INTRODUCTION
Rotator cuff muscles play a significant role in the extensive range of motion (ROM) of the shoulder joint. Tears in this muscle group significantly affect shoulder function and quality of life [1-3]. Rotator cuff tears are among the most common shoulder pathologies, with higher prevalence in individuals older than 50 years and a progressive trend in most cases [4-6]. Rotator cuff repair (RCR) has advanced significantly in the past few decades. The goal of RCR is to eliminate pain and improve function by enhancing shoulder strength and ROM [7,8]. Surgical interventions have shifted from open repair to arthroscopic repair, showing comparable or improved outcomes [7,8]. Today, arthroscopic repair is regarded as the gold standard technique due to its advantages over open procedures in terms of complications and morbidity [7,8].
Various techniques for arthroscopic repair have been explored, including single-row, double-row, and double-row transosseous repairs. Studies comparing these strategies have reported varied results [9-13]. Some studies and meta-analyses suggest that double-row repairs provide more comprehensive restoration with lower retear rates and better functional outcomes than single-row repairs [9,10]. However, other meta-analyses have shown equivalent results between the techniques. The transosseous anchorless repair (TAR) approach is a more contemporary and effective alternative to open biomechanical intervention [11-13]. Despite the theoretical advantages of both double row anchor repair (DRR) and TAR techniques, there is a paucity of high-quality comparative studies evaluating their clinical outcomes, particularly in the context of full-thickness rotator cuff tears. This study aims to address this gap by retrospectively comparing the functional outcomes of patients who underwent arthroscopic RCR using either DRR or TAR. We hypothesize that the two techniques will demonstrate comparable improvements in shoulder function and patient-reported outcomes, while potentially highlighting differences in specific aspects of recovery and complication rates.
To this end, we conducted a retrospective, observational, and comparative analysis of patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair at a single tertiary care hospital. The primary objective was to determine the functional outcomes associated with each repair technique, as measured by standardized clinical assessments and patient-reported outcome measures. Secondary objectives included the evaluation of complication rates and factors influencing surgical outcomes.
METHODS
This was a retrospective, observational, and comparative study of a consecutive series of patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff surgery at Ortho-One Orthopaedic Specialty Centre. Prior to study commencement, the Institutional Ethics Committee of Ortho-One Orthopaedic Specialty Centre approved the study protocol (No. 6/I/2022). The study followed the Declaration of Helsinki (2016 revision), Good Clinical Practice, and Indian Council of Medical Research biomedical research standards. Written informed consent was obtained from patients.
This retrospective analysis investigated data from a prospectively retained database to determine the functional outcomes of patients who underwent arthroscopic rotator cuff surgery with either double row repair (DRR) (Fig. 1) or TAR (Fig. 2). We retrospectively reviewed the records of patients who underwent surgery during the period from January 2022 to May 2023. The inclusion criteria were (1) patients aged 18 years or older, (2) patients who underwent arthroscopic rotator cuff surgery using either DRR or TAR for small to large full-thickness rotator cuff tears within the specified period and with a minimum follow-up of 1 year, (3) body mass index less than 32 kg/m2, and (4) patients with preoperative Goutallier stage of 0, 1, or 2.
The exclusion criteria were (1) patients with partial rotator cuff tears, (2) patients with cuff tear arthropathy, (3) patients who underwent arthroscopic rotator cuff surgery using DRR or TAR and had a follow-up less than 1 year or incomplete functional assessment records, (4) patients who underwent arthroscopic rotator cuff surgery other than DRR or TAR, (5) history of disorders of the shoulder (osteonecrosis / osteoarthritis) or muscular atrophy, and (6) patients with subscapular injuries.
Matching of Participants
To minimize potential confounding factors and ensure comparability between the DRR and TAR groups, a matching process was implemented. Patients were matched based on age, sex, body mass index, and severity of rotator cuff tear (Goutallier stages). This matching process aimed to create two comparable cohorts, enhancing the validity of the analysis.
