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Clinical data lacking on whether single- or double-row fixation is superior for cuff repair
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There is not enough clinical data to determine which is better for rotator cuff repair: single- or double-row fixation, according to a Philadelphia orthopedic surgeon.
The gold standard in rotator cuff surgery remains open rotator cuff repair, said Matthew L. Ramsey, MD, associate professor of orthopedic surgery, Thomas Jefferson University, Philadelphia. The classic technique includes an open superior approach with a subperiosteal release of the anterior from the deltoid, coracoacromial ligament excision, anterior acromioplasty, cuff mobilization and then cuff repair to the bone.
The landmark paper by Harryman demonstrated a link between structural healing and functional outcome with open repair.
In a study comparing open and arthroscopic repair, Evan Flatow, MD, and colleagues found satisfactory clinical results, Ramsey said during Orthopedics Today Hawaii 2011. For small rotator cuff tears, those less than 3 cm, healing was equivalent whether they were repaired open or arthroscopically. Larger tears, greater than 3 cm, healed better with open repair.
 Matthew L. Ramsey |
The best way to promote cuff healing remains a mystery, Ramsey said. Is single-row fixation optimal or is double-row fixation better?
Single-row advantages
There are several advantages of single-row fixation. Operating room time is shorter, and the surgeon uses fewer anchors, which lowers costs and reduces the tuberosity burden. The tuberosity burden is an important issue, Ramsey said. “We are loading the tuberosity with bioabsorbable material,” he said. “The more [anchors] you put in there, the more reactivity you have in the tuberosity.”
Performing single-row fixation is a technically easier procedure; however, the footprint is not anatomic. “There is some biomechanical evidence that these are inferior from a strength standpoint,” Ramsey said.
Double-row fixation has a longer OR time and requires more anchors — increasing costs and the tuberosity burden, he said. The need for increased visualization means the procedure is more challenging. Biomechanical data, however, indicates that fixation strength is improved.
Footprint reconstruction is better with dual-row anchor repair, Ramsey said. Compared with dual-anchor repair, contact pressure is higher with the suture bridge technique. According to Christopher Ahmad, MD’s, research, suture bridge fixation is better than dual anchor when it comes to rotational forces.
Clinical evidence lacking
Correlating the data with clinical results is difficult. “I will tell you that there is little evidence in this regard,” Ramsey said.
A 2007 study by Charousset found no clinical difference between a single-row and double-row repair. Nineteen of 31 double-row (dual anchor) shoulders healed while 14 of 35 single-row shoulders healed. “Not a significant difference in anatomic healing,” Ramsey said.
Further, a systematic review of six articles — all level 1, 2, and 3 clinical studies — with direct comparisons of single- and double-row techniques demonstrated equivalent healing rates, Ramsey said.
What the literature needs now is a study comparing the single-row and suture bridge techniques. “Most would agree that from a biomechanical standpoint, that the suture bridge technique is superior to the single-row or dual-row anchor repairs,” Ramsey said.
“What we’re lacking right now is any real good, solid clinical data to support one vs. the other.” – by Colleen Owens
References:
- Ramsey ML. Single vs. double row: Does it really matter? Presented at Orthopedics Today Hawaii 2011. Jan. 16-19, 2011. Koloa, Hawaii.
- Matthew L. Ramsey, MD, is a shoulder and elbow surgeon. He can be reached at the Shoulder and Elbow Service, Rothman Institute, 925 Chestnut St., Fl 5, Philadelphia, PA 19107-4290; 267-339-3738; email: mlramsey2@verizon.net.
