Systematic Review

Does Suture Technique Affect Re-rupture

in Arthroscopic Rotator Cuff Repair? A Meta-analysis
Matthew J. Brown, M.D., David A. Pula, M.D., Melissa A. Kluczynski, M.S.,
Terry Mashtare, Ph.D., and Leslie J. Bisson, M.D.

Purpose: To evaluate the effects of suture configuration, repair method, and tear size on rotator cuff (RC) repair healing.
Methods: We conducted a literature search of articles that examined surgical treatment of RC tears published between
January 2003 and September 2014. For single-row (SR) repairs, we calculated rerupture rates for simple, mattress, and
modified Mason-Allen sutures while stratifying by tear size. All double-row repairsdthose using 2 rows of suture anchors
(DA) and those using a suture bridge (SB)dwere performed using mattress sutures, and we compared rerupture rates by
repair method while stratifying by tear size. A random-effects model with pooled estimates for between-study variance
was used to estimate the overall rerupture proportion and corresponding 95% confidence interval for each group.
Statistical significance was defined as P < .05. Results: A total of 682 RC repairs from 13 studies were included. For SR
repairs of tears measuring less than 3 cm, there was no significant difference in rerupture rates for modified Mason-Allen
sutures versus simple sutures (P ¼ .18). For SR repairs of tears measuring 3 cm or more, there was no significant difference
in rerupture rates for mattress sutures versus simple sutures (P ¼ .23). The rates of rerupture did not differ between SB
and DA repairs for tears measuring less than 3 cm (P ¼ .29) and 3 cm or more (P ¼ .50). Conclusions: For SR repairs,
there were no significant differences in rerupture rates between suture techniques for any repair method or tear size. All
DA and SB repairs were secured with mattress sutures, and there were no differences in the rates of rerupture between
these methods for either size category. These findings suggest that suture technique may not affect rerupture rates after RC
repair. Level of Evidence: Level IV, systematic review of Level I through IV studies.

R otator cuff (RC) tears may be associated with pain

and reduced physical functioning, and they often
become more prevalent with age.1-3 Repair may be
warranted if failure of nonoperative treatment occurs.
The goal of surgery is to obtain healing of the RC to its
footprint and subsequently improve functioning and
patient satisfaction; however, findings in the literature
remain controversial.4 The importance of RC healing
has been shown by many studies,5,6 although other
studies have shown functional improvement in the
absence of RC healing.7-10
From UBMD Orthopaedics and Sports Medicine, University at Buffalo,
State University of New York at Buffalo, Buffalo, New York, U.S.A.
The authors report the following potential conflict of interest or source of
funding: The authors receive support from Ralph C. Wilson Foundation.
Money paid to the Department of Orthopaedics and Sports Medicine, Uni-
versity at Buffalo, State University of New York.
Received May 10, 2014; accepted February 5, 2015.
Address correspondence to Leslie J. Bisson, M.D., UBMD Orthopaedics and
Sports Medicine, School of Medicine and Biomedical Sciences, University at
Buffalo, 462 Grider St, Buffalo, NY 14215, U.S.A. E-mail: ljbisson@buffalo.edu
Ó 2015 by the Arthroscopy Association of North America
0749-8063/14404/$36.00
http://dx.doi.org/10.1016/j.arthro.2015.02.004
Factors that influence the successful healing of RC tears
include age, comorbidities, bone quality, tear size, tissue
quality, and activity level.4 However, all of these factors are
inherent to the patient and thus non-modifiable. Repair
technique and suture technique may also affect healing
and are under the surgeon’s control.4 Many authors have
compared healing for single-row (SR) and double-row
(DR) repairs, but findings remain controversial.11-14 Su-
ture technique is another factor under the surgeon’s con-
trol, and common techniques include simple, mattress,
and Mason-Allen sutures. The weakest point of the repair
has been shown to be the suture-tendon interface, with
suture pullout being the most common cause of repair
failure.15,16 Biomechanical studies have shown the supe-
riority of mattress sutures for SR repairs and modified
Mason-Allen sutures for DR repairs.17,18 However, very
few clinical studies have compared outcomes of various
suture techniques after RC repair.18-20
The primary purpose of our study was to evaluate the
effects of suture configuration, repair method, and tear
size on RC repair healing. We hypothesized that for
larger tears, DR repair methods would be preferable to
SR repair methods and that suture technique would
also influence RC rerupture rates.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2015: pp 1-7 1
