rotator cuff repair with knotless and knot-tying double-row techniques. All relevant studies were published between 2008 and 2021. The search terms used for this review were (“rotator cuff” OR “supraspinatus” OR “infraspinatus” OR “subscapularis” OR “teres minor”) AND “repair” AND (“knot” OR “knotted” OR “knotless”). Eligible studies were included based on the following criteria: (1) clinical studies with evidence level 1 to 3, (2) English-language articles, (3) studies making direct comparisons between knot-tying and knotless double-row techniques of arthroscopic rotator cuff repair, (4) studies reporting postoperative patient-reported outcomes and retear rates, and (5) full-text availability. The exclusion criteria were (1) basic science or biomechanics articles, (2) case series or case reports, (3) study reviews, (4) studies on rotator cuff repair associated with shoulder arthroplasty or trauma, and (5) overlap of patient populations when the study was conducted by the same authors or institutions.

Data Extraction and Bias Assessment

The 2 reviewers (N.P., N.T.) independently screened all titles, abstracts, and the full texts of the retrieved studies to determine study eligibility. Any disagreements were resolved by a third author (T.I.). Data extracted from the included studies were (1) article information, (2) patient characteristics, (3) surgical techniques and implants, (4) retear rate and retear location (type 1 or type 2 according to Cho classification⁶), (5) functional outcome scores, (6) range of motion, and (7) muscle strength.

The Methodology Index for Non-Randomized Studies (MINORS) criteria were used for methodological quality assessment of the included studies.²⁴

Statistical Analysis

The retrieved data were analyzed by use of RevMan version 5.3 (The Cochrane Collaboration). For each study, odds ratios (ORs) with 95% CIs were calculated for dichotomous outcomes, and mean differences (MDs) with 95% CIs were calculated for continuous outcomes. Statistical heterogeneity was proven by the chi-square test. If the test showed P < .1, the included studies had statistical heterogeneity. A fixed-effects model was applied if there was no statistical and graphical evidence of heterogeneity. A random-effects model was used when there was statistical or graphical evidence of heterogeneity.

Results

Included Studies

Using the identified search criteria, 698 studies were deemed eligible. After an initial screening, 416 duplicate studies were excluded. Of the remaining 282 abstracts screened, 249 were excluded. The final subjective synthesis included 12 articles.^¶ Figure 1 summarizes the study selection process.

Figure 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram showing the study selection process.

The 12 articles included a total of 1411 shoulders, with tear sizes being medium in 4 studies,^12,13,16,22 medium to large in 3 studies,^9,28,29 small to massive in 2 studies,^10,23 and not reported in 3 studies.^3,11,19 One study²³ was categorized as having level 1 evidence, 3 studies^3,13,22 had level 2 evidence, and 8 studies^{9

–12,16,19,28,29} had level 3 evidence. The studies had a MINORS score ranging from 15 to 19, indicating that the methodology was fair to good. Details of the included studies are shown in Table 1 and Appendix Table A1.

Table 1

Details of the Included Studies and MINORS Score ^a

Lead Author (Year)	LOE	Mean Age, y	Knotless/Knot-tying Groups, n	Tear Size, cm	Imaging Modality	Mean Follow-up, mo		PROs	MINORS Score
Lead Author (Year)	LOE	Mean Age, y	Knotless/Knot-tying Groups, n	Tear Size, cm	Imaging Modality	Clinical	Imaging	PROs	MINORS Score
Rhee (2012)²²	2	61.0	51/59	1-3	MRI	21.7	6.8	VAS	16
Kim (2014)¹²	3	59.9	61/96	1-4	MRI	NR	6.2	NR	15
Boyer (2015)³	2	58.5	35/38	NR	MRI	25.2	13.0	VAS, CS	17
Hug (2015)¹¹	3	63.3	22/20	NR	MRI	24.4	24.0	CS, WORC, SSV	16
Lee (2017)¹⁶	3	59.0	69/59	Knotless: 1.76; knot-tying: 1.87	MRI	38.3	6.0	VAS, CS, ASES	17
Millett (2017)¹⁹	3	59.0	109/39	NR	MRI	34.8	52.8	ASES, SF-12 PCS	15
Honda (2018)¹⁰	3	63.8	24/29	NR	MRI	24.0	24.0	UCLA, JOA	17
Kim (2018)¹³	2	59.7	50/50	1-4	MRI/US	24.0	6.0	VAS, CS, UCLA, ASES	19
Gürpınar (2019)⁹	3	56.7	57/64	1-5	MRI	19.0	19.0	VAS, CS	18
Zwolak (2020)²⁹	3	61.9	19/64	1-5	NR	12.0	NR	QuickDASH, SPADI	17
Xu (2021)²⁸	3	63.2	134/158	3-5	MRI	15.6	14.0	CS, UCLA, ASES	17
Şahin (2021)²³	1	55.1	53/51	NR	MRI	24.3	9.6	VAS, CS	18

