Journal of Clinical Orthopaedics and Trauma 64 (2025) 102951

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Journal of Clinical Orthopaedics and Trauma

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Original article

Outcomes of arthroscopic rotator cuff repair via single-row anchor

technique versus transosseous anchorless technique: A randomized
controlled trial
Mustafa Mohamed Mesriga, Mohamed Kamal Mesregah * , Ahmed Abdel-Monem Dewidar,
Hany Elsayed Saad, Ayman Mohamed Ebied
Department of Orthopaedic Surgery, Menoufia University Faculty of Medicine, Menoufia, Shebin-El-Kom, Egypt

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Rotator cuff tears can be addressed using various repair techniques. This study sought to compare
Rotator cuff tear the clinical and radiologic outcomes and costs after arthroscopic single-row anchor repair and arthroscopic
Rotator cuff repair transosseous repair for small to medium-sized tears.
Arthroscopic
Methods: The study was a prospective randomized clinical trial (registered as trial number
Transosseous
Single-row
PACTR202404475835971 in the Pan African Clinical Trial Registry, Apr 04, 2024) that included 62 patients,
Anchors randomized into two equal groups. Group A: single-row anchor repair (n = 31) and Group B: transosseous repair
ASES (n = 31). Patients were clinically evaluated using the American Shoulder and Elbow Surgeons (ASES) score and
OSS Oxford Shoulder Score (OSS), in addition to evaluation of range of motion (ROM) of forward flexion, external
rotation (ER), and internal rotation (IR). Total implant costs were calculated and compared.
Results: In both groups, the ROM increased significantly, P < 0.001. The mean differences between preoperative
and postoperative forward flexion, ER, and IR were comparable in both groups, P = 0.933, 0.817, and 0.151,
respectively. The mean ASES score and OSS improved significantly in both groups at last follow-up, P < 0.001.
The mean follow-up ASES score was 91.1 ± 3.5 in Group A and 90.8 ± 2.7 in Group B, P = 0.818. The mean
follow-up OSS was 42.4 ± 2.1 in Group A and 41.5 ± 1.9 in Group B, P = 0.214. The average financial cost of
operation was significantly lesser in the transosseous group than the anchors group, P < 0.001.
Conclusion: Anchorless transosseous rotator cuff repair can achieve similar excellent functional outcomes as the
single-row anchor repair, with equivalent tendon healing results. However, the transosseous technique has
substantially lower costs.

1. Introduction double-row, or transosseous techniques.11,12 However, anchor-based

techniques have several complications, including anchor pull-out,
Rotator cuff tears have become common in orthopedic practice.1,2 greater tuberosity osteolysis, difficult revision, and high financial
Open transosseous repair was considered the ideal technique for treating costs.13–15
rotator cuff tears, with the advantages of accurate preparation and Technology has allowed for a fully arthroscopic transosseous repair
maximization of tendon footprint contact area, which is crucial for that eliminates the need for anchors.14,16–18 This method has the ad­
successful healing.3,4 Rotator cuff repair techniques have advanced over vantages of transosseous repair, restoring the anatomic footprint, and
the last few decades from open to all-arthroscopic techniques, especially compressing across the rotator cuff tendon, besides the benefits of
with the development of suture anchors.5–7 arthroscopic surgery.8,19,20
There are various types of suture configurations, and many factors However, transosseous repair is susceptible to failure, often resulting
should be considered when choosing an appropriate surgical option from suture cutout through the outer cortex of the greater tuberosity.8
because the risk of non-healing and re-tear is still high.8–10 This study sought to compare the outcomes of arthroscopic single-
Anchor-based rotator cuff repair can be executed using single-row, row anchor repair and arthroscopic transosseous repair for small to

* Corresponding author. Department of Orthopaedic Surgery, Menoufia University Faculty of Medicine, Menoufia, 32511, Shebin-El-Kom, Egypt.
E-mail address: [Link]@[Link] (M.K. Mesregah).

[Link]
Received 23 November 2024; Received in revised form 4 February 2025; Accepted 16 February 2025
Available online 18 February 2025
0976-5662/© 2025 Delhi Orthopedic Association. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
M.M. Mesriga et al. Journal of Clinical Orthopaedics and Trauma 64 (2025) 102951

medium-sized rotator cuff tears. It was hypothesized that there would be A physician without clinical involvement in the study enrolled the
no significant differences between the two techniques in terms of clinical participants with a concealed allocation sequence. The study partici­
outcomes or imaging findings. pants were kept blinded to their assigned group.