2 M. J. BROWN ET AL.
Methods
Literature Search
We conducted a literature search using PubMed, the
Cochrane Database of Systematic Reviews, and the
Cochrane Central Register of Controlled Trials to find
articles on RC repair published between January 2003
and September 2014. Search terms included RC, supra-
spinatus, therapy, repair, healing, and imaging. The
literature search was limited to journal articles published
in English. The references of included articles were also
reviewed to identify any additional articles that may not
have been captured by our literature search. The search
process was outlined with a flow diagram modeled after
the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) statement.21
The title and abstract were reviewed for all articles
identified through our search. Clinical studies that
examined the results of surgical treatment for RC tears
were examined in more detail. The inclusion criteria
were as follows: full-thickness RC tears were studied;
preoperative tear size was reported; surgical approach,
repair method, and suture technique were reported; a
simple, mattress, or modified Mason-Allen suture
technique was used; tendons were treated by primary
arthroscopic repair; and RC healing was assessed at
least 1 year postoperatively using magnetic resonance
imaging, ultrasonography, or arthrography (or a com-
bination of these imaging techniques). The exclusion
criteria were insufficient data, RC integrity assessed less
than 1 year postoperatively or not assessed, sub-
scapularis tears, open repair, partial-thickness tears,
non-suture repair, nonoperative treatment, revision
surgery, use of a graft in the repair, and studies exam-
ining the effect of platelet-rich plasma on RC repairs.
The methodologic quality of each study was assessed
with the Quality Appraisal Tool (QAT), which is
commonly used in orthopaedic systematic reviews and
is used to evaluate all types of study designs.22 Two of
the authors (M.J.B., M.A.K.) independently reviewed
and computed QAT scores for each study. The highest
possible score on the QAT is 30, and a higher score
represents higher methodologic quality.
Statistical Analysis
The following data were extracted from each study:
first author, publication year, study design, level of
evidence, sample size for analyses, patient age, preop-
erative tear size, repair method, suture technique, i-
maging follow-up time, imaging method, and structural
healing rate. Preoperative tear size was categorized
either as less than 3 cm or as 3 cm or more. Arthro-
scopic repair methods were divided into SR and DR
repairs, with DR repairs further divided into those using
2 rows of anchors (DA) and those using a suture bridge
(SB). The suture techniques examined were simple
sutures, mattress sutures, and modified Mason-Allen
sutures. Structural tendon healing was categorized as
complete or reruptured.
The association between structural healing rates and
suture techniques was examined. This analysis was
restricted to SR repairs because this was the only repair
method for which suture techniques could be compared.
For each study, the numbers of complete and reruptured
RCs were obtained. We calculated weighted proportions
for reruptured RCs and corresponding exact 95%
Fig 1. PRISMA (Preferred Reporting
Items for Systematic Reviews and
Meta-Analyses) flow diagram for meta-
analysis examining effects of suture
configuration and rotator cuff healing
after surgical repair.
 SUTURE TECHNIQUE AND ROTATOR CUFF REPAIR 3

confidence intervals. We assumed a random-effects
model with pooled estimates for between-study vari-
ance. Because most studies did not make direct com-
parisons of suture technique or repair method, we
conducted a subgroup analysis by obtaining a combined
confidence interval for each suture technique or repair
method and conducting a 2-sample Z test to compare the
effects. Forest plots were created to summarize the re-
sults of the meta-analysis. All analyses were stratified by
preoperative tear size.
All DR repairs (DA and SB) used mattress sutures in
this study. Therefore we examined the association be-
tween structural healing rates and DR repair methods
using the same statistical procedures described earlier.
An intraclass correlation coefficient was calculated to
estimate inter-rater reliability for the QAT scores. An I2
statistic was calculated for each subgroup analysis to
estimate heterogeneity between studies. Statistical sig-
nificance was defined as P < .05. Statistical analyses
were performed with SAS software, version 9.4 (SAS
Institute, Cary, NC).
