Single- versus double-row repair for full-thickness rotator cuff tears using suture anchors. A systematic review and meta-analysis of basic biomechanical studies

  • Erik HohmannEmail author
  • Anya König
  • Cor-Jacques Kat
  • Vaida Glatt
  • Kevin Tetsworth
  • Natalie Keough



The purpose of this study was to perform a systematic review and meta-analysis comparing single- and double-row biomechanical studies to evaluate load to failure, mode of failure and gap formation.

Materials and methods

A systematic review of MEDLINE, Embase, Scopus and Google Scholar was performed from 1990 through 2016. The inclusion criteria were: documentation of ultimate load to failure, failure modes and documentation of elongation or gap formation. Studies were excluded if the study protocol did not use human specimens. Publication bias was assessed by funnel plot and Egger’s test. The risk of bias was established using the Cochrane Collaboration’s risk of bias tool. Heterogeneity was assessed using χ 2 and I 2 statistic.


Eight studies were included. The funnel plot was asymmetric suggesting publication bias, which was confirmed by Egger’s test (p = 0.04). The pooled estimate for load to failure demonstrated significant differences (SMD 1.228, 95% CI: 0.55–5.226, p = 0.006, I 2 = 60.47%), favouring double-row repair. There were no differences for failure modes. The pooled estimate for elongation/gap formation demonstrated significant differences (SMD 0.783, 95% CI: 0.169–1.398, p = 0.012, I 2 = 58.8%), favouring double-row repair.


The results of this systematic review and meta-analysis suggest that double-row repair is able to tolerate a significantly greater load to failure. Gap formation was also significantly lower in the double-row repair group, but both of these findings should be interpreted with caution because of the inherent interstudy heterogeneity.

Level of evidence

Systematic review and meta-analysis.


Basic science Biomechanics Rotator cuff tear Single-row repair Double-row repair Meta-analysis Systematic review 


Compliance with ethical standards

Conflict of interest

The authors declare no conflict of interest in relation to the presented body of research.