2. Methods
2.4. Preoperative evaluation
2.1. Study design
A detailed history was taken, including the medical history of the
This study was conducted as a prospective, randomized controlled patients, history of previous trauma to the diseased shoulder, history of
clinical trial, adhering to CONSORT guidelines. The study protocol was previous shoulder injections, and the time from onset of symptoms to
approved by Menoufia University Institutional Review Board (No: 04/ operation.
2024ORTH1, Jan 2019), and written consent was taken from all par­ The preoperative active range of motion (ROM) of forward flexion,
ticipants. This trial was registered in the Pan African Clinical Trial external rotation (ER) at 0-degree abduction, and internal rotation (IR)
Registry (PACTR) (ID: PACTR202404475835971; Date: Apr 04, 2024). at 90-degree abduction for both groups were determined with a
goniometer.
Patients were clinically evaluated preoperatively via American
2.2. Participants
Shoulder and Elbow Surgeons (ASES) score22 and Oxford Shoulder Score
(OSS).23 The ASES score comprises two subscores including pain visual
The study included patients with rotator cuff tears admitted to
analog scale (VAS) and activity of daily living (ADL) reported as a single
Menoufia University Department of Orthopedic Surgery between
overall score for shoulder pain and function.22 The OSS 12-item
January 2019 and January 2022.
patient-reported outcome measure to evaluate the effectiveness of
Inclusion criteria encompassed small to medium-sized full-thickness
shoulder surgery.23
supraspinatus tendon tears confirmed by magnetic resonance imaging
Patients underwent radiological imaging with shoulder plain X-ray
(MRI), at least three months of conservative measures.
anteroposterior and axial views and MRI scan.
Exclusion criteria were patients with massive rotator cuff tears,
subscapularis tears, irreparable tears, frozen shoulder, inflammatory or
rheumatologic diseases, glenohumeral osteoarthritis, and previous 2.5. Surgical interventions
shoulder surgery.
Overall, 86 patients were evaluated for inclusion eligibility, and 24 Surgeries were performed in beach-chair position, with general
patients were excluded for not meeting the inclusion criteria. anesthesia. A mixture of 10 ml of lidocaine and 0.5 ml of 25 % adren­
aline was injected into the shoulder joint and sub-acromial space before
2.3. Randomization and blinding sterilization. Standard portals for shoulder arthroscopy were done, and
the arthroscope was inserted. The subacromial bursa was resected, and
The study patients (n = 62) were randomized into two intervention the bone footprint was prepared. Repair with anchors or transosseous
groups, Group A (n = 31): arthroscopic single-row anchor repair and tunnel technique was done according to randomization. Sub-acromial
Group B (n = 31): arthroscopic transosseous anchorless repair, using the decompression and acromioplasty were performed after the repair
sequentially numbered, opaque sealed envelopes method,21 Fig. 1. process.

Fig. 1. CONSORT flow chart of study participants.

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M.M. Mesriga et al. Journal of Clinical Orthopaedics and Trauma 64 (2025) 102951