RCR Surgery Techniques
DRR technique
With the patient in beach chair or lateral decubitus position, routine diagnostic arthroscopy of the shoulder joint was performed, and the articular side of the full thickness rotator cuff was identified. Subacromial arthroscopy was conducted using the posterior viewing portal, and a standard anterolateral portal was established as a working portal. After thorough subacromial decompression and if necessary, acromioplasty was performed in the presence of type III acromion using the standard posterolateral viewing portal. The footprint of the rotator cuff was prepared until it showed a bleeding bed. The torn margins of the rotator cuff were identified, cleaned, and assessed for reducibility. Either one double-loaded or two double-loaded suture anchors were placed for the medial row, and a horizontal mattress stitch configuration was used through the rotator cuff. One limb of the suture was cut after the knots were tied, and the sutures were parked in the anterior working portal. The suture limbs were passed through the knotless anchor and fixed to the lateral cortex of the greater tuberosity using a knotless 5.5-mm anchor for completion of the double row parachute technique [14].
TAR technique
The patient was positioned in the beach chair or lateral decubitus position based on the surgeon’s preference. A standard arthroscopic posterior portal was created, and diagnostic arthroscopy was performed. Following standard cuff mobilization and tear pattern recognition, a two-tunnel construct was selected. A medial 2.9-mm awl was introduced through the superomedial portal, creating a medial tunnel adjacent to the articular margin. The TransOs Tunneling device (Tensor Surgical) was introduced in an inverted manner through the portal, piercing the subdeltoid fascia. The device was rotated 180° into the subacromial space at the previously placed tunnel. The tip was translated into the tunnel, and the handle was rotated to achieve low purchase on the humerus, maximizing the bone bridge length, which is typically between 15 and 20 mm. A shuttling suture was passed, and a triplet of three differently coloured sutures was placed in the tunnel. The second tunnel was similarly created, and another triplet of sutures was placed. The inferior limbs were secured to the surgical drapes to prevent suture sliding and maintain an external topographic representation of the internal suture position for meticulous suture management. The sutures were passed through the tendon to optimally restore the anatomy [15].
The two groups followed a similar rehabilitation protocol. For 6 weeks, the arm was immobilized in a shoulder immobilizer allowing all but shoulder movements. From 6 to10 weeks, active assisted ROM exercises were initiated. Between weeks 10 to 12, active exercises were initiated, and shoulder strengthening exercises were initiated at 12 weeks. Recorded details for each patient were age, sex, diabetes mellitus, smoking status (history reported as active smoking of cigarettes/e-cigarettes in the last year), type of injury, body side, Cofield full thickness tear classification [16], surgical procedure and clinical assessment, shoulder ROM, imaging reports, and functional evaluations (preoperatively and postoperatively at 3-, 6-, and 1-year final follow-up) using the American Shoulder and Elbow Surgeons (ASES) [17] and University of California, Los Angeles (UCLA) [18] shoulder scale evaluations.
Statistics
Statistical analysis was performed using IBM SPSS Statistics for Windows version 21 (IBM Corp.). The data were expressed using descriptive statistics of numbers, percentages, means with standard deviations, and medians with interquartile ranges. Data were assessed for normalcy. The Mann-Whitney U- and t-tests were used to compare two independent variables, and the chi-square test was used for categorical data. P-values <0.05 were considered statistically significant.
RESULTS
During the retrospective study period, 42 patients underwent arthroscopic rotator cuff surgery using either DRR or TAR. Twenty patients (n=20; male=13, female=7) underwent the DRR procedure, while 22 patients (n=22; male=13, female=9) underwent the TAR procedure. The mean age of DRR patients was 60.7±8.0 years, while TAR patients had a mean age of 59.9±7.5 years (P=0.733). Table 1 summarizes the baseline and perioperative characteristics of the two groups, showing no significant differences in baseline and perioperative functional outcomes and ROM parameters.
