Single-Row Suture with Tension-Reducing Augmentation Versus Double-Row Suture Bridge Repair for Medium-to-Large U-Shaped Supraspinatus Tears: A Retrospective Cohort Study with 2-Year Follow-Up

Single-Row Suture with Tension-Reducing Augmentation Versus Double-Row Suture Bridge Repair for Medium-to-Large U-Shaped Supraspinatus Tears: A Retrospective Cohort Study with 2-Year Follow-Up | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Single-Row Suture with Tension-Reducing Augmentation Versus Double-Row Suture Bridge Repair for Medium-to-Large U-Shaped Supraspinatus Tears: A Retrospective Cohort Study with 2-Year Follow-Up Yongde Wu, Zhenghui Shang, Xianhua Cai, Zhangsheng Dai This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9022014/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Double-row suture bridge (DRS-B) repair is widely used for medium-to-large U-shaped supraspinatus tendon tears and yields satisfactory clinical outcomes. However, it is associated with higher surgical complexity, increased anchor, and potential complications—including stiffness, chondral injury, and hardware-related issues. Single-row suture repair combined with tension-reducing (SRS-TR) is an emerging alternative designed to simplify fixation while preserving tendon biology and reducing mechanical stress. This study aimed to compare the early-to-midterm clinical and radiographic outcomes of SRS-TR versus DRS-B for medium-to-large U-shaped supraspinatus tears. Methods Primary endpoints included A retrospective cohort study was conducted on 60 patients diagnosed with medium-to-large (2–5 cm in maximal width) U-shaped supraspinatus tears, who underwent arthroscopic repair between January 2020 and January 2025. Patients were allocated to either the SRS-TR group (n = 30) or the DRS-B group (n = 30) based on surgeon preference and intraoperative decision-making (no randomization). Evaluation indicators included intraoperative anchor usage, and acromiohumeral distance (AHD),length of hospital stay, follow-up duration, postoperative shoulder range of motion (ROM), visual analogue scale (VAS) for pain, UCLA Shoulder Rating Scale, American Shoulder and Elbow Surgeons (ASES) score, patient-reported surgical satisfaction, tendon integrity (Sugaya classification on MRI at ≥ 6 months), and retear rate. All assessments were performed at standardized intervals: baseline, 3 days, 3 months, 6 months, 12 months,24 monthsand final follow-up. Results The SRS-TR group demonstrated significantly shorter operative time (mean difference: −49.6 min, P = 0.033), lower anchor usage (mean 3 vs.4 anchors, P < 0.001), and reduced incidence of intraoperative anchor revision (0% vs. 13.3%, P = 0.038) compared with the DRS-B group. AHD was significantly greater in the SRS-TR group both at 3 days postoperatively (mean 9.91 mm vs. 7.12 mm, P = 0.022) and at final follow-up (mean 11.81 mm vs. 9.12 mm, P = 0.043), suggesting improved superior tendon reduction and less superior migration of the humeral head. No postoperative complications (infection, neurovascular injury, stiffness, or anchor-related adverse events) occurred in either group. There were no statistically significant differences between groups in hospital stay, follow-up duration,ROM,VAS,UCLA, ASES, surgical satisfaction, or retear rate (Sugaya Type IV–V: 3.3% in SRS-TR vs. 6.6% in DRS-B; P = 0.141). Conclusions At a mean follow-up of 23.1 months, both SRS-TR and DRS-B achieved comparable functional outcomes, pain relief, and patient satisfaction in patients with medium-to-large U-shaped supraspinatus tears. However, SRS-TR offered significant procedural advantages—including shorter operative time, reduced anchor burden, lower intraoperative revision rates, and superior maintenance of AHD—suggesting potentially enhanced biological healing and reduced mechanical strain on the repaired tendon. These findings support SRS-TR as a safe, efficient, and cost-effective alternative to DRS-B for selected U-shaped tears. Level of evidence Level III, comparative study Arthroscopy Double-row suture bridge Single-row suture with tension reduction Supraspinatus tendon tear U-shaped tear Acromiohumeral distance Tendon healing Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Rotator cuff tears (RCTs) are highly prevalent, affecting approximately 36% of symptomatic individuals and 16.9% of asymptomatic individuals in the general population [ 1 ]; overall prevalence estimates range from 20% to 30% [ 1 , 2 ]. Pain is the predominant clinical manifestation of RCTs and is often severe enough to markedly impair sleep quality and shoulder function [ 3 ]. Persistent pain may precipitate progressive functional decline and contribute to secondary glenohumeral joint pathology [ 4 ], underscoring the urgent need for effective therapeutic interventions [ 5 ]. Arthroscopic rotator cuff repair (ARCR) has become the standard of care, with single-row (SR), double-row (DR), and modified suture bridge configurations widely adopted [ 1 , 3 , 5 , 6 ]. Recent emphasis has shifted toward low-tension repair techniques, given mounting evidence that excessive tension compromises tendon perfusion and healing. While DR suture bridge repair offers superior tendon–bone contact area, contact pressure, and biomechanical strength—translating into improved anatomic healing rates in multiple studies [ 1 – 7 ]—it entails greater technical complexity and carries theoretical risks, including tendon strangulation, reduced vascularity, and iatrogenic overtensioning [ 7 , 8 ]. Notably, postoperative retear rates remain unacceptably high, ranging from 10% to 30% [ 8 ]. In contrast, medialized SR suture bridge repair offers procedural simplicity and may be advantageous for retracted tendons [ 9 ]; however, in medium-to-large tears, its limited footprint coverage and suboptimal tension restoration result in inferior biomechanical support and higher failure rates, restricting its utility in cases requiring substantial tension reduction [ 7 ]. To address these limitations—particularly the inadequate tension distribution and footprint coverage inherent in conventional SR repair for large RCTs—we developed an enhanced SR technique: the single-row suture with transosseous lateral reinforcement (SRS-TR). This approach augments a standard SR construct with free lateral row anchors, thereby improving tension distribution across the tendon–bone interface and facilitating secure, low-tension approximation of the anatomical footprint. We hypothesize that the SRS-TR technique will yield superior fixation stability and lower complication rates compared with conventional SR and DR configurations. Methods General information Clinical datas were retrospectively collected from 60 patients diagnosed with medium to large U-shaped tear of the supraspinatus muscle. The cohort comprised 25 males and 35 females, with a mean age of 65 ± 9.7 years (range: 55–75 years). A total of 23 cases involved the left shoulder and 37 involved the right shoulder. The etiology was traumatic in 18 patients, while 42 patients had no identifiable cause.The patients were divided into two groups of 30 cases each (Fig. 1 ). The observation group was treated with three screws and the single-row suture combined with tension-reducing technique:tension reduction in the outer row combined with single-row repair and fixation(Fig. 2 ). The control group was treated with four screws and the double-row suture bridge technique for repair (Fig. 3 ). The hospitalization time, follow-up time, operation time, intraoperative screw removal, and the muscle strength of shoulder abduction and flexion, VAS, UCLA, ASES, and surgical satisfaction at the last follow-up were recorded. The healing of the rotator cuff was evaluated by Sugaya classification MRI, and AHD was measured by anteroposterior X-ray. Inclusion and exclusion criteria Inclusion criteria were as follows: (1) preoperative MRI confirming a medium-sized supraspinatus tendon tear with Goutallier grade 0–IV fatty infiltration; (2) failure of conservative management and patient willingness to undergo minimally invasive surgical