2.6. Single-row anchor repair 2.9. Outcome measures

Suture anchors were positioned just lateral to the articular surface The primary outcome measures were the functional outcomes using
within the rotator cuff footprint. Placement started at the posterior the ASES score and the OSS and ROM at the last follow-up, in addition to
margin of the tear, with anchors spaced approximately 1 cm apart. The the state of healing of the cuff to the greater tuberosity using shoulder
knots were tied from anterior to posterior direction with simple or ultrasound at one-year follow-up. The secondary outcome measure was
mattress stitches, Fig. 2. the financial cost of the implants used for each procedure, including the
One or two anchors were used, depending on the tear size, with the price of the anchors in Group A and the price of sutures in Group B. The
aim of achieving full coverage of the footprint. A single anchor was cost of the reusable tunneler device of the hospital was not added to the
utilized in 8 patients, and two anchors in 23 patients. The following total cost for Group B.
types of anchors were used in the repair: HEALIX TI™ Dual Threaded
Suture Anchor (DePuy Synthes) in 8 cases, JuggerKnot® All-Suture 2.10. Statistical analysis
Anchor (Zimmer Biomet) in 14 cases, and TWINFIX Suture Anchor in
9 cases. Sample size estimation was based on a review of past literature
(Karaduman et al.24 and Castagna et al.25 studies) using Statistics and
Sample Size Pro Version 8.0 at 80 % power and 95 % confidence level
2.7. Transosseous anchorless repair
(CI). Statistical analysis of data was done utilizing IBM SPSS V. 23 (IBM
Corp, Armonk, NY). Quantitative data were reported as mean, standard
The transosseous repair was performed using the Tensor TransOs
deviation (SD), and range, and comparisons were made using the paired
Reusable Bone Tunneler (Tensor Surgical Inc., Chattanooga, Tennessee,
samples t-test or the Mann-Whitney U test. Qualitative data were
USA). The first awl was used to make the medial holes in the greater
expressed as frequencies (N) and percentages (%), with comparisons
tuberosity that was 2.9 mm in diameter just lateral to the articular
performed utilizing the chi-square test or Fisher’s exact test. A P-value of
cartilage margin with a trajectory about 70–80◦ upright from the foot­
<0.05 was indicative of statistical significance.
print of the tuberosity.
Then, the tunneler device was introduced from the anterior tunnel
3. Results
into the sub-acromial space. A second awl loaded with passing suture
(Vicryl suture 2) was used to make a horizontal hole 1.9 mm in diameter
3.1. Demographics and baseline characteristics
laterally in the lateral aspect of the greater tuberosity typically to create
1.5 cm bone bridge, so the passing suture was taken by the tunneler
Group A included 10 (32.3 %) males and 21 (67.7 %) females with an
inside the greater tuberosity.
average age of 56.4 ± 6.6 (range 48–70) years. Group B included 14
Then, the tunneler device was withdrawn with the passing suture
(45.2 %) males and 17 (54.8 %) females with an average age of 55.3 ±
held by its tip. Then, the passing suture was used to shuttle two or three
5.4 (range, 45–68) years. In both groups, dominant side was affected in
FiberWire or Orthocord sutures number 2 in each tunnel. The medial
18 (58 %) patients, while non-dominant side was affected in 13 (42 %)
and lateral limbs of sutures were taken out through the anterior portal. A
patients. Age, sex, occupation, hand dominance, history of trauma, and
suture passer was used to pass each tunnel’s medial sutures through the
duration of symptoms showed no significant differences between the
rotator cuff tendon from anterior to posterior. Finally, sutures were tied
two groups. Additionally, both groups were similar regarding the pre­
in a simple knot configuration using the lateral limb as the post, Fig. 3.
operative ROM and preoperative ASES score and OSS, Table 1.

2.8. Postoperative care 3.2. Clinical outcomes

Local injection of lidocaine in the portal was performed after portal The mean follow-up period was 28.4 ± 3.8 (range, 24–36) months
closure for immediate postoperative analgesia. A broad arm sling was and 29.1 ± 3.1 (range, 24–39) months in Group A and Group B,
applied to the affected limb. One gram of third-generation cephalo­ respectively, P = 0.479. In the two groups, the mean range of flexion,
sporin IV infusion every 12 h for 24 h and non-steroidal anti-inflam­ ER, and IR increased significantly postoperatively, P < 0.001, Table 2.
matory drugs were administrated. The mean differences between preoperative and postoperative
The rehabilitation program consisted of four phases. Phases I and II flexion, ER, and IR were similar in both groups, P = 0.933, 0.817, and
were done under our direct supervision during follow-up visits in the 0.151, respectively, Table 3.
clinic, while phases III and IV were done under the supervision of the The mean ASES score and OSS improved significantly in the two
physiotherapist. Phase I started immediately after surgery, using an arm groups at last follow-up, P < 0.001, Table 4.
immobilizer with passive ROM exercises. Phase II started 4–6 weeks The mean follow-up ASES score was comparable in Group A, 91.1 ±
after surgery by introducing active-assisted ROM exercises. Phase III 3.5 (range, 83–94) and Group B, 90.8 ± 2.7 (range, 86–94), P = 0.818.
started approximately 10–12 weeks postoperatively and included Similarly, the mean follow-up OSS was comparable in Group A, 42.4 ±
stretching and strengthening exercises and resistance activities. Phase IV 2.1 (range, 39–45) and Group B, 41.5 ± 1.9 (range, 38–44), P = 0.214.
was the advanced strengthening phase and was initiated 16–18 weeks The mean cost of used implants was significantly lower in the
postoperatively. transosseous group, 213.3 ± 67.6 (range, 133.3–300) USD, than in the

Fig. 2. Arthroscopic single-row anchor ROTATOR CUFF repair. A) and B) Anchor placement at the margin of the articular cartilage. C) Sutures tied in a
mattress fashion.