Results
The literature search yielded a total of 4,502 unique
articles, of which 13 met the inclusion criteria for this
study (Fig 1). From these studies, data were available
for 682 RC repairs and were included in this analysis.
The characteristics of the included studies are presented
in Table 1. The mean age of patients included in this
study was 59.2 years. Table 2 presents frequencies of
suture techniques by repair method and tear size.
SR Repairs
Most of the tears repaired by SR methods measured
less than 3 cm and used simple sutures (Table 2). None
of the SR repairs of tears measuring less than 3 cm used
mattress sutures, and none of the SR repairs of tears
measuring 3 cm or more used modified Mason-Allen
sutures. There were no statistically significant differ-
ences in rerupture rates between modified Mason-
Allen sutures and simple sutures for tears measuring
less than 3 cm (P ¼ .18) (Fig 2). There were also no
statistically significant differences in rerupture rates
between mattress sutures and simple sutures for tears
measuring 3 cm or more (P ¼ .23) (Fig 3).
DR Repairs
All DR repairs (DA and SB) used mattress sutures
(Table 2). Most tears repaired by DA techniques
measured less than 3 cm, and most tears repaired by SB
techniques measured 3 cm or more. There were no
statistically significant differences in rerupture rates be-
tween SB and DA repairs for tears measuring less than 3
cm (P ¼ .29) (Fig 4) and 3 cm or more (P ¼ .50) (Fig 5).
Study Quality and Homogeneity
The QAT scores ranged from 22 to 27, and the
intraclass correlation was 0.93 (95% confidence

Table 1. Study Characteristics

Study Level of QAT Sample Mean Repair Suture Mean Imaging Imaging
Authors Year Design Evidence Score* Size Age, yr Method Technique Follow-up, mo Method
Akpinar et al.7 2011 CS IV 22 26 55.9 SR Simple 12 US
Berdusco et al.23 2013 CS IV 25 11 58.8 SR Simple 25 MRI
Deutsch et al.8 2008 CS IV 25 39 54 SR Simple 38 MRI
Franceschi et al.12 2007 RCT I 27 26 63.5 SR Mattress 23 MRA
2007 RCT I 27 26 59.6 DA Mattress 23 MRA
Gerhardt et al.13 2012 RCS III 25.5 19 61.5 SR Modified 23 MRI
Mason-Allen
2012 RCS III 25.5 20 61.2 DA Mattress 23 MRI
Kim et al.24 2012 PCS II 25.5 25 57.5 DA Mattress 24 MRI
Kim et al.9 2012 CS IV 23 73 58.3 SB Mattress 29 MRI, US
Ma et al.14 2012 RCT II 24 27 60.8 SR Simple 33 MRA
2012 RCT II 24 26 61.6 DA Mattress 33 MRA
Mihata et al.6y 2011 RCS III 26 23 59 DA Mattress 24 MRI
2011 RCS III 26 107 63.6 SB Mattress 24 MRI
Moosmayer et al.25z 2014 RCT I 27 60 59 SR Modified 12 MRI
Mason-Allen
Park et al.26 2014 RCS III 26 95 60.7 SB Mattress 24 US
Sethi et al.27 2010 CS IV 25 40 62.9 SB Mattress 16 MRI
Sugaya et al.10 2005 CS IV 24.5 39 57.7 SR Simple 14 MRI
CS, case series; DA, double-row repair with 2 rows of suture anchors; MRA, magnetic resonance arthrography; MRI, magnetic resonance
imaging; PCS, prospective cohort study; QAT, Quality Appraisal Tool; RCS, retrospective cohort study; RCT, randomized controlled trial; SB,
suture-bridge repair; SR, single-row repair; US, ultrasonography.
*The average QAT score from 2 raters is reported. The QAT score ranges from 0 to 30.
y
Patients with subscapularis tears were removed from the analyses of Mihata et al.
z
Moosmayer et al. compared rotator cuff repair with physiotherapy. Only data from the surgical repair group were included, and data from the
physiotherapy group were excluded from our analysis.
4 M. J. BROWN ET AL.
Table 2. Frequencies of Suture Technique by Repair Method and Tear Size (n ¼ 682)
SR (n ¼ 247)
Tear <3 cm Tear 3 cm
Suture Technique (n ¼ 168) (n ¼ 79)
Simple sutures 89 (53%) 53 (67.1%)
Mattress sutures 0 26 (32.9%)
Modified 79 (47%) 0 0
Mason-Allen sutures
NOTE. Data are given as number (percent of column total).
