Knotted Transosseous Equivalent Technique for Rotator Cuff Repair Shows Superior Biomechanical Properties Compared to a Knotless Technique: A Systematic Review and Meta-Analysis.

Abstract Purpose To compare the biomechanical properties of the knotted versus knotless transosseous equivalent (TOE) techniques for rotator cuff repair (RCR). Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and the Cochrane Library to identify studies that compared the biomechanical properties of knotted and knotless TOE RCR techniques. The search phrase used was: (Double Row) AND (rotator cuff) AND (repair) AND (biomechanical). Evaluated properties included ultimate load to failure, cyclic displacement, stiffness, footprint characteristics, and failure mode. Results Eight studies met inclusion criteria, including a total of 67 specimens in each group. Four of six studies reporting on ultimate load to failure found tendons repaired with the knotted TOE technique to experience significantly higher ultimate load to failure compared to knotless TOE repairs (knotted range, 323.5-549.0, knotless range, 166.0-416.8, p Conclusion Based on the included cadaveric studies, rotator cuff tendons repaired via the knotted TOE technique display superior time-zero biomechanical properties including greater ultimate load to failure compared to rotator cuffs repaired via the knotless TOE technique. Sutures tearing through the tendon remains a common failure method for both techniques.