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M.M. Mesriga et al. Journal of Clinical Orthopaedics and Trauma 64 (2025) 102951

Fig. 3. Arthroscopic transosseous (anchorless) ROTATOR CUFF repair. A) Identification of the tear. B) The first awl was used to create a tunnel in the greater
tuberosity. C) Application of the tunneler. D) Orthocord passing through the tunnel. E) Sutures tied over the rotator cuff tendon.

anchors group, 360 ± 82.8 (range, 200–400) USD, P < 0.001. (n = 35). Both groups had similar ASES scores. However, transosseous
repair group experienced significantly less pain in the 3rd and 4th
3.3. Radiological outcomes postoperative weeks.30
Flanagin et al.19 reported significant improvements in forward
The one-year follow-up ultrasound revealed a healed cuff to the flexion, ER, and IR in a series of 109 shoulders treated with arthroscopic
greater tuberosity, except in two patients in Group A and one in Group B transosseous repair, with a mean final follow-up ASES score of 94.6.
who showed non-healed supraspinatus tendon, P = 0.554. MRI scan Plachel et al.31 reported significant improvement in active ROM in 56
confirmed the non-healed tendon, Fig. 4. patients with complete tears managed with arthroscopic transosseous
repair. Patients were satisfied with the clinical outcomes, achieving a
4. Discussion mean follow-up ASES score of 92.31 Srikumaran et al.32 reported that
both transosseous and transosseous-equivalent techniques resulted in no
Open rotator cuff repair using transosseous sutures to secure the cuff difference in operative time, ROM, and clinical scores.
to the bony footprint was considered the gold standard. This approach In our study, the structural healing rate on shoulder ultrasound was
demonstrated consistent healing outcomes and proven biomechanical similar in the two groups. Randelli et al.30 reported that both were
efficacy.26,27 With the advent of arthroscopic techniques, anchor fixa­ similar in rotator cuff integrity at 15 months of follow-up. Srikumaran
tion has emerged as the new gold standard.28 Nevertheless, transosseous et al.32 reported no difference in the re-tear rates. Gulotta et al.33 con­
fixation was not entirely abandoned, as modified arthroscopic tech­ ducted a study of 193 patients with arthroscopic rotator cuff repair and
niques incorporating this method were later introduced.29 reported no association between tendon healing on the ultrasound at 5
In this study, we compared the arthroscopic transosseous anchorless years and the ASES score.
repair procedure with the arthroscopic single-row suture anchor repair In the last two decades, rotator cuff repairs have become increasingly
technique. Both methods achieved excellent functional outcomes with common, leading to concern about the societal and economic impact.14
significant improvement of ROM, ASES score, and OSS without signifi­ In our study, the transosseous procedure had a statistically significant
cant difference between them. lower cost compared to the single-row repair group. Black et al.34 re­
Published literature reported favorable functional outcomes ported substantial implant-related cost savings with the transosseous
following arthroscopic treatment of rotator cuff tears. Garofalo et al.17 anchorless technique compared to the transosseous equivalent repair
compared 42 patients treated with arthroscopic single-row anchor with anchors. Seidl et al.35 compared the costs of arthroscopic trans­
repair and 54 patients treated with arthroscopic transosseous repair. osseous repair and arthroscopic transosseous equivalent anchor repair
ASES scores improved significantly without a significant difference be­ and reported significantly lower costs with arthroscopic transosseous
tween the two groups.17 Randelli et al.30 compared patients treated with repair. However, the operating time and the clinical scores were
arthroscopic transosseous repair (n = 31) and single-row anchor repair similar.35

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M.M. Mesriga et al. Journal of Clinical Orthopaedics and Trauma 64 (2025) 102951