^a ASES, American Shoulder and Elbow Surgeons shoulder score; CS, Constant score; JOA, Japanese Orthopaedic Association Score; LOE, level of evidence; MINORS, Methodological Index for Non-Randomized Studies; MRI, magnetic resonance imaging; NR, not reported; PRO, patient-reported outcome; QuickDASH, Quick Disabilities of the Arm, Shoulder and Hand Questionnaire; SF-12 PCS, 12-Item Short Form Health Survey–Physical Component Score; SPADI, Shoulder Pain and Disability Index; SSV, Subjective Shoulder Value; UCLA, University of California at Los Angeles Shoulder Scale; US, ultrasound; VAS, visual analog scale; WORC, Western Ontario Rotator Cuff Index.

Retear Rate and Type

Eleven studies^{3,9

–13,16,19,22,23,28} reported the overall retear rate of both knot-tying and knotless techniques. The overall retear rates of the knot-tying and knotless group were 20.1% and 20.4%, respectively. No statistically significant difference was found between the 2 techniques (OR, 0.99; 95% CI, 0.67-1.47; P = .96) (Figure 2). However, type 1 retear rates were significantly higher in knotless double-row rotator cuff repair (OR, 3.15; 95% CI, 1.70-5.83; P = .0003) (Figure 3), while type 2 retear rates were significantly higher in knot-tying double-row rotator cuff repair (OR, 0.42, 95% CI, 0.23-0.77; P = .005) (Figure 4).

Figure 2.

Forest plot comparing the overall retear rate between techniques. M-H, Mantel-Haenszel.

Figure 3.

Forest plot comparing the type 1 retear rate between techniques. M-H, Mantel-Haenszel.

Figure 4.

Forest plot comparing the type 2 retear rate between techniques. M-H, Mantel-Haenszel.

Clinical Outcomes

For postoperative clinical outcomes, 7 studies^{3,9,11,13,16,23,28} reported the Constant score, 3 studies^13,16,28 reported the American Shoulder and Elbow Surgeons (ASES) shoulder score, and 3 studies^10,13,28 reported the University of California at Los Angeles (UCLA) shoulder rating scale. In comparison with the knotless technique, the knot-tying technique had a statistically higher postoperative Constant score (MD, 1.28; 95% CI, 0.03-2.53; P = .04). (Figure 5A) However, there was no statistically significant difference between the ASES score (MD, 0.95; 95% CI, –0.67 to 2.57; P = .25) (Figure 5B) and the UCLA score (MD, 0.18; 95% CI, –0.70 to 1.06; P = .69) (Figure 5C).

Figure 5.

Forest plot comparing the (A) Constant score, (B) American Shoulder and Elbow Surgeons shoulder score (ASES), and (C) University of California at Los Angeles (UCLA) shoulder rating scale between techniques. IV, inverse variance.

Range of Motion

For range of motion, 5 studies^3,9,16,23,29 reported postoperative flexion, 2 studies^23,29 reported postoperative abduction, and 3 studies^16,23,29 reported postoperative external rotation. There was no statistically significant difference for postoperative flexion (MD, –1.22; 95% CI, –4.45 to 2.00; P = .46) (Figure 6A), abduction (MD, –1.01; 95% CI, –6.48 to 4.46; P = .72) (Figure 6B), and external rotation (MD, –0.48; 95% CI, –3.62 to 2.66; P = .77) (Figure 6C).

Figure 6.

Forest plot comparing postoperative range of motion between techniques: (A) flexion, (B) abduction, and (C) external rotation. IV, inverse variance.

Discussion

The main finding of this review was that there was no significant difference in overall retear rates between the knotless and knot-tying techniques (OR, 0.99; 95% CI, 0.67-1.47; P = .96). However, type 2 retear (failure at the musculotendinous junction) rates were significantly higher in the knot-tying technique (OR, 0.42; 95% CI, 0.23-0.77; P = .005), while type 1 retear (failure at the tendon-bone interface) rates were significantly higher in the knotless technique (OR, 3.15; 95% CI, 1.70-5.83; P = .0003). Both techniques had similar clinical results.

