Rotator cuff tears remain one of the most prevalent causes of shoulder pain and occupational disability, affecting approximately 20% of the population over age 60. While arthroscopic repair has become the global gold standard—replacing traditional open techniques. Historically, focused on simple mechanical fixation of the tendon edge to the bone. The Double-Row technique emerged as a solution to these limitations. Byutilizing both a medial row (near the articular margin) and a lateral row (on the greater tuberosity), the procedure creates a "compression envelope" or Transosseous Equivalent construct. This design aims to maximize the tendon-to-bone contact area, distribute mechanical stress more evenly across the repair, restore the pressurized footprint required for biological integration.

AIM

To assess clinical outcomes, shoulder range of motion, pain relief and complications following arthroscopic double row repair technique in patients with full thickness rotator cuff tear.

METHODS

Study design and setting, patients, preoperative assessment, surgical technique, postoperative rehabilitation, outcome measures, and statistical analysis are described.

Study Design

This was a prospective observational study done over a period of 18 months from june  2024 to december 2025 conducted in the Department of Orthopaedics at Tertiary Care Hospital, Surat.

Study Poplation

All patients between 40-60 years of age with full thckness rotator cuff tear admitted in Department of Orthopaedics at Tertiary Care Hospital, Surat, Gujarat, during the mentioned study period and fulfilling the selection criteria mentioned below were recruited for the study.

Study Duration: 18 months

Inclusion criteria

• Age 40–60 years
• Symptomatic full thickness rotator cuff tear
• Persistent shoulder pain unresponsive to conservative treatment (e.g., physical therapy, medications, or corticosteroid injections) for at least 6 months.
• High functional demand, such as athletes or manual laborers, who require restoration of shoulder strength and range of motion.
• Patient’s giving consent
• Patient compliant and willing to have their surgery

Exclusion criteria

• Active infection
• Neuromuscular disorders
• Significant comorbidities or conditions that contraindicate surgery or anesthesia (e.g.,
• severe cardiovascular or pulmonary disease).
• patient not willing to give

SAMPLE SIZE

15 patients were recruited for this study. Informed written consent was obtained from the patient before recruitment.

Scoring System

The Constant-Murley Score (CMS) is a standardized scoring system that assesses shoulder function. It has a maximum score of 100 points and is divided into four subscales:

Pain: 15 points

Activities of daily living (ADL): 20 points Range of motion (ROM): 40 points Strength: 25 points

The CMS is a combination of patient-reported outcomes, performance measurement, and clinician-reported outcomes. The patient self-reports pain and ADL, while the clinician tests ROM and strength. The CMS is widely used in international studies.

constant scoring system

2.The American Shoulder and Elbow Surgeons (ASES) score is a patientreported outcome measure that assesses shoulder function and pain: Scoring: The ASES score is a 100-point scale that combines a patient-rated questionnaire with a physician-rated section. The patient-rated section includes a pain visual analog scale (VAS) and 10 questions about activities of daily living (ADL). The pain score is calculated by subtracting the VAS from 10 and multiplying by 5. The functional score is calculated by multiplying the sum of the 10 ADL questions by 5/3. The pain and function scores are then added together to get the final ASES score. Interpretation: Higher ASES scores indicate better outcomes.

ASES scoring system

Surgical technique:

Patient Position:

 Arthroscopic double-row repair in the lateral decubitus position combines

 specialized limb traction with a multi-anchor construct to optimize tendon-to-bone

 healing. The patient is placed on their non-operative side on a vaccum sealed

benbag .A well-padded axillary roll is inserted under the non-operative axilla to

protect the brachial plexus.

Traction:

The operative arm is suspended in approximately 15° of forward flexion and 45° of      abduction using a traction device with roughly 10–15 lbs of weight.

Portals:

Posterior (Viewing): Established slightly more laterally than in the beach-chair

position, typically in line with the posterolateral acromion.

Anterior (Working): Created just lateral to the coracoid process.