DA, double-row repair with 2 rows of suture anchors; SB, suture-bridge repair; SR, single-row repair.
interval, 0.69 to 1.00), which indicates excellent inter-
rater reliability for the QAT. The I2 estimates of het-
erogeneity ranged from 0% to 87.5%, indicating that
there was considerable heterogeneity in a few of the
subgroup analyses (Table 3).
Discussion
Contrary to our hypothesis, rerupture rates did not
differ by suture technique when stratified by repair
method and tear size. Results from studies comparing
various suture techniques have been inconsistent. Ponce
et al.17 found that mattress stitches increased load to
failure by 21 N compared with simple sutures. In a
prospective study of arthroscopic SR repairs, Ko et al.19
found higher rates of patient satisfaction and lower
rerupture rates for mattress sutures compared with
simple sutures. On the other hand, Burkhart et al.28
found that repairs by simple sutures were significantly
stronger than repairs by mattress sutures when using
transosseous fixation in cadaveric shoulders. This
finding was justified by the observation that most repairs
Repair Method
DA (n ¼ 120) SB (n ¼ 315)
Tear <3 cm Tear 3 cm Tear <3 cm Tear 3 cm
(n ¼ 64) (n ¼ 56) (n ¼ 117) (n ¼ 198)
0 0 0 0
64 (100%) 56 (100%) 117 (100%) 198 (100%)
0 0 0
failed at the knot, and each simple suture repair con-
tained 2 knots as opposed to the single knot used in a
mattress stitch, accounting for the significant difference
in load to failure. Furthermore, a study by Schneeberger
et al.29 concluded that arthroscopically placed modified
Mason-Allen sutures were significantly weaker than
mattress sutures placed in cadaveric shoulders. Howev-
er, we did not have sufficient data to compare mattress
and modified Mason-Allen sutures for any tear size. We
did not find significant differences in rates of rerupture
between simple and modified Mason-Allen sutures for
tears measuring less than 3 cm. In addition, we did not
find a significant difference in rates of rerupture between
simple and mattress sutures for tears measuring 3 cm or
more.
DR repairs (DA and SB) have evolved to increase the
biomechanical properties of the repair and to restore
the anatomic footprint.4 These come in different vari-
ations, including 2 rows of anchors and the
transosseous-equivalent method or SB. The SB tech-
nique retains the medial-row suture limbs and fixes
Fig 2. Forest plot of rerupture rates of
single-row repairs for modified Mason-
Allen versus simple sutures for tears
measuring less than 3 cm. Rerupture
rates and 95% confidence intervals are
reported. The difference in the esti-
mated overall rerupture rates between
modified Mason-Allen (MMA) sutures
and simple sutures is 0.104 (P ¼
.1767). (LCL, lower confidence limit;
UCL, upper confidence limit.)
 SUTURE TECHNIQUE AND ROTATOR CUFF REPAIR
Fig 3. Forest plot of rerupture rates of
single-row repairs for mattress versus
simple sutures for tears measuring
3 cm or more. Rerupture rates and
95% confidence intervals are reported.
The difference in the estimated overall
rerupture rates between mattress and
simple sutures is 0.424 (P ¼ .2308).
(LCL, lower confidence limit; UCL,
upper confidence limit.)
them laterally, compressing the RC tissue.9,24 We
compared these differing types of DR methods and
their effects on RC healing. No statistically significant
differences in rerupture rates were found between DA
and SB configurations for tears measuring less than 3
cm and tears measuring 3 cm or more. This finding is
consistent with the literature. Kim et al.24 showed that
the arthroscopic conventional SB technique resulted in
patient satisfaction ratings, functional outcomes, and
rates of rerupture comparable to those with the
arthroscopic DA technique in full-thickness RC tears.