  1. 1.
    Roth KM, Warth R, Lee JT, Millett PJ, ElAttrache NS (2014) Arthroscopic single-row versus double-row repair for full-thickness posterosuperior rotator cuff tears. JBJS Rev 2(7):e6. CrossRefGoogle Scholar
  2. 2.
    Lee TQ (2013) Current biomechanical concepts for rotator cuff repair. Clin Orthop Surg 5:89–97. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Park MC, Cadet ER, Levine WN, Bigliani LU, Ahmad CS (2005) Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques. Am J Sports Med 33(8):1154–1159. CrossRefPubMedGoogle Scholar
  4. 4.
    Ahmad CS, Stewart AM, Izquierdo R, Bigliani LU (2005) Tendon-bone interface motion in transosseous suture and suture anchor rotator cuff repair techniques. Am J Sports Med 33(11):1667–1671. CrossRefPubMedGoogle Scholar
  5. 5.
    Park JS, McGarry MH, Campbell ST, Seo HJ, Lee YS, Kim SH et al (2015) The optimum tension for briging sutures in transosseous-equivalent rotator cuff repair: a cadaveric biomechanical study. Am J Sports Med 43(9):2118–2125. CrossRefPubMedGoogle Scholar
  6. 6.
    Ahmad CS, Kleweno C, Jacir AM, Bell JE, Gardner TR, Levine WN et al (2008) Biomechanical performance of rotator cuff repairs with humeral rotation: a new rotator cuff repair failure model. Am J Sports Med 36:888–892. CrossRefPubMedGoogle Scholar
  7. 7.
    Esquivel AO, Duncan DD, Dobrasevic N, Marsh SM, Lemos SE (2015) Load to failure and stiffness. Anchor placement and suture pattern effects on load to failure in rotator cuff repairs. Orthop J Sports Med 7(3):2325967115579052. CrossRefGoogle Scholar
  8. 8.
    Ma CB, Comerford L, Wilson J, Puttlitz CM (2006) Biomechanical evaluation of arthroscopic rotator cuff repairs: double-row compared with single-row fixation. J Bone Jt Surg Am 88:403–410. CrossRefGoogle Scholar
  9. 9.
    Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K (2004) The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Jt Surg Am 86A:219–224CrossRefGoogle Scholar
  10. 10.
    Mazzocca AD, Millett PJ, Guanche CA, Santangelo SA, Arciero RA (2005) Arthroscopic single-row versus double-row suture anchor rotator cuff repair. Am J Sports Med 33(12):1861–1868. CrossRefPubMedGoogle Scholar
  11. 11.
    Smith CD, Alexander S, Hill AM, Huijsmans PE, Bull AMJ, Amis AA et al (2006) A biomechanical comparison of single and double-row fixation in arthroscopic rotator cuff repair. J Bone Jt Surg 88A(11):2425–2431. CrossRefGoogle Scholar
  12. 12.
    Mascarenhas R, Chalmers PN, Sayegh ET, Bhandari M, Verma NN, Cole B et al (2014) Is double-row rotator cuff repair clinically superior to single-row rotator cuff repair: a systematic review of overlapping meta-analyses. Arthroscopy 30(9):1156–1165. CrossRefPubMedGoogle Scholar
  13. 13.
    Burks RT, Crim J, BrownN Fink B, Greis PE (2009) 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 37(4):674–682. CrossRefPubMedGoogle Scholar
  14. 14.
    Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions. Version 5.1.9 [updated March 2011]. The Cochrane CollaborationGoogle Scholar
  15. 15.
    Moher D, Liberati A, Tetzlaff J, Altman DG (2010) Preferred reporting items for systematic reviews and meta-analysis: the PRISMA statement. Int J Surg 8:336–341. CrossRefPubMedGoogle Scholar
  16. 16.
    Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ (2007) Part I: footprint contact characteristics for transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg 16(4):461–468. CrossRefPubMedGoogle Scholar
  17. 17.
    Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ (2007) 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 16(4):469–476. CrossRefPubMedGoogle Scholar
  18. 18.
    Pietschmann MF, Hölzer A, Rösl C, Scharpf A, Niethammer T, Jansson V et al (2010) What humeri are suitable for comparative testing of suture anchors? An ultrastructural bone analysis and biomechanical study of ovine, bovine and human humeri and four different anchor types. J Biomech 43(6):1125–1130. CrossRefPubMedGoogle Scholar
  19. 19.
    Hartling L, Hamm M, Milne A, Vandermeer B, Santaguida PL, Ansari M et al (2012) Validity and inter-rater reliability testing of quality assessment instruments. (Prepared by the University of Alberta Evidence-based Practice Center under Contract No. 290-2007-10021-I.) AHRQ Publication No. 12-EHC039-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2012. Accessed 12 Aug 2016
  20. 20.
    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Barber FA, Drew OR (2012) 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 28(9):1197–1205. CrossRefPubMedGoogle Scholar
  22. 22.
    Domb BG, Glousman RE, Brooks A, Hansen M, Lee TQ, ElAttrache NS (2008) High-tension double-row footprint repair compared with reduced tension single-row repair for massive rotator cuff tears. J Bone Jt Surg 90(Suppl 4):35–39. CrossRefGoogle Scholar
  23. 23.
    Kim DH, ElAtrrache NS, Tibone JE, Jun BJ, DeLaMora SN, Kitne RS et al (2006) Biomechanical comparison of a single-row versus double-row suture anchor technique for rotator cuff repair. Am Sports Med 34(3):407–414. CrossRefGoogle Scholar