Table 1 Table 3
Demographics and baseline characteristics of the two groups. Comparison between both groups regarding the mean difference of ROM.
Characteristics Group Aa n = Group Bb n = P- ROM Group Aa Group Bb P-value
31 31 value
Mean flexion difference ​ ​ 0.933
Age, years (mean ± SD) 56.4 ± 6.6 55.3 ± 5.4 0.475 Mean ± SD 70.7 ± 21.3 68.3 ± 35.7
Gender (n, %) ​ ​ 0.297 Range (30–95) (10–135)
Male 10 (32.3 %) 14 (45.2 %) Mean ER difference ​ ​ 0.817
Female 21 (67.7 %) 17 (54.8 %) Mean ± SD 32 ± 8.8 29.3 ± 13.4
Affected side (n, %) ​ ​ 1.000 Range (15–50) (5-50)
Dominant 18 (58 %) 18 (58 %) Mean IR difference ​ ​ 0.151
Non-dominant 13 (42 %) 13 (42 %) Mean ± SD 26.3 ± 6.9 20.7 ± 10.5
Occupation (n, %) ​ ​ 0.520 Range (15–40) (0-35)
Housewife 19 (61.3 %) 15 (48.4 %)
Manual worker 4 (12.9 %) 6 (19.4 %) ROM, range of motion; ER, external rotation; IR, internal rotation.
Farmer 4 (12.9 %) 2 (6.5 %) P-value <0.05 is significant.
a
Carpenter 2 (6.5 %) 2 (6.5 %) Single-row anchors group.
b
Teacher 2 (6.5 %) 4 (12.9 %) Transosseous group.
Engineer 0 (0 %) 2 (6.5 %)
History of trauma (n, %) ​ ​ 0.544
Yes 8 (25.8 %) 6 (19.4 %) Table 4
No 23 (74.2 %) 25 (80.6 %) Preoperative and postoperative ASES score and OSS in both groups.
Symptoms duration, months (mean 4.2 ± 1.5 4.8 ± 2.3 0.229
Preoperative Postoperative P-value
± SD)
Preoperative ROM, degrees (mean ​ ​ ​ ASES score, mean ± SD (range)
± SD) Group Aa 55.1 ± 6.2 (45–65) 91.1 ± 3.5 (83–94) <0.001
Flexion 85.3 ± 9.2 92.7 ± 30.2 0.197 Group Bb 56.8 ± 6.8 (44–66) 90.8 ± 2.7 (86–94) <0.001
External rotation 41.3 ± 6.9 42.2 ± 10.8 0.762 OSS, mean ± SD (range)
Internal rotation 42.7 ± 6.2 41.7 ± 6.2 0.528 Group A 30.9 ± 3.3 (25–36) 42.4 ± 2.1 (39–45) <0.001
ASES score, mean ± SD 55.1 ± 6.2 56.8 ± 6.8 0.308 Group B 31.7 ± 2.9 (26–36) 41.5 ± 1.9 (38–44) <0.001
OSS, mean ± SD 30.9 ± 3.3 31.7 ± 2.9 0.315
ASES, American Shoulder and Elbow Surgeons; OSS, Oxford Shoulder Score.
ROM, rang e of motion; ASES, American Shoulder and Elbow Surgeons; OSS, P-value <0.05 is significant.
Oxford Shoulder Score. a
Single-row anchors group.
P-value <0.05 is significant. b
Transosseous group.
a
Single-row anchors group.
b
Transosseous group.
row anchor repair and arthroscopic transosseous repair, with similar
significant improvements in clinical scores and imaging outcomes.
Table 2 However, the financial costs of the transosseous technique are signifi­
Preoperative and postoperative range of motion in both groups. cantly lower than the single-row anchor technique.
Preoperative Postoperative P-value
Patient consent
Flexion, mean ± SD (range)
Group Aa 85.3 ± 9.2 (70–100) 156.7 ± 17.9 (120–175) <0.001
Group Bb 92.7 ± 30.2 (30–160) 164.3 ± 6.5 (150–175) <0.001 Informed consent to participate in this study was taken from the
External rotation, mean ± SD (range) patients.
Group A 41.3 ± 6.9 (30–50) 72.7 ± 9.4 (50–80) <0.001
Group B 42.2 ± 10.8 (30–70) 72.7 ± 6.2 (60–80) <0.001
Internal rotation, mean ± SD (range)
Credit author statement
Group A 42.7 ± 6.2 (30–55) 68.4 ± 8.4 (50–80) <0.001
Group B 41.7 ± 6.2 (30–55) 64.9 ± 3.9 (60–70) <0.001 M.M.M. designed the study, performed the surgeries, and wrote the
P-value <0.05 is significant. preliminary manuscript. M.K.M. did analysis and interpretation of data
a
Single-row anchors group. and manuscript preparation. A.A.D., A.M.E and H.E.S. contributed to the
b
Transosseous group. study design and final manuscript revision.

The arthroscopic transosseous technique has not been widely adop­ Ethical clearance
ted, possibly because of the absence of the tunneler device, technical
challenges, unfamiliarity with the procedure, or insufficient marketing The current study was approved by the Institutional Review Board
efforts. In addition, the transosseous technique is more technically (IRB).
demanding than anchor-based techniques and has a steep learning curve
to master its technical skills. Source of funding
This study has some limitations, including the relatively small sam­
ple size. Additionally, we excluded massive tears. As a result, the po­ No financial support was received for this study.
tential outcomes regarding re-tear rates and non-healing in these types
of tears remain uncertain.
Declaration of competing interest
5. Conclusion
The authors declare that they have no known competing financial
Rotator cuff tears can be effectively treated with arthroscopic single- interests or personal relationships that could have appeared to influence
the work reported in this paper.

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M.M. Mesriga et al. Journal of Clinical Orthopaedics and Trauma 64 (2025) 102951

Fig. 4. A non-healed supraspinatus tendon in Group B. A) Ultrasound showing non-healed tendon. B) MRI scan showing non-healed tendon.

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