repair; (3) intraoperative confirmation of a full-thickness supraspinatus tear measuring 2–5 cm in width, with favorable tendon quality and significant retraction under tension; (4) a U-shaped tear configuration of the supraspinatus tendon; and (5) patient ability to comply with postoperative rehabilitation protocols. Exclusion criteria included: (1) excessive intraoperative tension preventing complete anatomical coverage of the footprint; (2) concomitant subscapularis or long head of biceps tendon pathology requiring surgical intervention; (3) history of multiple prior shoulder surgeries involving the rotator cuff; and (4) incomplete follow-up or follow-up duration shorter than 18 months. This study constituted a retrospective observational analysis approved by the institutional ethics committee, with the requirement for individual informed consent waived. Operative technique Two groups of patients underwent surgical intervention under general anesthesia. In cases presenting with joint stiffness, manual release was performed to achieve normal range of motion following adequate anesthetic depth. During the procedure, patients were positioned laterally in a 45-degree semi-recumbent posture and secured accordingly, with robotic arm-assisted traction applied. Arthroscopic evaluation was conducted via a posterior approach to rule out labral or subscapularis muscle injuries and to assess potential pathology of the long head of the biceps tendon. Instruments including a radiofrequency ablation device and arthroscopic shaver were introduced through an anterior portal to achieve complete release of the subscapularis-tendon interval as well as the middle and inferior glenohumeral ligament bundles. The subacromial space was meticulously debrided to remove hypertrophic subacromial bursa and adhesions located on the superior and inferior surfaces of the supraspinatus and infraspinatus tendons. In instances where excessive tension impeded reduction, anterior release of the coracohumeral ligament was performed. When signs of impingement were observed, acromioplasty was carried out, and the rotator cuff footprint was prepared by surface freshening. The characteristics of the supraspinatus tendon tear—including tear type, width, tendon quality, and direction of retraction—were evaluated using probing instruments and forceps. It was confirmed that the medial tendon edge could be fully reduced to the anatomical footprint under tension, reaching a position 2 mm lateral to the articular cartilage margin. In the SRS-TR group, the external-row technique involved initial use of a suture hook with PDS-II suture for guidance, followed by placement of two free-running non-absorbable sutures (Johnson & Johnson Size 2.0) passed from the intra-articular side of the supraspinatus tendon-abdominal junction through the tendon substance to the subacromial side, with all four suture ends retained for subsequent tensioning. For the single-row component, two anchors were inserted approximately 5 mm from the cartilage margin, and sutures were passed and secured accordingly. Under conditions of abduction and optimal reduction, the free sutures designated for external-row fixation were tensioned. Once anatomical alignment of the tendon's lateral edge to the greater tuberosity was achieved, a Johnson & Johnson SwiveLock anchor was implanted on the lateral aspect of the greater tuberosity and compressed for secure fixation. Subsequently, the two Single row rivets were tied to ensure closure of the joint capsule (Fig. 2 ). In the DRS-B group, the conventional double-pulley suture-bridge technique was employed (Fig. 3 ). Beginning on the first postoperative day, patients were instructed to perform active flexion and extension exercises of the wrist and elbow joints, along with isometric contractions of the shoulder joint and other passive rehabilitation activities. Sutures were removed one week after surgery. A shoulder abduction brace was worn for immobilization during the initial six weeks postoperatively. Active rehabilitation exercises, including forward flexion, abduction, and internal and external rotation of the shoulder joint, were initiated at six weeks post-surgery. Shoulder strengthening exercises were progressively intensified starting at 12 weeks postoperatively, allowing patients to gradually resume normal daily activities and sports. Regular follow-up evaluations were scheduled at baseline, 3 days, 3 months, 6 months, 12 months,24 months,and final follow-up. Observation indicators Pain severity was assessed using the 11-point Visual Analog Scale (VAS) (0 = no pain; 10 = worst imaginable pain). Shoulder function was evaluated using two validated patient-reported and clinician-assessed instruments: The UCLA Shoulder Rating Scale, comprising five domains—pain (0–10), function (0–10), forward flexion range of motion (0–5), forward flexion strength (0–5), and patient satisfaction (0–5)—yielding a total score of 0–35 (higher scores indicate better function). The American Shoulder and Elbow Surgeons (ASES) Score, integrating pain (0–50) and function (0–50) subscales ( activities of daily living, range of motion, strength, stability), with a total score of 0–100 (higher scores reflect superior shoulder function). All three scores (VAS, UCLA, ASES) were recorded preoperatively and at the final postoperative follow-up. Additional objective and procedural outcomes included: Length of hospital stay (days) .Duration of clinical follow-up (months) Operative time (minutes) .Intraoperative nail removal (yes/no) Passive range of motion (PROM) for shoulder flexion, abduction, and external rotation (measured in degrees, preoperatively and at final follow-up) .Patient satisfaction, categorized on a 5-point ordinal scale: very satisfied, satisfied, somewhat satisfied, dissatisfied, and very dissatisfied. Imaging Assessments MRI was performed within 3 days postoperatively, and at 3 months and 2 years post-surgery, to evaluate rotator cuff tendon continuity and healing. Healing was graded using the Sugaya classification: Type I: Homogeneous low signal, normal tendon thickness Type II: Normal thickness but increased signal intensity Type III: Residual thickness < 50% of normal, without complete discontinuity Type IV: Discontinuity visible in 1–2 adjacent MRI slices Type V: Tendon gap evident in ≥ 3 consecutive slices Types I–III were defined a priori as indicative of successful structural healing[ 3 ]. Anteroposterior (AP) radiographs of the shoulder were obtained preoperatively and postoperatively to measure the acromiohumeral distance (AHD) (mm), a radiographic surrogate for superior humeral head migration. Statistical methods Data analysis was performed using SPSS version 24.0. Categorical data are presented as frequencies and percentages (%), and group comparisons were conducted using the chi-square test. Continuous variables are summarized as mean ± standard deviation (M ± SD). For normally distributed data, independent samples t-tests were applied to compare group means. Statistical significance was defined as a two-tailed p-value less than 0.05. Results Preoperative Assessment and Representative Case Presentations All patients were successfully followed up. No significant differences in baseline characteristics prior to the procedure were observed, as shown in Table 1 . Representative cases are illustrated in Figs. 4 and Figs. 5 . Table 1 Comparison of preoperative general data between the two groups Age [years, x ± s] The SRS-TR group(n = 30) the DRS-B group(n = 30) P value a 52.3 ± 15.2 55.7 ± 17.2 0.876 b Gender ( male/female) 14༏16 15༏15 0.781 b Disease history duration (months, x ± s) 8.6 ± 2.2 7.2 ± 3.1 0.893 b Comorbidities: Hypertension Coronary Heart Disease / Others 8 9 0.631 b Fat infiltration (grade III + IV) 14 13 0.431 b Acromion classification (II + III) 23 21 0.631 b Osteoporosis condition (severe) 14 12 0.763 b There was a statistically significant difference in the operation time and the intraoperative nail removal rate a P<.05 was considered statistically significant b t test Comparison of perioperative data between the two