Rotator Cuff Repair: Is Knot Tying in Suture Bridges Really Necessary?
"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.
Repair Trends and Projections
A study published in 2021 analyzed contemporary rotator cuff repair practice and outcomes, including hospital readmissions and two-year reoperation rates, using laterality tracking. A separate US commercially insured population analysis found that repairs became more frequent, particularly among people aged 50–64, with a growing share performed arthroscopically and in outpatient settings. That analysis also reported increasing comorbidity complexity among patients undergoing repair. A 2026 study plans to project open and arthroscopic repair utilization in Medicare through 2050, incorporating post-COVID recovery data; the supplied material does not report its projected results.
A Challenging Arthroscopic Procedure
Arthroscopic rotator cuff repair is commonly performed, but it can remain challenging to execute despite technological advances, according to a 2021 review. The supplied AAOS snippet emphasizes meticulous preoperative planning, a systematic intraoperative approach, and attention to technical details for successful repair. For partial-thickness tears, conversion repair completes the defect to full thickness before standard arthroscopic repair; the described tradeoff is possible damage to intact cuff tissue, while removing devitalized tissue is an advantage over in situ repair.
From Open to Arthroscopic Repair
Rotator cuff repair techniques evolved from open surgery toward arthroscopic repair, and the techniques continue to develop, including through proposed and tested fixation methods and biological solutions intended to enhance tendon healing. A 2021 review describes arthroscopic rotator cuff repair as having become the gold standard over the preceding 30 years. It reports that from 2004 to 2009, the proportion of repairs performed arthroscopically rose from 48.8% to 74.3%, while the proportion of open procedures fell from 51.2% to 25.7%.
Does Medial Knot Tying Impact Healing After Rotator Cuff Repair?
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.
- 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).
Evidence Limits and Retear Concerns
A prospective randomized clinical trial comparing knot-tying and knotless suture-bridge repair cautioned that its statistical power could be questioned and that a type II error could not be excluded, because the observed retear-rate difference was smaller than the difference used in its sample-size calculation. A systematic review of retear types included 12 studies covering 1,411 shoulders, but only one study had level 1 evidence, three had level 2, and eight had level 3. Separately, a review focused primarily on level 3–4 studies said it could not provide a direct quantitative comparison of technique outcomes. A 2023 report states that rotator cuff repair retear rates range from 13% to 79% and evaluates long-term revision results at a minimum 10-year follow-up.
Knotless and Knot-Tying Outcomes
In a comparison of arthroscopic repair using a modified Mason-Allen medial-row stitch, the reported retear rate was 5.9% in the knotless suture-bridge group and 18.6% in the knot-tying group; the difference was statistically significant (P < .001). The supplied sources do not establish that this result applies to every repair technique or patient group. For arthroscopic versus mini-open repair, a separate analysis reported no statistically significant difference in pain reduction or functional outcomes, with insignificant heterogeneity at six months and 12–24 months.
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.
Technology and Emerging Approaches
A 2025 narrative review describes how technological innovations and refined surgical techniques have expanded the indications for arthroscopy, including for rotator cuff pathology. It examines the historical evolution, current trends, and future perspectives of arthroscopic shoulder surgery. A 2026 market overview reports growing preference for arthroscopic rotator cuff repair, citing its minimally invasive nature and faster recovery times. It also says bioinductive scaffolds and platelet-rich plasma therapies are gaining traction; the supplied source characterizes these as trends, not established proof of improved outcomes.