Biomechanical Evaluation of Arthroscopic Rotator Cuff Repairs: Double-Row Compared with Single-Row Fixation

Authors: C. Benjamin Ma, Lyn Comerford, Joseph Wilson, and Christian M. Puttlitz

References: J Bone Joint Surg Am. 2006;88:403-410

Background: Recent studies have shown that arthroscopic rotator cuff repairs can have higher rates of failure than do open repairs. Current methods of rotator cuff repair have been limited to single-row fixation of simple and horizontal stitches, which is very different from open repairs. The objective of this study was to compare the initial cyclic loading and load-to-failure properties of double-row fixation with those of three commonly used single-row techniques.

Methods: Ten paired human supraspinatus tendons were split in half, yielding four tendons per cadaver. The bone mineral content at the greater tuberosity was assessed. Four stitch configurations (two-simple, massive cuff, arthroscopic Mason-Allen, and double-row fixation) were randomized and tested on each set of tendons. Specimens were cyclically loaded between 5 and 100 N at 0.25 Hz for fifty cycles and then loaded to failure under displacement control at 1 mm/sec. Conditioning elongation, peak-to-peak elongation, ultimate tensile load, and stiffness were measured with use of a three-dimensional tracking system and compared, and the failure type (suture or anchor pull-out) was recorded.

Results: No significant differences were found among the stitches with respect to conditioning elongation. The mean peak-to-peak elongation (and standard error of the mean) was significantly lower for the massive cuff (1.1 ± 0.1 mm) and double-row stitches (1.1 ± 0.1 mm) than for the arthroscopic Mason-Allen stitch (1.5 ± 0.2 mm) (p < 0.05). The ultimate tensile load was significantly higher for double-row fixation (287 ± 24 N) than for all of the single-row fixations (p < 0.05). Additionally, the massive cuff stitch (250 ± 21 N) was found to have a significantly higher ultimate tensile load than the two-simple (191 ± 18 N) and arthroscopic Mason-Allen (212 ± 21 N) stitches (p < 0.05). No significant differences in stiffness were found among the stitches. Failure mechanisms were similar for all stitches. Rotator cuff repairs in the anterior half of the greater tuberosity had a significantly lower peak-to-peak elongation and higher ultimate tensile strength than did repairs on the posterior half.

Conclusions: In this in vitro cadaver study, double-row fixation had a significantly higher ultimate tensile load than the three types of single-row fixation stitches. Of the single-row fixations, the massive cuff stitch had cyclic and load-to-failure characteristics similar to the double-row fixation. Anterior repairs of the supraspinatus tendon had significantly stronger biomechanical behavior than posterior repairs.

Clinical Relevance: The results of this study support the concept that double-row fixation can improve the initial fixation strength of arthroscopic rotator cuff repairs.


Schematic diagrams of the four stitch configurations in this study. (A) The two-simple repair: two simple stitches through one anchor. (B) The arthroscopic Mason-Allen repair: a horizontal mattress and simple stitch through the same suture anchor. (C) The massive cuff repair: a horizontal loop tied separately to act as a checkrein loop and two simple stitches through one anchor passed medial to the horizontal loop. (D) Double-row fixation: two simple stitches through a laterally based suture anchor and one horizontal mattress stitch through a medially based suture anchor.


Data on the Biomechanical Behavior of the Four Stitches and the Number of Anchor Pull-outs in the Ten Specimens:


Two Simple

Arthroscopic Mason-Allen

Massive Cuff

Double Row

Cyclic loading test*
   Conditioning elongation (mm) 2.0 ± 0.3 2.3 ± 0.3 1.5 ± 0.3 1.3 ± 0.1
   Peak-to-peak elongation (mm) 1.4 ± 0.2 1.5 ± 0.2{dagger}{ddagger} 1.1 ± 0.1 1.1 ± 0.1
Load-to-failure test*
   Ultimate tensile load (N) 191 ± 18{dagger}{ddagger} 212 ± 21{dagger}{ddagger} 250 ± 21{dagger} 287 ± 24
   Stiffness (N/mm) 93 ± 6 101 ± 17 114 ± 13 112 ± 14
No. of anchor pull-outs





* The values are given as the mean and the standard error

{dagger} Compared with the double-row fixation, the difference was significant (p < 0.05)

{ddagger} Compared with the massive cuff, the difference was significant (p < 0.05)


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