Thank you very much for the opportunity to participate in this OLC course. My charge today is to talk about whether we still have value with single-row rotator cuff repair. My disclosures are available at the meeting app and on the AAOS website. When we look at single-row versus double-row, there still remains significant controversy. There's significant industry pressure as well as peer pressure indicating and saying, hey, I did a great double-row. But in 2020, single-row rotator cuff repairs still have value. Not all single-row repairs are the same. It's important to understand based on the number of sutures per anchor and most importantly the anchor location, which is critical whether it's placed medially or laterally on the footprint. But in 2020, single-row rotator cuff repairs still have value. Not all single-row repairs are the same. It's important to understand based on the number of sutures per anchor and most importantly the anchor location, which is critical whether it's placed medially or laterally on the footprint. When we look at what we do at SCOE, we have a huge rotator cuff experience doing over five to six hundred rotator cuff repairs a year. And on our hand, single-row makes sense. We're a tertiary rotator cuff referral center and we typically see the biggest tears that are out there. Sometimes it can't even get a single-row and have to look at graphs. And it is rare that I see a non-retracted acute traumatic anatomic tear that would be amenable to a solid, safe double-row repair. What we talk about primarily is what we call a SCOE row repair. We use the strongest anchors and the best bone, just lateral to the articular cartilage. We use triple-loaded anchors, maximizing our passes per centimeter, using high-strength suture and provide the best healing environment. We fix the rotator cuff where it lies. If that's medialized, it's an in-situ repair. We micro-fracture the tuberosity, creating bone marrow vents and keep tension off the repair. There have been proposed advantages of double-row, saying that it's biomechanically stronger, but we have data that calls this into question. There's better coverage of the anatomic footprint, questionable. We look at the compression of the footprint, contact area, and increased strength. But what we have to really look at is what is being compared. We look at some of the systematic reviews that are out there dating back to 2014, and it's important to understand what is actually being compared when you look at these meta-analyses that tell you one thing or another. When we look at the anatomy of the rotator cuff, things changed back in 2009, when Moshizuki did his work, indicating that the footprint of the supraspinatus is actually much smaller than previously believed and only represents a small triangular area on the anterior aspect of the tuberosity. If you look at the humeral insertion of the supraspinatus, what we see, looking at this video on the left, is that you have this intact infraspinatus, and the supraspinatus inserts into this small area on the tuberosity right in here. Christian Gerber has also shown us significant changes that occur with rotator cuff tears. As a tear becomes more chronic, there's changes to the fibropenation angle, and you end up with a shorter, more stubby fiber, which is irreversible. And so consequently, if you pull the rotator cuff when you have a shorter tendon, you're going to put more tension on the repair if you pull it out to increased length. When we look at single row versus double row repairs, the discussion should include not only the number of rows, but where the rotator cuff is being positioned for fixation. And not all single row repairs are the same, and it's based on this concept of tension. Davidson, many years ago, showed us that the increased tension on a rotator cuff is deleterious, and your functional outcome is actually inversely proportional to the amount of tension on your repair. We did a study looking at this. So what we did is we attached a tensiometer to the rotator cuff here, and we put tension on a grasper as we pulled the tendon from the medial position to the lateral position. And what we found is there's a over five-fold increase in force required to pull that rotator cuff. So even if you can pull it out to the lateral aspect of the tuberosity, you are going to introduce significant increased tension on that repair. So again, not all single rows are repair. And so it's important to look at where your anchors are being placed and what is being compared when you look at single row versus double row. So there's a significant difference in the amount of tension that's experienced by a medial versus a laterally based repair. If you look at some of the often quoted papers included in every meta-analysis or systematic review, the paper by Bob Birx, very well done, level one study looking at single row versus double row. But they found no clinical or MRI difference between the patients. If you read their paper carefully, their single row repairs used double loaded anchors on the lateral edge of the footprint. And that is not what we are recommending today. Included in JBJS, paper out of Canada from Peter Lapner's group, no functional difference in quality of life outcomes, single row versus double row, multi-center randomized control trial. And again, double loaded anchors placed laterally on the footprint, not what we recommend today. If you look at fixation strength, Alan Barber has done terrific work looking at comparing this. And what we understand is if you use three sutures per anchor in a single row, you're going to get excellent fixation and it's a hundred percent increase in strength over a double loaded anchor. We've also shown with cyclical loading that it is more resistant to gap formation than a suture bridge repair. And this was just published this year in 2020. If you look at a biomechanical comparison between a single row, what we call a scowy row repair and a suture bridge double row rotator cuff repair, what we found is, is that the rotator cuff repaired with a scowy row had superior biomechanical properties and had significantly less gap displacement when looked at this under cyclical loading. Fixation strength is clearly known to be the key to success. If you look at the paper by Scott Rodeo and the HSS group, what they found is that it's the number of suture anchors that's important. And what they have also explained is that the assertion that double row repairs are biomechanically superior is actually false if you use more sutures for your repair. So let's go back to these systematic reviews from the one from Shoulder and Elbow in 2014. No detectable difference in outcome scores between single row and double row repairs, but the vast majority of the data on single row was flawed. And then while they reported a higher single row retear rate, they were using double loaded anchors placed laterally on the footprint. So