Lateral/Anterosuperior-Lateral: Positioned to provide a perpendicular trajectory 

for anchor insertion. 

Fig.1

Footprint Preparation:

Debridement: Clear the subacromial bursa using a shaver through the lateral portal.

Decortication: Lightly abrade the greater tuberosity with a burr to create a bleeding bone bed while preserving the dense cortical bone needed for anchor stability

Marrow Stimulation (Crimson Duvet): Create small vents or "microfractures" in the footprint using an awl or K-wire. This releases mesenchymal stem cell and growth factor form a blood clot (the "crimson duvet") to enhance tendon-to-bone healing.

Tendon Mobilization: 

Debride the frayed edges of the SSP and release any adhesions to ensure the tendon can be reduced to the lateral margin of the footprint without excessive tension

Fig.2

Medial Row Fixation:

Anchor Placement: Insert 2–3 suture anchors (often double- or triple-loaded) at articular margin (medial edge of the footprint).

Suture Passing: Use a suture passer to pass limbs through the tendon approximately 10–12 mm medial to its lateral edge. Research often recommends a horizontal mattress configuration to improve load distribution.

Tying (Optional): In conventional double-row techniques, medial row knots are tied before proceeding laterally; however, knotless "suture-bridge" techniques bypass thisto preserve tendon vascularity. 

Lateral Row Fixation (Suture-Bridge Technique)

• Suture Retrieval:Retrieve one or more suture limbs from each medial anchor through the lateral portal.
• Anchor Insertion:Load these sutures into knotless anchors (e.g., SwiveLock).
• Compression:Use the sutures to "bridge" and compress the tendon down onto the footprint as the lateral anchors are fully seated into the lateral greater tuberosity.
• Final Inspection:Confirm the repair covers the entire footprint without "dog-ear" deformities. 

Fig. 3 Intra operative photo

REHABILITATION PROTOCOL

case 1

Fig. 6

                                                                                Fig. 7

Fig. 8

Fig.9- Pre-op Xray

Fig.10- Post Op Xray

Fig. 11

Fig.12

Fig.13

RESULTS

The functional outcomes in case of arthroscopic massive rotator cuff tear using double row technique are generally positive, but outcomes can vary depending on several factors such as tear size, patient age, and adherence to rehabilitation protocols.

Here’s a summary of common findings:

1. Most patients experience significant pain reduction following surgery. While improvement continues throughout the healing process, the most substantial relief is typically noted within the first months.
2. Surgery commonly restores shoulder strength and range of motion. Depending on the severity of tear and the dedication to rehabilitation, a full recovery of function generally takes between 6 and 12 months.
3. Most patients report high level of satisfaction with their surgical outcomes. A successful return to daily activities, including work and sports, is common result.
4. Rehabilitation Clinical success relies on comprehensive post operative rehabilitation that prioritizes the gradual recovery of shoulder kinematics, strength and functional stability.

DISCUSSION

The double-row (DR) technique achieves superior anatomical footprint restoration, re-establishing up to 100% of the native insertion area. This expanded contact area and increased interface pressure provide a more robust environment for biological tendon-to-bone healing

Biomechanical studies confirm that the double row construct provides enhanced mechanical stability, characterized by increased ultimate load to failure, greater stiffness, and reduced gap formation under cyclic loading. These superior biomechanical properties may facilitate more accelerated postoperative rehabilitation protocols by minimizing early strain at the repair site.

CONCLUSION

Arthroscopic rotator cuff repair performed using the double-row technique represents a reliable and effective surgical approach, resulting in significant improvements in pain relief, shoulder function, and range of motion. Restoration of the native tendon footprint combined with enhanced biomechanical stability may facilitate superior tendon healing and lower re-tear rates, particularly in patients with medium to large rotator cuff tears.  

Although favorable functional outcomes have been demonstrated, optimal results depend on appropriate patient selection and surgical expertise. Further high-quality comparative studies are warranted to define clear indications and to determine the long-term superiority of the double-row technique.

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