  24. 24.
    Lorbach O, Kieb M, Raber F, Busch LC, Kohn D, Pape D (2012) Comparable biomechanical results for a modified single-row rotator cuff reconstruction using triple loaded suture anchors versus a suture-bridging double-row repair. Arthroscopy 28(2):178–187. CrossRefPubMedGoogle Scholar
  25. 25.
    Hughes RE, An KN (1996) Force analysis of rotator cuff muscles. Clin Orthop Relat Res 330:75–83CrossRefGoogle Scholar
  26. 26.
    Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl UJ (2014) Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-analysis of level I randomized clinical trials. J Shoulder Elbow Surg 23(4):586–597. CrossRefPubMedGoogle Scholar
  27. 27.
    Zhang Q, Ge H, Zhou Yuan C, Chen K, Cheng B (2013) Single-row or double-row fixation techniques for full thickness rotator cuff tears: a meta-analysis. PLoS ONE 8(7):e68515. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Jost PW, Khair MM, Chen DX, Wright TM, Kelly AM, Rodeo SA (2012) Suture number determines strength of rotator cuff repair. J Bone Jt Surg Am 94(14):e100. CrossRefGoogle Scholar
  29. 29.
    Goschka AM, Hafer JS, Reynolds KA, Aberle NS II, Baldini TH, Hawkins MJ et al (2015) Biomechanical comparison of traditional anchors to all-suture anchors in a double-row rotator cuff repair cadaver model. Clin Biomech 30:808–813. CrossRefGoogle Scholar
  30. 30.
    Burkhart SS, Diaz Pagan JL, Wirth MA, Athanasiou KA (1997) Cyclic loading of anchor-based rotator cuff repairs: confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation. Arthroscopy 13(6):720–724CrossRefPubMedGoogle Scholar
  31. 31.
    Nelson CO, Sileo MJ, Grossman MG, Serra-Hsu F (2008) Single-row modified mason-allen versus double-row arthroscopic rotator cuff repair: a biomechanical and surface area comparison. Arthroscopy 24(8):941–948. CrossRefPubMedGoogle Scholar
  32. 32.
    Abtahi AM, Granger EK, Tashjian RZ (2015) Factors affecting healing after arthroscopic rotator cuff repair. World J Orthop 6(2):211–220. CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Perser K, Godfrey D, Bisson L (2011) Meta-analysis of clinical and radiographic outcomes after arthroscopic single-row versus double-row rotator cuff repair. Sports Health 3(3):268–274CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Sheibani-Rad S, Giveans MR, Arnoczky SP, Bedi A (2013) Arthroscopic single-row versus double-row repair: a meta-analysis of the randomized clinical trials. Arthroscopy 29(2):343–348CrossRefPubMedGoogle Scholar
  35. 35.
    DeHaan AM, Axelrad TW, Kaye E, Silvestri L, Puskas B, Foster TE (2012) Does double-row rotator cuff repair improve functional outcome of patients compared with single-row technique? A systematic review. Am J Sports Med 40(5):1176–1185CrossRefPubMedGoogle Scholar
  36. 36.
    Yang J Jr, Robbins M, Reilly J, Maerz T, Anderson K (2017) The clinical effect of rotator cuff repair: a meta-analysis of arthroscopic single-row and double-row repairs. Am J Sports Med 45(3):733–741CrossRefPubMedGoogle Scholar
  37. 37.
    Haidich AB (2010) Meta-analysis in medical research. Hippokratia 14(Suppl 1):29–37PubMedPubMedCentralGoogle Scholar
  38. 38.
    Ioannidis JPA, Haidich A-B, Pappa M, Pantazis N, Kokori SI, Tektonidou MG et al (2001) Comparison of evidence of treatment effects in randomized and non-randomized studies. JAMA 286:821–830CrossRefPubMedGoogle Scholar
  39. 39.
    Parimi M, Zhao C, Thoreson AR, An KN, Amadio PC (2012) Does velocity affect failure strength after tendon repair? J Biomech 45(16):2939–2942. CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Ikai M, Fukunaga T (1968) Calculation of muscle strength per unit of cross-sectional area of human muscle. Int Z Angew Physiol einschliesslich Arbeitsphysiol 26:26–31Google Scholar
  41. 41.
    Thornton A, Lee P (2000) Publication bias in meta-analysis: its causes and consequences. J Clin Epidemiol 53:207–216CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2017

Authors and Affiliations

  • Erik Hohmann
    • 1
    • 2
    • 10
    Email author
  • Anya König
    • 3
  • Cor-Jacques Kat
    • 4
  • Vaida Glatt
    • 5
  • Kevin Tetsworth
    • 6
    • 7
    • 8
    • 9
  • Natalie Keough
    • 3
  1. 1.Clinical Medical SchoolUniversity of QueenslandSt. LuciaAustralia
  2. 2.Faculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
  3. 3.Department of Anatomy, Faculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
  4. 4.Faculty of EngineeringUniversity of PretoriaPretoriaSouth Africa
  5. 5.University of Texas Health Science CenterSan AntonioUSA
  6. 6.Department of Orthopaedic SurgeryRoyal Brisbane HospitalHerstonAustralia
  7. 7.Department of Surgery, School of MedicineUniversity of QueenslandSt. LuciaAustralia
  8. 8.Queensland University of TechnologyBrisbaneAustralia
  9. 9.Orthopaedic Research Institute of AustraliaSydneyAustralia
  10. 10.Department of Orthopaedic Surgery and Sports MedicineValiant Clinic/Houston Methodist GroupDubaiUnited Arab Emirates

Personalised recommendations