groups A total of 60 patients with a mean follow-up of 23.1 months were selected in the study( 24 months in the SRS-TR group and 22 months in the DRS-B group). During surgery, Loosening of rivet occurred in 4 cases in the control group(3 case in internal rivet and 1 cases in external rivet). The 4 cases achieved initial stability following positional adjustment. The operative time in the SRS-TR group (101.00 ± 12.59 minutes) and the intraoperative nail removal rate (0%) were significantly lower than those in the DRS-B group (150.40 ± 20.52 minutes; 13%)(Table 2 and Fig. 6 ). Table 2 Comparison of perioperative data between the two groups The time of operation(min, x ± s) The SRS-TR group(n = 30) the DRS-B group(n = 30) P value a 101.00 ± 12.59 150.40 ± 20.52 0.033 b Total hospital stay time(d, x ± s) 7.55 ± 2.34 8.11 ± 3.23 0.238 b follow-up period(m, x ± s) 24.51 ± 6.54 23.11 ± 5.23 0.718 b Loosening of rivet (cases, %) 0, 0% 4, 13% 0.038 c a P<.05 was considered statistically significant b Pearson χ 2 test c t test Shoulder flexion angle and VAS, UCLA and ASES scores The range of motion for shoulder joint flexion, abduction, external rotation, and internal rotation, as well as VAS, UCLA and ASES scores, showed significant improvement in both groups compared to preoperative values. At the final follow-up, these outcomes were further improved relative to those recorded at 3 days postoperatively. Postoperative patient satisfaction was high, exceeding 90.0%. At the final follow-up, there was no statistically significant difference in the retearing rate between the two groups (p = 0.141) (Table 3 ). Table 3 Comparison of Shoulder flexion angle and VAS, UCLA and ASES scores Full range activity time (d,x ± s) point-in-time The SRS-TR group (n = 30) the DRS-B group (n = 30) P value a 131.43 ± 3.17 134.12 ± 32.56 0.672 c VAS scores(scores, x ± s) pre-operation 8.9 ± 1.1 8.6 ± 1.1 0.821 c Three days after the operation 3.4 ± 1.0 4.0 ± 0.9 0.332 c At the last follow-up visit 0.78 ± 0.3 0.9 ± 0.4 0.343 c P value a < 0.001 < 0.001 UCLA scores(scores, x ± s) pre-operation 13.4 ± 2.7 13.7 ± 2.8 0.341 c Three days after the operation 18.3 ± 2.6 17.0 ± 2.5 0.231 c At the last follow-up visit 31.8 ± 1.9 30.1 ± 2.1 0.403 c P value a < 0.001 < 0.001 ASES scores(scores, x ± s) pre-operation 32.4 ± 3.2 36.2 ± 3.1 0.612 c Three days after the operation 62.2 ± 5.7 58.0 ± 5.2 0.280 c At the last follow-up visit 95.2 ± 3.0 94.4 ± 4.5 0.121 c P value a < 0.001 < 0.001 abduction ROM (°) pre-operation 86.5 ± 21.7 89.0 ± 21.9 0.932 c Three days after the operation 102.0 ± 22.5 99.3 ± 23.0 0.240 c At the last follow-up visit 148.2 ± 23.7 142.8 ± 22.2 0.795 c P value a < 0.001 < 0.001 anteflexion ROM (°) pre-operation 70.5 ± 26.7 72.8 ± 27.0 0.917 c Three days after the operation 120.3 ± 21.2 111.4 ± 22.0 0.142 c At the last follow-up visit 154.1 ± 20.4 153.7 ± 19.3 0.242 c P value a < 0.001 < 0.001 Postoperative re-tear (n,%) At the last follow-up visit 1, 3.3% 2, 6.6% 0.141 b a P<.05 was considered statistically significant b Pearson χ 2 test c t test AHD and number of Sugaya classified indicators (person) At the 6-month follow-up, 2 patients in the SRS-TR control group and 0 patients in the DRS-B group were found to have full-thickness rotator cuff tears on MRI, with no significant tendon retraction observed. Both patients reported satisfaction with symptom relief and did not require additional intervention. The acromiohumeral distance (AHD) values in the SRS-TR group at postoperative day 3 and at the final follow-up (9.91 ± 1.13 mm and 11.81 ± 1.12 mm, respectively) were significantly higher than those in the DRS-B group (7.12 ± 1.92 mm and 9.12 ± 2.02 mm, respectively), with statistically significant differences (P = 0.022 and P = 0.043). ( Table 4 ). Table 4 Comparison of AHD and Number of Sugaya classified indicators (person) AHD(mm, x ± s) point-in-time The SRS-TR group (n = 30) the DRS-B group (n = 30) P value a pre-operation 6.41 ± 1.17 6.42 ± 2.18 0.678 c Three days after the operation 9.91 ± 1.13 7.12 ± 1.92 0.022 c At the last follow-up visit 11.81 ± 1.12 9.12 ± 2.02 0.043 c P value a < 0.001 0.05 > 0.05 a P<.05 was considered statistically significant b Pearson χ 2 test c t test Discussion The most significant finding of this study is that the suture-bridge–based single-row–tensioned repair (SRS-TR) technique demonstrates comparable clinical efficacy to the conventional double-row suture-bridge (DRS-B) technique at intermediate-term follow-up for medium-to-large U-shaped supraspinatus tears. Although prior studies have reported no significant differences in retear rates between single-row and double-row rotator cuff repair techniques overall [ 10 ], single-row approaches may be associated with higher failure rates specifically in large or extensive tears [ 11 , 12 ]. In contrast, the double-row technique is widely recommended for such cases due to its superior capacity for anatomical tendon repositioning and enhanced biomechanical fixation strength [ 13 ]. Our findings indicate that the SRS-TR technique successfully integrates key advantages of the single-row approach—such as technical simplicity and reduced suture-related tendon trauma—while mitigating several limitations of conventional single-row fixation, particularly with respect to fixation stability and footprint restoration. Notably, SRS-TR was associated with a significantly shorter operative duration and reduced procedural costs, attributable to lower anchor utilization. Although the DRS-B technique offers well-documented biomechanical advantages [ 9 , 14 , 15 ], it is technically demanding: conventional double-row or modified Mason–Allen suture-bridge configurations typically require three to four separate suture passes per inner-row anchor—performed using either a suture hook or suture passer—thereby increasing surgical complexity, intraoperative time, and potential for iatrogenic tendon injury. By contrast, the SRS-TR technique achieves robust fixation with only two suture passes per anchor, resulting in improved procedural efficiency, reduced technical demand, and diminished risk of tendon trauma. According to the Sugaya classification system [ 3 ], tendon healing integrity was superior in the SRS-TR group compared with the DRS-B group. While arthroscopic rotator cuff repair (ARCR) demonstrates long-term efficacy—particularly for small and medium-sized tears—over a 10-year follow-up [ 15 ], recent evidence (2019–2024) indicates that retear rates after ARCR for large, high-tension tears range from 25% to 94% [ 2 ]. Preclinical studies in rabbit models have shown that low-tension mechanical stimulation enhances healing at the tendon–bone interface, whereas excessive tension impairs tissue integration and increases susceptibility to postoperative retear [ 14 ]. Cho et al. [ 17 ] observed that, following double-row suture-bridge repair, recurrent tears occurred most frequently near the inner-row anchor sutures—structures that pose significant technical challenges for revision surgery. In the DRS-B technique, the medial row must simultaneously achieve tension reduction and sufficient compression; however, knot-tying at this site exacerbates local soft-tissue stress, potentially compromising tendon viability [ 7 , 8 , 18 , 19 ]. This has led to the recognition of a distinct retear pattern—termed “medial failure”—characterized by rupture proximal to the reconstruction site at the musculotendinous junction, likely resulting from focal tendon strangulation and stress concentration [ 20 ]. To address tension-related failure in large tendon defects, numerous modifications have been proposed [ 7 , 21 ], including optimized anchor positioning and refined suture configurations [ 21 – 23 ]. Although traditional single-row and modified Mason–Allen techniques reliably achieve tendon-to-bone apposition, their limited footprint coverage concentrates mechanical stress and increases the risk of suture cut-through [ 24 ]. Consequently, these techniques provide inadequate mechanical support for medium-to-large tears and are associated with higher retear rates [ 19 ], limiting their applicability in demanding clinical scenarios. In contrast, the SRS-TR technique employs a standard single-row foundation augmented by free lateral-row anchors, thereby improving tension distribution across the repaired tendon and enabling secure, anatomic footprint approximation. Furthermore, single-row sutures are tied under controlled low tension to achieve stable closure of the joint capsule—enhancing tendon insertion contact and creating a favorable microenvironment for biological healing. This construct not only reinforces medial-row suture stability but also minimizes the risk of joint fluid ingress into the tendon–bone interface [ 25 , 26 ], a known contributor to impaired healing. The absence of statistically significant differences in retear rates between groups may reflect limitations inherent to this study—including its relatively short follow-up duration, single-center design, and modest sample size. Neyton et al. [ 27 ] reported that a reduction in acromiohumeral distance (AHD) following rotator cuff repair is associated with an improved structural and functional prognosis—and specifically, that a postoperative decrease in AHD correlates with a lower risk of supraspinatus retear. In the present study, AHD in the SRS-TR group decreased significantly by postoperative day 3 and remained stably reduced at final follow-up, suggesting enhanced tendon healing and potentially reduced retear risk during rehabilitation. For patients with medium-to-large, high-tension supraspinatus tears, medial-row anchor pullout remains a recognized concern. Compared with the DRS-B technique, the SRS-TR group exhibited a significantly lower intraoperative anchor dislodgement rate. Moreover, SRS-TR enabled more spatially dispersed suture configurations and greater intraoperative flexibility. In this technique, traction tension was primarily borne by the lateral-row anchors—decoupling reduction forces from the medial-row fixation and allowing real-time, image-guided adjustment to achieve and stabilize anatomic tendon reduction. Joint capsule closure was accomplished using a simplified single-row configuration, independent of lateral-row anchor position or tension. In contrast, the DRS-B technique relies on medial-row anchor placement with sutures passed more medially to optimize tendon footprint contact and reduction. However, limited arthroscopic visualization—combined with inherent tendon elasticity—makes precise intraoperative prediction of optimal medial-row suture passage points challenging, introducing procedural uncertainty. Conversely, excessively lateral or loose suture placement compromises reliable anatomical reduction [ 28 ]. Notably, four instances of anchor dislodgement occurred in the DRS-B group; analysis suggested contributing factors included overaggressive cortical debridement and localized stress concentration—both of which may elevate mechanical load at the repair site and impair biological healing [ 29 ]. Tendon reduction and retraction tension represent a critical determinant of postoperative retear risk [ 30 ]. Although supraspinatus tendon reduction tension is influenced by multiple factors—including tendon quality [ 22 ] and chronicity of tear [ 31 ]—intraoperative assessment of tear morphology and precise tissue repositioning are equally essential for achieving optimal tension [ 32 ]. Conventionally, greater tendon retraction correlates with higher reduction tension [ 30 , 32 ], and accurate intraoperative quantification of reduction tension is therefore pivotal to optimizing surgical outcomes and minimizing retear rates. However, no standardized, clinically validated threshold for defining “high tension” during rotator cuff repair currently exists, and reported measurements vary considerably across studies. Davidson et al. evaluated reduction tension in 67 rotator cuff repairs and found that tension exceeding 8 lbf (≈ 35.6 N) was associated with suboptimal functional and structural outcomes [ 33 ]. In a cadaveric study simulating posterosuperior reverse L-shaped tendon defects across seven shoulder specimens, mean traction force required for anatomical reduction was 16.02 N, whereas malreduction necessitated a significantly higher mean force of 19.52 N [ 28 ]. Among symptomatic patients enrolled in randomized controlled trials, supraspinatus tendon tears remain the most common pathology [ 34 ]. In the present study, we focused on U-shaped supraspinatus tears with 2–5 cm retraction; however, we did not systematically quantify reduction tension or investigate its relationship with tension-relieving suture techniques. Consequently, the optimal tension threshold at which adjunctive tension-relieving strategies—such as the SRS-TR technique—should be employed remains undefined and warrants further investigation in prospective, biomechanically informed studies. Limitations This study has several limitations that warrant careful consideration. First, tensioned external fixation and knot-tying in single-row repair techniques may reduce the subacromial space, and the inherently limited visualization associated with such approaches can complicate suture management. Preemptive subacromial synovectomy, subacromial release, and acromioplasty may therefore be indicated to improve arthroscopic exposure and enhance surgical precision. Second, single-row repair concentrates suture ends at a localized site, potentially increasing the risk of foreign-body reaction; prolonged mechanical irritation and friction may further promote subacromial cortical bone resorption, with possible implications for long-term clinical durability. Third, tensioned external fixation may be suboptimal for patients with massive rotator cuff tears or advanced fatty degeneration of the supraspinatus—conditions associated with diminished tissue quality and higher failure risk. In such cases, augmenting the number of lateral-row anchors may improve load distribution and construct stability. Finally, osteoporosis of the humeral greater tuberosity may compromise anchor fixation strength, predisposing to early loosening or pullout and thereby undermining initial biomechanical integrity [ 35 ]. Notably, this study did not systematically assess greater tuberosity bone quality or its impact on fixation integrity—representing a potential source of unmeasured confounding. Conclusions This study demonstrates that the SRS-TR technique achieves favorable safety and efficacy outcomes at intermediate-term follow-up for medium-to-large U-shaped supraspinatus tendon tears. Compared with the conventional DRS-B technique, SRS-TR offers several advantages: enhanced technical simplicity, significantly shorter operative time, lower intraoperative anchor dislodgement rates, and comparable retear rates. Nevertheless, definitive conclusions regarding optimal tension management remain limited by the absence of standardized, quantitative intraoperative tension measurement. Large-scale, high-quality multicenter randomized controlled trials are therefore warranted—incorporating rigorous stratification by tear size, quantitative assessment of reduction tension, and standardized biomechanical reporting—to elucidate the most effective tension-mitigating strategies and inform evidence-based surgical recommendations. Abbreviations SRS-TR single-row suture combined with tension-reducing DRS-B double-row suture bridge RCTs rotator cuff tears ARCR arthroscopic rotator cuff repair MRI Magnetic resonance imaging VAS pain visual analogue scale UCLA university of California Los Angeles ASES American Shoulder and Elbow Surgeon's Form AHD acromiohumeral distance Declarations Ethics approval and consent to participate This study was approved by The Ethics Committee of China Three Gorges University. All methods were carried out in accordance with relevant guidelines and regulations (protocol 20254801). Clinical trial number Not applicable Consent for publication Not applicable Availability of data and materials Yes, I have research data to declare. "If you require the raw data, please contact the corresponding author at Zhangsheng Dai [email protected] ." Competing interests No, I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Author contributions YW carried out the studies, participated in collecting data, and drafted the manuscript. CX and ZS performed the statistical analysis and participated in its design. ZD helped to draft the manuscript and performed the data acquisition & analysis. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elb Surg. 2010;19(1):116–20. Clinker C, Soule S, Presson AP, Zhang C, Joyce C, Tashjian RZ, et al. Does dynamically tensioning suture alter outcomes after rotator cuff repair? J Shoulder Elb Surg. 2025;34(10):2378–84. Zuo J, Chen C, Guo J, Lin J, You T, Chen P, et al. Efficacy of rotator cuff suture and arthroscopic 360° capsular release in patients with rotator cuff tear with limited shoulder movement. BMC Surg. 2023;23(1):379. Yamamura K, Mikami Y, Irii A, Nishimoto H, Mukaihara S, Yoshikawa T, et al. A novel therapy using fish scale collagen scaffold for rotator cuff healing in a rat model. J Shoulder Elb Surg. 2022;31(12):2629–37. Kilicoglu IO, Zukor DJ, Adeeb N, Park T, Menendez ME, Denard PJ. Determining the minimal clinically important difference and patient acceptable symptom state after isolated subscapularis repair in arthroscopic shoulder surgery. JSES Int. 2024;8(3):472–7. Fox MA, Hughes JD, Drain NP, Wagala N, Patel N, Nazzal E, et al. Knotted and knotless double row transosseous equivalent repair techniques for arthroscopic rotator cuff repair demonstrate comparable post-operative outcomes. Knee Surg sports Traumatol arthroscopy:official J ESSKA. 2023;31(5):1919–24. Christoforetti JJ, Krupp RJ, Singleton SB, Kissenberth MJ, Cook C, Hawkins RJ. Arthroscopic suture bridge transosseus equivalent fixation of rotator cuff tendon preserves intratendinous blood flow at the time of initial fixation. J Shoulder Elb Surg. 2012;21(4):523–30. Imam M, Sallam A, Ernstbrunner L, Boyce G, Bardakos N, Abdelkafy A, et al. Three-year functional outcome of transosseous-equivalent double-row vs. single-row repair of small and large rotator cuff tears: a double-blinded randomized controlled trial. J Shoulder Elb Surg. 2020;29(10):2015–26. Lee KW, Moon KH, Ma CH, Lee GS, Yang DS, Choy WS. Clinical and radiologic outcomes after medializing and not medializing rotator cuff tendon attachment site on chronic retracted rotator cuff tears. Arthroscopy. 2018;34(8):2298–307. Azar M, Vandermeijden O, Pireau N, Chelli M, Gonzalez JF, Boileau P. Arthroscopic revision cuff repair: do tendons have a second chance to heal? J Shoulder Elb Surg. 2022;31(12):2521–31. Hao B, Li H, Liang A. Effects of early exercise and immobilization after arthroscopic rotator cuff repair surgery: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2025;26(1):254. Quan X, Wu J, Liu Z, Li X, Xiao Y, Shu H, et al. Outcomes after Double-Layer repair versus En masse repair for delaminated rotator cuff injury: A systematic review and Meta-analysis. Orthop J Sports Med. 2023;11(10):23259671231206183. Di Benedetto P, Mancuso F, Tosolini L, Buttironi MM, Beltrame A, Causero A. Treatment options for massive rotator cuff tears: a narrative review. Acta Biomed. 2021;92(S3):e2021026. Plachel F, Siegert P, Rüttershoff K, Thiele K, Akgün D, Moroder P, et al. Long-term Results of Arthroscopic Rotator Cuff Repair: A Follow-up Study Comparing Single-Row Versus Double-Row Fixation Techniques. AM J SPORT MED. 2021;48(7):1568–74. Moser M, Lund G, Seljøe US, Haldorsen B, Svege IC, Hennig T, et al. At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears. The Journal of bone and joint surgery. Am volume. 2019;101(12):1050–60. Lee BG, Cho NS, Rhee YG. Modified Mason-Allen suture bridge technique:a new suture bridge technique with improved tissue holding by the modified Mason-Allen stitch. Clin Orthop Surg. 2012;4(3):242–5. Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained? Am J Sports Med. 2011;39(10):2108–16. Nie S, Qin H, Tan H, Zhao P, Yan W, Zhou A, et al. Suture tape anchors for enhancing healing in rotator cuff tears: a retrospective cohort study. BMC Musculoskelet Disord. 2025;26(1):470. Honda H, Gotoh M, Mitsui Y, Nakamura H, Tanesue R, Shimokobe H, et al. Clinical and structural outcomes after arthroscopic rotator cuff repair: a comparison between suture Bridge techniques with or without medial knot tying. J Orthop Surg Res. 2018;13(1):297. Lädermann A, Christophe FK, Denard PJ, Walch G. Supraspinatus rupture at the musclotendinous junction: an uncommonly recognized phenomenon. J Shoulder Elb Surg. 2012;21(1):72–6. Maillot C, Martellotto A, Demezon H, Harly E, Le Huec JC. Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis. Clin J Sport Med. 2021;31(6):501–8. Dierckman BD, Wang DW, Bahk MS, Burns JP, Getelman MH. Vivo Measurement of Rotator Cuff Tear Tension:Medial Versus Lateral Footprint Position. American journal of orthopedics. (Belle Mead NJ). 2016;45(3):E83–90. Liu J, Chen M, Xu T, Tian Z, Xu L, Zhou Y. Functional results of modified Mason-Allen suture versus horizontal mattress suture in the arthroscopic Broström-Gould procedure for chronic ankle instability. J Orthop Surg Res. 2022;17(1):459. Zafra M, Uceda P, Muñoz-Luna F, Muñoz-López RC, Font P. Arthroscopic repair of partial-thickness articular surface rotator cuff tears: single-row transtendon technique versus double-row suture bridge (transosseous equivalent) fixation: results from a prospective randomized study. Arch Orthop Trauma Surg. 2020;140(8):1065–71. Lo IKY, Burkhart SS. Transtendon arthroscopic repair of partial-thickness, articular surface tears of the rotator cuff. Arthroscopy. 2004;20(2):214–20. Arrigoni P, Brady PC, Burkhart SS. The double-pulley technique for doublerow rotator cuff repair. Arthroscopy. 2007;;23(6):675.e1-4. Neyton L, Godenèche A, Nové-Josserand L, Carrillon Y, Cléchet J, Hardy MB. Arthroscopic suture-bridge repair for small to medium size supraspinatus tear: healing rate and retear pattern. Arthroscopy. 2013;29(1):10–7. Pastor MF, Kraemer M, Schwarze M, Hurschler C, Smith T, Wellmann M. The effect of rotator cuff malreduction on tendon tension: an evaluation of a custom-made digital tensiometer clamp. Arch Orthop Trauma Surg. 2018;138(2):219–25. Chung SW, Kim JY, Kim MH, Kim SH, Oh JH. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med. 2013;41(7):1674–83. Ho SWL. Repair of Massive Rotator Cuff Tear With Medialization and Balloon Spacer Insertion. Arthrosc Tech. 2023;13(1):102821. Lowry V, Lavigne P, Zidarov D, Matifat E, Cormier AA, Desmeules F. A Systematic Review of Clinical Practice Guidelines on the Diagnosis and Management of Various Shoulder Disorders. Arch Phys Med Rehabil. 2024;105(2):411–26. Araya-Quintanilla F, Gutiérrez-Espinoza H, Gana-Hervias G, Cavero-Redondo I, Álvarez-Bueno C. Association between type of rotator cuff tear and functional outcomes in patients with massive and irreparable rotator cuff tear: A pre-post intervention study. J Shoulder Elbow Surg. 2021;;30(6):1393–1401. Davidson PA, Rivenburgh DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elb Surg. 2000;9(6):502–6. Enger M, Schmidt M, Nordsletten L, Moosmayer S, Pripp AH, Melhuus K, et al. Physical examination tests in the acute phase of shoulder injuries with negative radiographs: a diagnostic accuracy study. BMC Musculoskelet Disord. 