Rotator cuff repair illustration showing suture bridge technique

Rotator Cuff Repair: Is Knot Tying in Suture Bridges Really Necessary?

Soraya Malik in Health & Wellness June 2025 • 5 min read.

"A new study questions the necessity of medial knot tying in arthroscopic rotator cuff repair, suggesting potential drawbacks for long-term tendon healing."

Rotator cuff tears are a common issue, affecting a significant portion of the adult population, especially as we age. When conservative treatments fail to provide relief, arthroscopic rotator cuff repair (ARCR) becomes a viable option to restore function and alleviate pain. However, the journey doesn't end with the surgery itself. One of the most critical concerns following ARCR is the risk of re-tears, which can occur despite advancements in surgical techniques.

To enhance initial fixation strength and promote tendon-bone healing, surgeons often employ a suture bridge technique during ARCR. This method aims to maximize contact area and ensure mechanical stability. A key component of the suture bridge is the medial row fixation, frequently involving knot tying due to its perceived biomechanical advantages. However, recent research has begun to question this approach, suggesting that medial knot tying might lead to strangulation and hinder the healing process.

The debate surrounding the necessity of medial knot tying has sparked interest in comparing clinical outcomes between suture bridge techniques with and without this step. While some studies have explored functional results, a comprehensive analysis of both functional and structural outcomes has been lacking. Addressing this gap, a recent study published in the Journal of Orthopaedic Surgery and Research delves into the effects of medial knot tying on tendon healing and overall success rates following ARCR.

Does Medial Knot Tying Impact Healing After Rotator Cuff Repair?

Rotator cuff repair illustration showing suture bridge technique

The study, conducted by Honda et al. (2018), compared two suture bridge techniques: one with medial knot tying (WMT group) and another without (WOMT group). The researchers followed 124 patients who underwent ARCR for rotator cuff tears, with 53 patients meeting the criteria for inclusion based on clinical and structural evaluations at 3, 12, and 24 months post-surgery. Clinical outcomes were assessed using the University of California Los Angeles (UCLA) and Japanese Orthopaedic Association (JOA) scores, while structural outcomes were evaluated using magnetic resonance images (MRI) and the Sugaya classification system.

Both the WMT and WOMT groups showed significant improvements in JOA and UCLA scores from pre-surgery to the 24-month follow-up, indicating that both techniques effectively improved patient function and reduced pain. However, a closer look at the structural outcomes revealed some interesting differences:

Re-tear Rates: No significant difference in postoperative re-tears (Sugaya types 4 and 5) was observed between the two groups at any point during the follow-up period.
Complete Healing: At the 24-month mark, the WOMT group showed a significantly higher rate of complete tendon healing (Sugaya type 1) compared to the WMT group (P = 0.024).
Incomplete Healing: Conversely, the WMT group exhibited a significantly larger number of incompletely healed tendons (Sugaya types 2 and 3) at 24 months post-surgery (P = 0.024).

These findings suggest that while both techniques provide comparable clinical benefits, medial knot tying might hinder long-term tendon healing. The increased incidence of incomplete healing in the WMT group raises questions about the potential drawbacks of this approach.

Rethinking the Role of Medial Knot Tying

The study by Honda et al. (2018) challenges the conventional wisdom surrounding medial knot tying in suture bridge techniques for ARCR. While biomechanical studies often highlight the advantages of medial knot tying, this research suggests that it may not necessarily translate to superior long-term structural outcomes. The increased rate of incomplete healing observed in the WMT group indicates that the potential for strangulation and subsequent tendon necrosis at the medial row may outweigh the biomechanical benefits.

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Everything You Need To Know

What is arthroscopic rotator cuff repair (ARCR), and why is it performed?

Arthroscopic rotator cuff repair (ARCR) is a surgical procedure used to repair torn rotator cuff tendons. It becomes a viable option when conservative treatments fail to alleviate pain and restore function in individuals with rotator cuff tears. The goal of ARCR is to reattach the torn tendon to the bone, promoting healing and restoring shoulder function. Post-operative re-tears are a significant concern, which surgeons attempt to address using various techniques like suture bridges.

What are suture bridge techniques in ARCR, and what is the role of medial knot tying within these techniques?

Suture bridge techniques in arthroscopic rotator cuff repair (ARCR) aim to enhance initial fixation strength and promote tendon-to-bone healing by maximizing contact area and ensuring mechanical stability. A key component is the medial row fixation, where medial knot tying is frequently used, as it is believed to provide biomechanical advantages. Recent research, however, questions if medial knot tying leads to strangulation, hindering the healing process and outweighing any biomechanical benefits.

How did the Honda et al. (2018) study evaluate the impact of medial knot tying on healing after ARCR?

The Honda et al. (2018) study compared two suture bridge techniques: one with medial knot tying (WMT group) and one without (WOMT group). The researchers followed 124 patients undergoing arthroscopic rotator cuff repair (ARCR) for rotator cuff tears, with 53 meeting inclusion criteria based on clinical and structural evaluations at 3, 12, and 24 months post-surgery. Clinical outcomes were assessed using the University of California Los Angeles (UCLA) and Japanese Orthopaedic Association (JOA) scores. Structural outcomes were evaluated using magnetic resonance images (MRI) and the Sugaya classification system to assess tendon healing.

What were the key findings of the Honda et al. (2018) study regarding re-tear rates and tendon healing between the WMT and WOMT groups?

The Honda et al. (2018) study found no significant difference in postoperative re-tear rates (Sugaya types 4 and 5) between the WMT (with medial knot tying) and WOMT (without medial knot tying) groups. However, at the 24-month mark, the WOMT group showed a significantly higher rate of complete tendon healing (Sugaya type 1) compared to the WMT group. Conversely, the WMT group exhibited a significantly larger number of incompletely healed tendons (Sugaya types 2 and 3) at 24 months post-surgery.

What are the potential implications of the Honda et al. (2018) study's findings for arthroscopic rotator cuff repair techniques and the use of medial knot tying?

The Honda et al. (2018) study challenges the conventional belief in the necessity of medial knot tying in suture bridge techniques for arthroscopic rotator cuff repair (ARCR). While medial knot tying is often favored for its perceived biomechanical advantages, the study suggests it may not translate to superior long-term structural outcomes. The increased rate of incomplete healing in the WMT group suggests that the potential for strangulation and subsequent tendon necrosis at the medial row may outweigh the biomechanical benefits. These findings imply that a knotless approach might be preferable for long-term tendon healing, thus, warranting a re-evaluation of surgical techniques.