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Tomasz Poboży

Rotator cuff repair: when does a double-row technique offer an advantage?

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Tomasz Poboży

Polish version: Stożek rotatorów — kiedy naprawa dwurzędowa ma przewagę?

A meta-analysis of 18 randomized trials suggests fewer retears and slightly better function with double-row repair for large rotator cuff tears, but no demonstrated advantage for small-to-medium tears. Tear size may help justify a more extensive footprint reconstruction; two rows are not necessarily better for every tear.

Why this study matters

Double-row (DR) repair restores more tendon contact with the greater tuberosity than single-row (SR) repair, but is more complex, usually uses more implants and takes longer. Anatomical restoration matters clinically when it improves patient outcomes or repair durability. The meta-analysis published online in Arthroscopy on 24 August 2026 restricted inclusion to RCTs and examined tear-size subgroups.

Review methods

PubMed, Cochrane Library, Embase and Web of Science were searched for randomized comparisons of arthroscopic SR and DR repair. Outcomes included retear, function, motion and operating time. Eighteen RCTs involved 1,308 patients, with subgroup analysis around a 30 mm threshold. The public abstract did not detail every rehabilitation protocol, healing assessment or follow-up period.

Main results

  • Overall UCLA scores favoured DR by a small standardised mean difference: SMD −0.28 (95% CI −0.44 to −0.12; I² = 7%).
  • Forward flexion favoured DR: SMD −0.38 (95% CI −0.58 to −0.19; I² = 26%).
  • Retear was more frequent after SR: OR 1.88 (95% CI 1.33–2.66; I² = 27%). For partial retears, OR was 2.81 (95% CI 1.50–5.24; I² = 3%).
  • SR repair had a shorter operating time.
  • In larger tears analysed around the 30 mm threshold, DR produced better ASES and UCLA scores and fewer retears.
  • Below 30 mm, clinical outcomes and retear rates did not differ significantly.

Clinical interpretation for an orthopaedic surgeon

The strongest signal concerns structural durability in larger tears. Greater tendon–bone contact may matter biologically and mechanically when a stable, low-tension repair is possible. Small overall functional differences require caution: statistical significance and standardised effect sizes do not establish that patients perceive a clinically important change.

In smaller tears, additional implants and operating time may not provide measurable benefit. Selection must still consider tissue quality and mobility, retraction, muscle atrophy and fatty infiltration, bone quality, tear configuration and repair tension.

Limitations

  • Trials were conducted in different periods using different SR and DR variants.
  • Imaging, rehabilitation, anchors and tear characteristics may differ.
  • A 30 mm threshold simplifies complex tear morphology.
  • Small functional differences may not exceed clinically important thresholds.
  • Cost-effectiveness and the best technique for each patient remain unresolved.

Implications for practice

DR repair has stronger support for large repairable tears, while well-performed SR remains reasonable for smaller tears. The study does not mandate DR at exactly 30 mm, replace intraoperative assessment or address irreparable tears requiring other reconstruction or salvage strategies.

References

  1. Seok HG, Park JJ, Park SG. Double-Row Repair Improves Outcomes for Large Rotator Cuff Tears but Offers No Advantage for Small-to-Medium Tears: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arthroscopy. Published online August 24, 2026. DOI: 10.1002/arj.70463. PMID 42636334.

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For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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