Rotator Cuff Repair: How Many Rows?

Technical considerations of the rotator cuff repair remain of great importance as retear rates remain high. The double-row (DR) rotator cuff repair was designed to better restore the native enthesis footprint to maximize healing. The DR repair features a medial and lateral row of suture anchors. Anatomical and cadaveric studies have demonstrated improved footprint restoration with DR repair. Biomechanically, the DR repair has a superior load to failure, decreased gap formation under cyclic loading, and greater contact areas and pressures. It is unclear whether the number of sutures per anchor may be more important than the number of rows and the row configuration. Medial row knots and suture tape constructs may improve the biomechanics of the repair, but the impact on clinical outcomes is unknown. High-quality clinical studies have shown that the DR repair in small to medium tears does not yield better clinical outcomes than the single-row (SR) and is not cost-effective. Healing rates seem to improve with the DR repair, and retear rates may be slightly reduced. However, in larger tears, the DR repair demonstrates favorable clinical outcomes with significant increases in functional scores, healing rates, and retear rates compared to SR repair. Although the DR repair has biomechanical advantages to SR constructs, clinical evidence suggests that the double-row repair should be reserved for large to massive tear patterns.