2025;26(1):546. Meyer DC, Fucentese SF, Koller B, Gerber C. Association of osteopenia of the humeral head with full-thickness rotator cuff tears. J Shoulder Elb Surg. 2004;13(3):333–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9022014","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602959284,"identity":"205fad0b-d3f0-45ac-b7ed-97e425febcbd","order_by":0,"name":"Yongde Wu","email":"","orcid":"","institution":"Second Affiliated Hospital of Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yongde","middleName":"","lastName":"Wu","suffix":""},{"id":602959286,"identity":"d1288b68-c51a-4adc-802b-8d8e6b9e33d9","order_by":1,"name":"Zhenghui Shang","email":"","orcid":"","institution":"The People's Hospital of China Three Gorges University, Yichang Central People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhenghui","middleName":"","lastName":"Shang","suffix":""},{"id":602959287,"identity":"6ae16586-8eb7-488d-aa18-08f9931170e6","order_by":2,"name":"Xianhua Cai","email":"","orcid":"","institution":"South China Hospital of Shenzhen University","correspondingAuthor":false,"prefix":"","firstName":"Xianhua","middleName":"","lastName":"Cai","suffix":""},{"id":602959290,"identity":"ad2b2603-ba13-4017-a3af-a9cdf81b5610","order_by":3,"name":"Zhangsheng Dai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBAC+/b2A4d/VNjwsLE3EKnFgOdM4mOGM2kyfDwHiNUikWBszNh2yEZOIoFILeYSCWnSBWwHeNgkH2+8wVBjE01Qi2XPw2PSM3ju8LBJpxVbMBxLy20gqOd4QpoEj8QzoJYcMwnGhsNEaDmQYCbBY3AY6LAzRGoxOAH0Pk8CUIsED5FaJHvOJD6ccSCNh40H6JcEYvzCz95+4MDHfzb28u2HN974UGNDhF+QHUl01CBpIVXHKBgFo2AUjAwAADPGPoSCQy+EAAAAAElFTkSuQmCC","orcid":"","institution":"Second Affiliated Hospital of Fujian Medical University","correspondingAuthor":true,"prefix":"","firstName":"Zhangsheng","middleName":"","lastName":"Dai","suffix":""}],"badges":[],"createdAt":"2026-03-03 15:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9022014/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9022014/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104572114,"identity":"cd6f5f26-669d-4f1d-b0d2-a34feb05c256","added_by":"auto","created_at":"2026-03-13 12:59:24","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":118777,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePatient selection flowchart of involvement in the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9022014/v1/97a455c4b8e2284dbecb0c41.jpg"},{"id":104781859,"identity":"a720a489-8c05-4d18-95b0-ef1bd72450b9","added_by":"auto","created_at":"2026-03-17 07:56:28","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59832,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSRS-TR.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Two free traction lines exit on the upper surface of the tendon.\u003c/p\u003e\n\u003cp\u003eB. A single row of rivets is placed, and a single row of suture with thread is performed.\u003c/p\u003e\n\u003cp\u003eC. After the free suture is reset and tightened, one external row is fixed, and two single rows are used to close the rupture and fix it.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9022014/v1/6fa601b44162f0b84c4c9bb7.jpg"},{"id":104572118,"identity":"5683a929-db54-4428-a08e-28801a66677b","added_by":"auto","created_at":"2026-03-13 12:59:24","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20622,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDRS-B.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. DRS-B: 2 internal row rivets, 2 external row rivets for fixed installation.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9022014/v1/5039982e96bc6f08b93d8356.jpg"},{"id":104572117,"identity":"1cb22320-4e1d-4d4a-899f-e076136cf77f","added_by":"auto","created_at":"2026-03-13 12:59:24","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":137919,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe SRS-TR group,An 80-year-old male with degenerative tear of the right rotator cuff.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. \u0026nbsp;Preoperative MRI T1 image: Supraspinatus muscle tear and retraction.\u003c/p\u003e\n\u003cp\u003eB. \u0026nbsp;Three days after the operation, MRI T1 image:the continuity of the supraspinatus muscle was restored upon re-examination.\u003c/p\u003e\n\u003cp\u003eC. \u0026nbsp;One year after the operation,MRI T1 image: the continuity of the supraspinatus muscle was good upon follow-up re-examination.\u003c/p\u003e\n\u003cp\u003eD. single-row suture and tension-reducing suture were placed during the operation.\u003c/p\u003e\n\u003cp\u003eE. The tension-reducing suture was repositioned and the opening was closed after the external fixation nail was removed during the operation.\u003c/p\u003e\n\u003cp\u003eF. The single-row knotting of the tendon was satisfactory during the operation.\u003c/p\u003e\n\u003cp\u003eG. Preoperative AHD was 7.71mm.\u003c/p\u003e\n\u003cp\u003eH.At the last follow-up, AHD was 11.86mm.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9022014/v1/893edb05d07378c1a5654c67.jpg"},{"id":104572120,"identity":"8c9217e2-2df9-4f22-9654-ded453d41b4e","added_by":"auto","created_at":"2026-03-13 12:59:25","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":123136,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ethe DRS-B group ,58-year-old female patient with a traumatic tear of the right rotator cuff.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Preoperative MRI T1 image: Supraspinatus muscle tear and retraction.\u003c/p\u003e\n\u003cp\u003eB. Follow-up examination 3 days after surgery: Continuity of the supraspinatus muscle was restored.\u003c/p\u003e\n\u003cp\u003eC. Follow-up examination 1 year and 2 months after surgery: Continuity of the supraspinatus muscle was acceptable.\u003c/p\u003e\n\u003cp\u003eD. Single-row suture and tension-reducing suture were placed during the operation.\u003c/p\u003e\n\u003cp\u003eE. The tension-reducing suture was repositioned and the opening was closed after the external fixation nail was removed during the operation.\u003c/p\u003e\n\u003cp\u003eF. \u0026nbsp;The single-row knotting of the tendon was satisfactory during the operation.\u003c/p\u003e\n\u003cp\u003eG. \u0026nbsp;Preoperative AHD was 8.09mm.\u003c/p\u003e\n\u003cp\u003eH. \u0026nbsp;At the last follow-up, AHD was 11.44mm.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9022014/v1/9e1ce099f3ecc40769935ab9.jpg"},{"id":104781842,"identity":"7b3c218d-ce18-49e7-89b2-429f990e56eb","added_by":"auto","created_at":"2026-03-17 07:56:25","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":31118,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe time required for the operation\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9022014/v1/eb262ee216e16165f8caa456.jpg"},{"id":106725735,"identity":"9f874c67-7280-40d0-9f1f-16c6e7d26ba4","added_by":"auto","created_at":"2026-04-12 18:33:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1634455,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9022014/v1/9a12d63d-a62d-46b4-a621-ad362bd2d8e1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-Row Suture with Tension-Reducing Augmentation Versus Double-Row Suture Bridge Repair for Medium-to-Large U-Shaped Supraspinatus Tears: A Retrospective Cohort Study with 2-Year Follow-Up","fulltext":[{"header":"Background","content":"\u003cp\u003eRotator cuff tears (RCTs) are highly prevalent, affecting approximately 36% of symptomatic individuals and 16.9% of asymptomatic individuals in the general population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; overall prevalence estimates range from 20% to 30% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Pain is the predominant clinical manifestation of RCTs and is often severe enough to markedly impair sleep quality and shoulder function [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Persistent pain may precipitate progressive functional decline and contribute to secondary glenohumeral joint pathology [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], underscoring the urgent need for effective therapeutic interventions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Arthroscopic rotator cuff repair (ARCR) has become the standard of care, with single-row (SR), double-row (DR), and modified suture bridge configurations widely adopted [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent emphasis has shifted toward low-tension repair techniques, given mounting evidence that excessive tension compromises tendon perfusion and healing. While DR suture bridge repair offers superior tendon\u0026ndash;bone contact area, contact pressure, and biomechanical strength\u0026mdash;translating into improved anatomic healing rates in multiple studies [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u0026mdash;it entails greater technical complexity and carries theoretical risks, including tendon strangulation, reduced vascularity, and iatrogenic overtensioning [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Notably, postoperative