Double-row rotator cuff repair can improve fixation strength, footprint contact area, and tendon healing.^{1,17,21,25,26} The knot-tying and knotless double-row repair of rotator cuff tears is the contentious issue. Eleven of the 12 studies in the current review assessed the overall retear rate and found no significant differences.^{3,9

–13,16,19,22,23,28} In their series of 110 patients, Rhee et al²² found that knotless double-row repair had a statistically lower retear rate (5.9%) than knot-tying double-row repair (18.6%). Similarly, Millett et al¹⁹ reported that knotless double-row repairs had a statistically lower retear rate (7.5%) than knot-tying double-row repairs (33.3%). A review by Kunze et al¹⁵ found no difference in the location of the retear between knotless and knot-tying double-row repairs. In the present systematic review, we analyzed studies by Gürpınar et al,⁹ Xu et al,²⁸ and Şahin et al.²³ The level 1 study by Şahin et al²³ suggested that knot-tying repair causes more type 2 failures.

Although we found significantly higher Constant scores after knot-typing versus knotless repair, this does not indicate a clinical difference. In patients with rotator cuff tears, the minimal clinically significant difference for the Constant score is 10.4 points.¹⁴ In addition, there were no significant differences between techniques in the postoperative ASES score, UCLA score, or range of motion.

The knot-tying repair technique may not be suitable in cases that have a higher risk of musculotendinous junction failure, such as a short tendon stump. Meanwhile, it may be reasonable to consider not using a knotless repair technique in those patient conditions in which there is a high risk of failure at the tendon-bone interface, such as osteoporosis, hypovitaminosis D, diabetes, and smoking.⁷

Limitations

This study has several limitations. First, as with any systematic review, some studies may have been missed by the search criteria used, and the inherent biases of each included study may have affected the results. Second, the included studies vary in terms of surgical techniques, surgical implants, patient data, follow-up periods, and imaging protocols. Third, the study heterogeneity in terms of other operations undertaken (eg, biceps tenotomy, tenodesis, acromioplasty, or distal clavicle excision) may influence outcomes. Fourth, retrospective studies are included in this study, meaning there is a potential for reporting and publication bias. There was no assessment of the publication bias. The majority of the included studies were level 3, indicating a poor level of evidence. Only one of the included studies was a level 1 randomized controlled trial. Finally, the clinical outcome scores used were variable, which complicates making comparisons between studies.

Conclusion

From the reviewed studies, there was no significant difference in overall retear rates between knotless and knot-tying techniques. Furthermore, both techniques demonstrated similar clinical outcomes. However, the type 2 failure rate is significantly higher in knot-tying repair, and the type 1 failure rate is significantly higher in knotless repair.

Footnotes

Notes

Acknowledgment

The authors thank Mr. David James Sims for language editing.

Final revision submitted August 18, 2022; accepted August 30, 2022.

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

APPENDIX

Table A1

Details of the Included Studies: Retears, Inclusion/Exclusion Criteria, and Surgical Technique