Functional Outcomes
Table 2 summarizes the functional outcomes and ROM at the various assessment time points. The TAR group showed substantially larger improvements in functional outcomes than the DRR group, as reflected by higher scores at 3- and 6-month post-surgery. The UCLA score (3 month: TAR, 23.82 vs. DRR, 22.30, P<0.001; 6 month: TAR, 28.18 vs. DRR, 26.60, P<0.001) and ASES score (3 month: TAR, 67.55 vs. DRR, 64.49, P=0.025; 6 month: TAR, 95.33 vs. DRR, 91.48, P<0.001) were significantly higher in the TAR group.
Range of Motion
While the TAR group had higher shoulder ROM values than the DRR group at the 1-year follow-up, there was no significant difference in ROM in forward flexion (FF), extension (EXT), external rotation (ER), internal rotation (IR), or abduction (ABD) (P>0.05) (Table 2). There were no complications encountered in either group during the period of study.
DISCUSSION
With the advent of newer techniques and configurations, the field of surgical intervention for arthroscopic cuff repair is expanding [7,8]. Recently, arthroscopic anchorless transosseous approaches have been developed to combine the nominal non-invasiveness of arthroscopic procedures with the biomechanical benefits of open procedures [19,20]. TAR is a new approach that offers the benefits of both minimally invasive arthroscopic surgery and open transosseous treatments, while minimizing neurovascular and other risks [21]. The demographics of our study cohort reflect a typical population undergoing RCR surgery. The mean age of patients in the groups (DRR: 60.7±8.0 years; TAR: 59.9±7.5 years) aligns with a previous study emphasizing the condition's prevalence in the aging population [22]. There were no significant differences in age distribution between the DRR and TAR groups (P=0.733), indicating a balanced baseline for comparison. Sex distribution also showed no significant difference between groups (P=0.939), with slightly higher male representation consistent with the reported incidence of rotator cuff tears [23]. This demographic similarity reduces potential confounding factors related to sex-specific biomechanical differences in shoulder anatomy and function.
In this retrospective research, we found that TAR had a substantially larger improvement in functional outcome as measured by the UCLA score at 3- and 6-month post-surgery compared to DRR (3 month: TAR, 23.82 vs. DRR, 22.30, P<0.001; 6 month: TAR, 28.18 vs. DRR, 26.60, P<0.001) and ASES score (3 month: TAR, 67.55 vs. DRR, 64.49, P=0.025; 6 month: TAR, 95.33 vs. DRR, 91.48, P<0.001). Although functional scores were higher in the TAR group than in the DRR group at 1-year follow-up, there was no significant difference in UCLA score (12 month: TAR, 28.95 vs. DRR, 28.40; P=0.101) or ASES score (12 month: TAR, 96.19 vs. DRR, 95.09; P=0.051). Similarly, although the TAR group had greater shoulder range of movement than the DRR group at 1-year follow-up, there was no significant (P>0.05) difference in ranges of movement in FF, Ext, ER, IR, and ABD. The hypothesis that the two techniques would produce equivalent functional outcome results was confirmed. However, the TAR group demonstrated significant improvement in functional outcomes in the early phases of post-surgical management (3 and 6 months) compared to the DRR group.