retear rates remain unacceptably high, ranging from 10% to 30% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In contrast, medialized SR suture bridge repair offers procedural simplicity and may be advantageous for retracted tendons [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; however, in medium-to-large tears, its limited footprint coverage and suboptimal tension restoration result in inferior biomechanical support and higher failure rates, restricting its utility in cases requiring substantial tension reduction [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address these limitations\u0026mdash;particularly the inadequate tension distribution and footprint coverage inherent in conventional SR repair for large RCTs\u0026mdash;we developed an enhanced SR technique: the single-row suture with transosseous lateral reinforcement (SRS-TR). This approach augments a standard SR construct with free lateral row anchors, thereby improving tension distribution across the tendon\u0026ndash;bone interface and facilitating secure, low-tension approximation of the anatomical footprint. We hypothesize that the SRS-TR technique will yield superior fixation stability and lower complication rates compared with conventional SR and DR configurations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eGeneral information\u003c/h2\u003e \u003cp\u003eClinical datas were retrospectively collected from 60 patients diagnosed with medium to large U-shaped tear of the supraspinatus muscle. The cohort comprised 25 males and 35 females, with a mean age of 65\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 years (range: 55\u0026ndash;75 years). A total of 23 cases involved the left shoulder and 37 involved the right shoulder. The etiology was traumatic in 18 patients, while 42 patients had no identifiable cause.The patients were divided into two groups of 30 cases each (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The observation group was treated with three screws and the single-row suture combined with tension-reducing technique:tension reduction in the outer row combined with single-row repair and fixation(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The control group was treated with four screws and the double-row suture bridge technique for repair (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The hospitalization time, follow-up time, operation time, intraoperative screw removal, and the muscle strength of shoulder abduction and flexion, VAS, UCLA, ASES, and surgical satisfaction at the last follow-up were recorded. The healing of the rotator cuff was evaluated by Sugaya classification MRI, and AHD was measured by anteroposterior X-ray.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003e \u003c/p\u003e \u003cp\u003eInclusion criteria were as follows: (1) preoperative MRI confirming a medium-sized supraspinatus tendon tear with Goutallier grade 0\u0026ndash;IV fatty infiltration; (2) failure of conservative management and patient willingness to undergo minimally invasive surgical repair; (3) intraoperative confirmation of a full-thickness supraspinatus tear measuring 2\u0026ndash;5 cm in width, with favorable tendon quality and significant retraction under tension; (4) a U-shaped tear configuration of the supraspinatus tendon; and (5) patient ability to comply with postoperative rehabilitation protocols. Exclusion criteria included: (1) excessive intraoperative tension preventing complete anatomical coverage of the footprint; (2) concomitant subscapularis or long head of biceps tendon pathology requiring surgical intervention; (3) history of multiple prior shoulder surgeries involving the rotator cuff; and (4) incomplete follow-up or follow-up duration shorter than 18 months. This study constituted a retrospective observational analysis approved by the institutional ethics committee, with the requirement for individual informed consent waived.\u003c/p\u003e\n\u003ch3\u003eOperative technique\u003c/h3\u003e\n\u003cp\u003eTwo groups of patients underwent surgical intervention under general anesthesia. In cases presenting with joint stiffness, manual release was performed to achieve normal range of motion following adequate anesthetic depth. During the procedure, patients were positioned laterally in a 45-degree semi-recumbent posture and secured accordingly, with robotic arm-assisted traction applied. Arthroscopic evaluation was conducted via a posterior approach to rule out labral or subscapularis muscle injuries and to assess potential pathology of the long head of the biceps tendon. Instruments including a radiofrequency ablation device and arthroscopic shaver were introduced through an anterior portal to achieve complete release of the subscapularis-tendon interval as well as the middle and inferior glenohumeral ligament bundles. The subacromial space was meticulously debrided to remove hypertrophic subacromial bursa and adhesions located on the superior and inferior surfaces of the supraspinatus and infraspinatus tendons. In instances where excessive tension impeded reduction, anterior release of the coracohumeral ligament was performed. When signs of impingement were observed, acromioplasty was carried out, and the rotator cuff footprint was prepared by surface freshening. The characteristics of the supraspinatus tendon tear\u0026mdash;including tear type, width, tendon quality, and direction of retraction\u0026mdash;were evaluated using probing instruments and forceps. It was confirmed that the medial tendon edge could be fully reduced to the anatomical footprint under tension, reaching a position 2 mm lateral to the articular cartilage margin.\u003c/p\u003e \u003cp\u003eIn the SRS-TR group, the external-row technique involved initial use of a suture hook with PDS-II suture for guidance, followed by placement of two free-running non-absorbable sutures (Johnson \u0026amp; Johnson Size 2.0) passed from the intra-articular side of the supraspinatus tendon-abdominal junction through the tendon substance to the subacromial side, with all four suture ends retained for subsequent tensioning. For the single-row component, two anchors were inserted approximately 5 mm from the cartilage margin, and sutures were passed and secured accordingly. Under conditions of abduction and optimal reduction, the free sutures designated for external-row fixation were tensioned. Once anatomical alignment of the tendon's lateral edge to the greater tuberosity was achieved, a Johnson \u0026amp; Johnson SwiveLock anchor was implanted on the lateral aspect of the greater tuberosity and compressed for secure fixation. Subsequently, the two Single row rivets were tied to ensure closure of the joint capsule (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the DRS-B group, the conventional double-pulley suture-bridge technique was employed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBeginning on the first postoperative day, patients were instructed to perform active flexion and extension exercises of the wrist and elbow joints, along with isometric contractions of the shoulder joint and other passive rehabilitation activities. Sutures were removed one week after surgery. A shoulder abduction brace was worn for immobilization during the initial six weeks postoperatively. Active rehabilitation exercises, including forward flexion, abduction, and internal and external rotation of the shoulder joint, were initiated at six weeks post-surgery. Shoulder strengthening exercises were progressively intensified starting at 12 weeks postoperatively, allowing patients to gradually resume normal daily activities and sports. Regular follow-up evaluations were scheduled at baseline, 3 days, 3 months, 6 months, 12 months,24 months,and final follow-up.