Lead Author (Year)	Retears, Knotless/Knot-Tying, n	Inclusion Criteria	Exclusion Criteria	Surgical Technique	Suture Type Used	Footprint Preparation
Rhee (2012)²²	3/11	Primary, medium-sized tear that could be repaired without undue tension with a suture bridge repair technique based on arthroscopic findings	SLAP lesion, distal clavicle resection, osteoarthritis, workers’ compensation, biceps procedure, revision surgery	Conventional suture bridge and knotless suture bridge	FiberWire suture (Arthrex)	Using a shaver to decorticate the footprint
Kim (2014)¹²	22/22	Full-thickness rotator cuff tear, tear size 1-4 cm	Subscapularis tear, revision surgery, severe tendon retraction, poor tendon quality, neurological involvement	Conventional suture bridge and knotless suture bridge	NR	Using a bur to decorticate the footprint
Boyer (2015)³	6/9	Full-thickness supraspinatus tendon tear, minimum follow-up of 12 mo, Goutallier stage <2, repair by a suture bridging technique	Shoulder stiffness, arthropathy, subscapularis tear	Knotted suture bridge and knotless bridge taping	FiberWire suture (Arthrex)	Using a bur to decorticate the footprint
Hug (2015)¹¹	5/5	Repairable rotator cuff tear of the supraspinatus tendon, crescent-shaped concerning Bateman grade 2-3, Patte stage 1-2	Shoulder stiffness, osteoarthritis, traumatic tears, and revision surgery	Knotless-anchor speed bridge and modified suture bridge knot-tying	FiberTape (Arthrex)	Using a bur to decorticate the footprint
Lee (2017)¹⁶	13/8	Full-thickness rotator cuff tear, repair of the tear using either knotted suture bridge or modified knotless tension band, follow-up MRI at 6 mo, minimum follow-up period of 24 mo, no history of fractures or surgeries on the affected shoulder, adherence to postoperative rehabilitation protocol	Subscapularis tear, osteoarthritis, revision surgery	Knotted suture bridge and modified knotless tension band	NR	NR
Millett (2017)¹⁹	3/4	Full-thickness rotator cuff tear, age >18 y, repair of the tear using either knotted suture bridge or knotless bridge taping	Conversion to an open surgery, used a patch to augment the repair, subscapularis tear, labral repair, microfracture, fracture fixation	Knotted suture bridge and knotless bridge taping	Knot-tying: suture; knotless: TAPE	NR
Honda (2018)¹⁰	14/18	Full-thickness rotator cuff tear, clinical evaluations and MRI at 3, 12, and 24 mo after surgery	Partial repair, open repair, revision surgery, fracture, osteoarthritis, rheumatic condition, neurological involvement	Conventional suture bridge and knotless suture bridge	FiberWire suture (Arthrex)	Using a bur to decorticate the footprint
Kim (2018)¹³	14/8	Full-thickness rotator cuff tear, tear size 1-4 cm	Tear <1 cm, tear >4 cm, subscapularis tear, neurological involvement, revision surgery, partial-thickness rotator cuff tear, osteoarthritis	Conventional suture bridge and knotless suture bridge	FiberWire suture (Arthrex)	NR
Gürpınar (2019)⁹	5/7	Rotator cuff tear diagnosed by MRI, tear size 1-5 cm, Patte stage 1-2	Patte stage 3, small tear (<1 cm), massive tear (>5 cm), subscapularis tear, traumatic tear, revision surgery, age >75 y, osteoarthritis, Goutallier stage >2	Conventional suture bridge and knotless suture bridge	NR	NR
Zwolak (2022)²⁹	NR	Full-thickness rotator cuff tear, repair of the tear using either conventional suture bridge or knotless-anchor speed bridge, completed 12-mo follow-up, adherence to postoperative rehabilitation protocol	Failure to adhere to postoperative rehabilitation protocol, missed one of the follow-up appointments, follow-up <12 mo, Bankart lesion, osteoarthritis, previous surgery, shoulder instability	Conventional suture bridge and knotless-anchor speed bridge	Knot-tying: Orthocord (DuPuy Mitek); knotless: FiberTape (Arthrex)	NR
Xu (2021)²⁸	20/27	Full-thickness rotator cuff tear, size 3-5 cm, persistent symptoms >3 mo after adequate nonoperative treatment, adherence to postoperative rehabilitation protocol	Follow-up <12 mo, subscapularis tear, labral tear, Hill-Sachs lesion, fracture, Goutallier stage >2	Knot-tying: modified double-pulley suture bridge; knotless: modified double-pulley suture bridge	Orthocord (DuPuy Mitek)	The footprint was prepared
Şahin (2021)²³	13/8	Full-thickness rotator cuff tear, repair of the tear using either knot-tying or knotless suture bridge	Age <18 y, partial-thickness rotator cuff tear, subscapularis tear, osteoarthritis, previous surgery, neurological disease, rheumatic condition, revision surgery	Conventional suture bridge and knotless suture bridge	Knot-tying: Ultrabraid (Smith & Nephew); knotless: 1 Ultratape and 1 Ultrabraid (Smith & Nephew)	Using a shaver and bur to decorticate the footprint

^a MRI, magnetic resonance imaging; NR, not reported; SLAP, superior labrum from anterior to posterior.

References

Apreleva

Ozbaydar

Fitzgibbons

Warner

. Rotator cuff tears: the effect of the reconstruction method on three-dimensional repair site area. Arthroscopy. 2002;18(5):519–526. doi:10.1053/jars.2002.32930

Boileau

Brassart

Watkinson

Carles

Hatzidakis

Krishnan

. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87(6):1229–1240. doi:10.2106/JBJS.D.02035

Boyer

Bouthors

Delcourt

, 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(2):478–486. doi:10.1007/s00167-013-2401-7

Brislin

Field

Savoie

FH III

. Complications after arthroscopic rotator cuff repair. Arthroscopy. 2007;23(2):124–128. doi:10.1016/j.arthro.2006.09.001

Cho

Lee

Rhee

. Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained? Am J Sports Med. 2011;39(10):2108–2116. doi:10.1177/0363546510397171

Cho

Lee

Rhee

. Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med. 2010;38(4):664–671. doi:10.1177/0363546509350081

Chung

Gong

Kim

. Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors. Am J Sports Med. 2011;39(10):2099–2107. doi:10.1177/0363546511415659

Gerber

Fuchs

Hodler

. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82(4):505–515. doi:10.2106/00004623-200004000-00006

Gürpınar

Polat

Tekin

Esin Polat

Çarkçı

Öztürkmen

. Comparison of early clinical results and re-tear rates of transosseous-equivalent rotator cuff repairs with or without medial knots. Joint Dis Relat Surg. 2019;30(3):193–200. doi:10.5606/ehc.2019.70137

10.