The same group also investigated whether the indi-
vidual configuration of sutures mattered and found no
significant differences in clinical outcome and RC
5
healing for single mattress/SB, double pulley/SB, and
double mattress/SB.9
Our analysis included considerably fewer SR repairs
than DR repairs, which may represent a shift toward DR
repairs that have been shown to improve healing and
clinical outcomes. In comparison, a meta-analysis of
studies published between 1980 and 2009 found that the
number of arthroscopic SR repairs was equivalent to the
number of arthroscopic DR repairs.30 The authors
remarked that the average publication date for SR re-
pairs was 2004, as compared with 2007 for DR repairs,
also suggesting a shift toward DR repairs.
The strengths of our study include the use of predefined
inclusion and exclusion criteria, the stratification of
Fig 4. Forest plot of rerupture rates of
double-row suture anchor versus suture
bridge techniques for tears measuring less
than 3 cm. Rerupture rates and 95%
confidence intervals are reported. The
difference in the estimated overall rerup-
ture rates between suture bridge (SB) and
double-row suture anchor (DA) repairs is
0.07 (P ¼ .2949). (AJSM, Am J Sports Med;
JBJS, J Bone Joint Surg Am; LCL, lower
confidence limit; UCL, upper confidence
limit.)
6 M. J. BROWN ET AL.
rerupture rates by preoperative cuff tear size and repair
method, and the inclusion of 682 total RC repairs. Few
studies have directly examined the effect of different
suture techniques on rerupture rates after surgical RC
repair, and more studies are needed in this area. This
study contributes to the scarce literature on this topic.
Limitations
There are multiple limitations to this study. None of
the studies that we included directly compared RC
healing for various suture techniques, and all levels of
evidence were included. However, well-designed,
prospective, randomized Level I studies on this topic
are lacking. In addition, we examined the effect of
suture technique on RC healing rather than clinical
outcomes, such as range of motion, pain, and physical
function. Pooling the clinical outcome data for studies
included in this analysis would have been inappro-
priate because of variation in outcome measures be-
tween studies. On the basis of the available data, we
were limited to using tear size categories of less than 3
cm and 3 cm or more, which are broad. DeOrio and
Cofield31 have defined finer cut points (i.e., <1 cm, 1 to
3 cm, 3 to 5 cm, and >5 cm), which could have been
helpful in examining potential threshold effects.
Adoption of standard categories would make future
Table 3. Results of I2 Test of Heterogeneity
SR of Tear <3 cm SR of Tear 3 cm
Simple MMA Simple Mattress
I2* 42.09% 0% 87.51% 58.90%
DA, double-row repair with 2 rows of suture anchors; DR, double-row repair; MMA, modified Mason-Allen; SB, suture-bridge repair; SR,
single-row repair.
*The higher the I2 value, the more heterogeneity between studies.
Fig 5. Forest plot of rerupture rates of
double-row suture anchor versus su-
ture bridge techniques for tears
measuring 3 cm or more. Rerupture
rates and 95% confidence intervals are
reported. The difference in the esti-
mated overall rerupture rates between
suture bridge (SB) and double-row
suture anchor (DA) repairs is 0.065
(P ¼ .4987). (AJSM, Am J Sports Med;
JBJS, J Bone Joint Surg Am; LCL, lower
confidence limit; UCL, upper confi-
dence limit.)
reviews and comparisons more accurate. Moreover,
stratifying by several factors (suture technique, repair
method, and tear size) led to small group sample sizes,
which could have prevented us from observing statis-
tically significant differences in rerupture rates.
Another limitation of this study is the lack of stan-
dardized criteria for evaluating RC integrity and the
variation in imaging techniques that were used.
Finally, the anchor type or number of sutures per an-
chor was not tracked in all of the various studies, which
varied across articles and may have affected healing
rates. Other topics that varied between articles included
rehabilitation technique, muscle atrophy, immobiliza-
tion, and use of sliding knots versus half-hitches.
However, we did not have sufficient data to adjust for
all of these factors.
Conclusions
For SR repairs, there were no significant differences in
rerupture rates between suture techniques for any repair
method or tear size. All DA and SB repairs were secured
with mattress sutures, and there were no differences in
the rates of rerupture between these methods for either
size category. These findings suggest that suture tech-
nique may not affect rerupture rates after RC repair.
DR of Tear <3 cm DR of Tear 3 cm
DA SB DA SB
33.31% 68.69% 81.17% 33.74%
 SUTURE TECHNIQUE AND ROTATOR CUFF REPAIR
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