Recent studies have characterized anchorless transosseous repair of the shoulder as a better method of RCR fixation, with enhanced biomechanical properties, higher compression over the rotator cuff footprint for optimal healing, and high radiological healing rates [21,24-27]. Randelli et al. [24], in a prospective randomized double blind clinical trial (level I) comparing 31 arthroscopic anchorless transosseous repairs to 35 anchored single-row anchor fixation repairs documented that patients who underwent DRR experienced quicker pain reduction in the first month and more rapid decrease in pain third week. However, the two arthroscopic repair procedures did not show significant differences in functional outcomes (Constant and shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) Questionnaire) or radiological findings [24]. In a retrospective matched cohort study, Srikumaran et al. [25] compared anchorless transosseous operation and anchored transosseous equivalent suture-bridge technique and found no significant differences in ROM, ASES evaluations, tear rates, and surgical duration at the end of one and 2 years. Flanagin et al. [26] conducted a retrospective review of patients who experienced anchorless arthroscopic transosseous cuff repair and documented significant improvement in FF and ER and IR (P<0.0001). The average postoperative subjective shoulder score was 93.7, with a basic shoulder test of 11.6 and an ASES score of 94.6. Similarly, in a retrospective comparative study in which 45 patients underwent anchorless transosseous repair and 25 underwent arthroscopic transosseous-equivalent (TOE) RCR, although there was statistical improvement in pre/post clinical outcomes for each technique, at a 2-year follow-up, clinical outcome data did not differ between the methods [27].
Toussaint et al. [28] concluded that the short-term clinical outcomes and structural integrity of a TOE technique were equivalent to those of other double-row suture anchor procedures used in 160 patients with a full-thickness RCR. In another work, Park et al. [29] reported considerable improvements in pain and function following TOE repair for patients with a full-thickness rotator cuff tear and found no clinical difference between TOE and double row RC repair. Imam and Abdelkafy [30] performed a prospective assessment on patients with magnetic resonance imaging-proven full-thickness rotator cuff tears who underwent transosseous equivalent suture bridge double row rotator cuff surgery. At 24 months, the patients had favourable post-operative functional outcomes in UCLA, ROM and retear rate.
Our research aligns with earlier comparison studies between anchored and anchorless arthroscopic procedures. Smoking is a significant consideration in the context of surgical outcomes, particularly in procedures like RCR. In our study, portions of patients in both the TAR and DDR groups were smokers. Although our findings did not reveal a significant difference in functional outcome between smokers and non-smokers within each group, the impact of smoking on surgical outcomes remains a critical concern in shoulder surgery. A study by Carbone et al. [31] demonstrated that cigarette smoking negatively impacts tendon vascularity and is correlated with rotator cuff tears and tear severity. Moreover, studies such as that by Møller et al. [32] have shown that smoking cessation before surgery can enhance wound healing and reduce complication rates compared to continued smoking.
The anchorless transosseous cuff repair procedure has the following advantages: simple suture management; promotion of faster healing; and cost effectiveness as there is no need for an implant, which additionally prevents implant-related complications and reduces pain [21,33]. Thus, in our study, both TAR and DDR techniques significantly improved functional outcome in patients with full thickness cuff tears. However, the TAR group showed greater improvement in functional outcome at the early stages of post-management (3 and 6 months) than the DDR group. Last, large-scale prospective trials with standardized protocols and outcome measures are essential to validate these findings across diverse patient populations and clinical settings, guiding evidence-based decision-making in RCR surgery.
The limitations of the study include its retrospective conduct and small sample size. Also, because the study was retrospective, the tear pattern was not characterized using other available classification and categorization methods. Finally, the retrospective data were collected from a single hospital setup. Further randomized control trials are needed to validate these findings.
CONCLUSIONS
In this retrospective comparative study of arthroscopic RCR techniques, TAR demonstrated superior early-term functional outcomes compared to DRR. Specifically, TAR showed significantly higher UCLA and ASES scores at 3- and 6-month postoperation, indicating better initial recovery compared to DRR. However, the techniques exhibited comparable functional outcomes at the 1-year follow-up. The findings suggest that TAR offers distinct advantages in early rehabilitation phases, potentially leading to quicker pain relief and functional improvement. Long-term outcomes, including ROM and overall clinical effectiveness, were similar between TAR and DRR groups. The anchorless transosseous technique emerges as a promising option due to its biomechanical benefits, reduced implant-related complications, and cost-effectiveness.
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