Honda

Gotoh

Mitsui

, 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(1):297. doi:10.1186/s13018-018-0990-z

11.

Hug

Gerhardt

Haneveld

Scheibel

. Arthroscopic knotless-anchor rotator cuff repair: a clinical and radiological evaluation. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2628–2634. doi:10.1007/s00167-014-3026-1

12.

Kim

Shin

Cha

Park

. Comparisons of retear patterns for 3 arthroscopic rotator cuff repair methods. Am J Sports Med. 2014;42(3):558–565. doi:10.1177/0363546514521577

13.

Kim

Shin

Lee

Yeon

Han

. 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(1):212. doi:10.1186/s13018-018-0921-z

14.

Kukkonen

Kauko

Vahlberg

Joukainen

Aärimaa

. Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery. J Shoulder Elbow Surg. 2013;22(12):1650–1655. doi:10.1016/j.jse.2013.05.002

15.

Kunze

Rossi

Beletsky

Chahla

. Does the use of knotted versus knotless transosseous equivalent rotator cuff repair technique influence the incidence of retears? A systematic review. Arthroscopy. 2020;36(6):1738–1746. doi:10.1016/j.arthro.2020.01.052

16.

Lee

Kim

, 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(7):2138–2146. doi:10.1007/s00167-016-4415-4

17.

Burkhart

. Double-row arthroscopic rotator cuff repair: re-establishing the footprint of the rotator cuff. Arthroscopy. 2003;19(9):1035–1042. doi:10.1016/j.arthro.2003.09.036

18.

Mall

Lee

Chahal

, et al. Transosseous-equivalent rotator cuff repair: a systematic review on the biomechanical importance of tying the medial row. Arthroscopy. 2013;29(2):377–386. doi:10.1016/j.arthro.2012.11.008

19.

Millett

Espinoza

Horan

, 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(10):1399–1408. doi:10.1007/s00402-017-2750-7

20.

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71

21.

Prasathaporn

Kuptniratsaikul

Kongrukgreatiyos

. Single-row repair versus double-row repair of full-thickness rotator cuff tears. Arthroscopy. 2011;27(7):978–985. doi:10.1016/j.arthro.2011.01.014

22.

Rhee

Cho

Parke

. Arthroscopic rotator cuff repair using modified Mason-Allen medial row stitch: knotless versus knot-tying suture bridge technique. Am J Sports Med. 2012;40(11):2440–2447. doi:10.1177/0363546512459170

23.

Şahin

Şentürk

Ersin

Arzu

Chodza

Erşen

. Repair integrity and functional outcomes between knot-tying and knotless suture-bridge arthroscopic rotator cuff repair: a prospective randomized clinical trial. Orthop J Sports Med. 2021;9(4):23259671211002482. doi:10.1177/23259671211002482

24.

Slim

Nini

Forestier

Kwiatkowski

Panis

Chipponi

. Methodological Index for Non-Randomized Studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–716. doi:10.1046/j.1445-2197.2003.02748.x

25.

Smith

Alexander

Hill

, et al. A biomechanical comparison of single and double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am. 2006;88(11):2425–2431. doi:10.2106/JBJS.E.00697

26.

Tuoheti

Itoi

Yamamoto

, et al. Contact area, contact pressure, and pressure patterns of the tendon-bone interface after rotator cuff repair. Am J Sports Med. 2005;33(12):1869–1874. doi:10.1177/0363546505278256

27.

Vaishnav

Millett

. 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(2)(suppl):83–90. doi:10.1016/j.jse.2009.12.012

28.

Liu

Pan

. Modified double-pulley suture-bridge techniques with or without medial knot tying show comparable clinical and radiological outcomes in arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2021;29(12):3997–4003. doi:10.1007/s00167-021-06708-3

29.

Zwolak

Meyer

Molnar

Kröber

. The functional outcome of arthroscopic rotator cuff repair with double-row knotless vs knot-tying anchors. Arch Orthop Trauma Surg. 2020;142(1):25–31. doi:10.1007/s00402-020-03584-3