again, understand what is being compared when you look at this, because if you have flawed assumptions, you can report whatever you want at the end of the day. Well, what about bone quality? If you're looking at the average person who's going to get a rotator cuff repair, a senior population person, perhaps 60 or older, the bone quality changes. Certainly if you're doing on a 30 year old female as seen on the left, it probably doesn't matter where you're putting your anchor. But in a 70 year old woman, I'd much rather my single row anchors be up here just underneath the anatomic neck as opposed to way out here laterally where there's very little bone underneath the cortex for support in that situation. So what we recommend is what we call a SCOE row. Again, we use the strongest anchor in the best bone, just off the articular cartilage margin. We maximize our passes per centimeter. We use these triple loaded anchors with high strength suture. I also like the partially absorbable suture as you see here on the right. It provides excellent tying capability and very solid fixation. And then we want to provide the best healing environment. Again, an in situ repair. I'm not specifically medializing it, but I'm fixing it where it lies so there's no tension on it. We keep tension off the repair. I use primarily simple sutures. Occasionally we'll use what we call a Mason Allen, as you see here, where I tie a horizontal mattress stitch and then place a simple stitch over the top. And once I've completed my repair, I microfracture my tuberosity. And what you see there is this rotator cuff has been repaired in situ where it lies, microfracturing the tuberosity and creating this crimson duvet to aid in a healing response, which will help get secure healing. What about the bone marrow vents? Well, several clinical papers have looked at this. Milano has showed significantly better healing rates in large tail with bone marrow vents. And Joe has also showed that there's better integrity of your repair. If you make bone marrow vents, only 4% were identified to have any leakage following their rotator cuff repair. Similarly, in a paper out of Japan, they looked at bone marrow stimulation at the footprint in terms of integrity of the rotator cuff. And what they found was there was improved rotator cuff healing, particularly in these large to massive tears. So this is an interesting patient. This is actually a radiologist. And if you look at the date of this, this is 2002. So this is before high strength suture, before all the things that have been out there. But what you can see, he got himself on his MRI scanner every week, and he sent us the MRI images to look at the healing. So if you look at the image on the left, four weeks post-op, you can see where the rotator cuff was repaired. There's essentially a naked footprint shortly after surgery. But look what happens between week four and week eight on the right. He essentially forms this neo-tendon and restores his footprint. And this is what we advocate for doing a good solid single row repair. We've also done biopsy results. If you look at the next slide, we've also done biopsy results at six months post-operatively. And what you see on the right side with polarized light microscopy, you can see strong birefringence indicating that this is tendon tissue. And when this was sent out for biopsy, the report came back intact rotator cuff tissue. So when we look at SCOE row, this was just published out of our institution in August of arthroscopy journal. What we compared was medium to large rotator cuff tears using a SCOE row technique. We did in-situ rotator cuff repair, minimizing the tension and adding bone marrow vents. The tear size was on average 2.8 centimeters. We used a minimum of two polyether ketone anchors or titanium anchors. So peak or titanium with a minimum two-year follow-up. Mean age was 59.7. The initial data was presented in the KSST, and this is the two-year follow-up. We did in-situ rotator cuff repair, minimizing the tension and adding bone marrow vents. The tear size was on average 2.8 centimeters. We used a minimum of two polyether ketone anchors or titanium anchors. So peak or titanium with a minimum two-year follow-up. Mean age was 59.7. The initial data was presented in the KSST, and this is the two-year follow-up. If you look at the results, we only had seven re-tears identified at two years. We had no type two failures, which I think is very important. 92.5% healed, which is not as good, but better than anything that's been presented in the literature before. When we look at our work scores, we did much better when we had an intact rotator cuff, which is very important. And our patients were completely satisfied with this results. So what we understand is we get excellent healing by MRI, and patients who have an intact repair have better shoulder function than those with re-tear. If we look at triple, single row versus double row, very little data outside of ours. Alan Barber published his results in 2016 looking at this, and he looked at both single row versus double row adding platelet-rich plasma fibrin membrane. And what he similarly found was no difference in re-tear by MRI or clinical outcomes, but he was more likely to get a type two failure with his double row repair options. Well, what about these type two failures? Cho has shown the difference looking at single row versus suture bridge techniques. And what he found was if you do a suture bridge repair and it fails, 74% of the time, it's going to introduce a type two failure at the musculotendinous junction, which is possibly catastrophic. There's no good way to revise a musculotendinous re-tear. You can do a side to side where you're really forcing yourself to have to do some form of allograft patch or possibly a superior capsular reconstruction. And what about cost? This has been published in JBJS work out of Stedman Hawkins, Ted Schlegel. And what they found was on the basis of the currently available data, double row rotator cuff repair is not cost-effective for any size rotator cuff repair. Level two study, JBJS. So my thoughts for rotator cuff repair in 2020, do a single row tension-free repair. There is not sufficient evidence to show a clinical advantage over a dual row repair. The clinical results are equivalent, even with laterally based tension single row repairs. The SCOE row repair, as we recommend, has no tension and leads to excellent outcomes with a reconstituted footprint. You've got 92% healing by MRI at two years minimum follow-up. We're unlikely to get a catastrophic type two musculotendinous failure and double row repair does not appear to be cost-effective. So I want to thank you very much for your attention and I hope this convinces you that single row still has some value for us today. Thank you very much.

single-row rotator cuff repair

double-row repair

sutures per anchor

fixation strength

SCOE experience