\u003c/p\u003e \n\u003ch3\u003eObservation indicators\u003c/h3\u003e\n\u003cp\u003ePain severity was assessed using the 11-point Visual Analog Scale (VAS) (0\u0026thinsp;=\u0026thinsp;no pain; 10\u0026thinsp;=\u0026thinsp;worst imaginable pain). Shoulder function was evaluated using two validated patient-reported and clinician-assessed instruments: The UCLA Shoulder Rating Scale, comprising five domains\u0026mdash;pain (0\u0026ndash;10), function (0\u0026ndash;10), forward flexion range of motion (0\u0026ndash;5), forward flexion strength (0\u0026ndash;5), and patient satisfaction (0\u0026ndash;5)\u0026mdash;yielding a total score of 0\u0026ndash;35 (higher scores indicate better function). The American Shoulder and Elbow Surgeons (ASES) Score, integrating pain (0\u0026ndash;50) and function (0\u0026ndash;50) subscales ( activities of daily living, range of motion, strength, stability), with a total score of 0\u0026ndash;100 (higher scores reflect superior shoulder function). All three scores (VAS, UCLA, ASES) were recorded preoperatively and at the final postoperative follow-up. Additional objective and procedural outcomes included: Length of hospital stay (days) .Duration of clinical follow-up (months) Operative time (minutes) .Intraoperative nail removal (yes/no) Passive range of motion (PROM) for shoulder flexion, abduction, and external rotation (measured in degrees, preoperatively and at final follow-up) .Patient satisfaction, categorized on a 5-point ordinal scale: very satisfied, satisfied, somewhat satisfied, dissatisfied, and very dissatisfied. Imaging Assessments MRI was performed within 3 days postoperatively, and at 3 months and 2 years post-surgery, to evaluate rotator cuff tendon continuity and healing. Healing was graded using the Sugaya classification: Type I: Homogeneous low signal, normal tendon thickness Type II: Normal thickness but increased signal intensity Type III: Residual thickness\u0026thinsp;\u0026lt;\u0026thinsp;50% of normal, without complete discontinuity Type IV: Discontinuity visible in 1\u0026ndash;2 adjacent MRI slices Type V: Tendon gap evident in \u0026ge;\u0026thinsp;3 consecutive slices Types I\u0026ndash;III were defined a priori as indicative of successful structural healing[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Anteroposterior (AP) radiographs of the shoulder were obtained preoperatively and postoperatively to measure the acromiohumeral distance (AHD) (mm), a radiographic surrogate for superior humeral head migration.\u003c/p\u003e\n\u003ch3\u003eStatistical methods\u003c/h3\u003e\n\u003cp\u003eData analysis was performed using SPSS version 24.0. Categorical data are presented as frequencies and percentages (%), and group comparisons were conducted using the chi-square test. Continuous variables are summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD). For normally distributed data, independent samples t-tests were applied to compare group means. Statistical significance was defined as a two-tailed p-value less than 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative Assessment and Representative Case Presentations\u003c/h2\u003e \u003cp\u003eAll patients were successfully followed up. No significant differences in baseline characteristics prior to the procedure were observed, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Representative cases are illustrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of preoperative general data between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge [years, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe SRS-TR group(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe DRS-B group(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.7\u0026thinsp;\u0026plusmn;\u0026thinsp;17.2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.876\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender ( male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14༏16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15༏15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.781\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease history duration (months, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.893\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities: Hypertension\u003c/p\u003e \u003cp\u003eCoronary Heart Disease / Others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.631\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFat infiltration (grade III\u0026thinsp;+\u0026thinsp;IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.431\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcromion classification (II\u0026thinsp;+\u0026thinsp;III)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.631\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOsteoporosis condition (severe)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.763\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was a statistically significant difference in the operation time and the intraoperative nail removal rate\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e P\u0026lt;.05 was considered statistically significant\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003e t test\u003c/p\u003e \n\u003ch3\u003eComparison of perioperative data between the two groups\u003c/h3\u003e\n\u003cp\u003eA total of 60 patients with a mean follow-up of 23.1 months were selected in the study( 24 months in the \u003cb\u003eSRS-TR\u003c/b\u003e group and 22 months in the \u003cb\u003eDRS-B\u003c/b\u003e group). During surgery, Loosening of rivet occurred in 4 cases in the control group(3 case in internal rivet and 1 cases in external rivet). The 4 cases achieved initial stability following positional adjustment. The operative time in the \u003cb\u003eSRS-TR\u003c/b\u003e group (101.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.59 minutes) and the intraoperative nail removal rate (0%) were significantly lower than those in the \u003cb\u003eDRS-B\u003c/b\u003e group (150.40\u0026thinsp;\u0026plusmn;\u0026thinsp;20.52 minutes; 13%)(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of perioperative data between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eThe time of operation(min, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe SRS-TR group(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ethe DRS-B group(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.59\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150.40\u0026thinsp;\u0026plusmn;\u0026thinsp;20.52\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.033\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hospital stay time(d, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.55\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.11\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.238\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efollow-up period(m, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.51\u0026thinsp;\u0026plusmn;\u0026thinsp;6.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.718\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoosening of rivet (cases, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0, 0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4, 13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e P\u0026lt;.05 was considered statistically significant\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003e Pearson χ\u003csup\u003e2\u003c/sup\u003etest\u003c/p\u003e \u003cp\u003e \u003csup\u003ec\u003c/sup\u003e t test\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eShoulder flexion angle and VAS, UCLA and ASES scores\u003c/h2\u003e \u003cp\u003eThe range of motion for shoulder joint flexion, abduction, external rotation, and internal rotation, as well as VAS, UCLA and ASES scores, showed significant improvement in both groups compared to preoperative values. At the final follow-up, these outcomes were further improved relative to those recorded at 3 days postoperatively. Postoperative patient satisfaction was high, exceeding 90.0%. At the final follow-up, there was no statistically significant difference in the retearing rate between the two groups (p\u0026thinsp;=\u0026thinsp;0.141) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Shoulder flexion angle and VAS, UCLA and ASES scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFull range activity time\u0026nbsp; (d,x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epoint-in-time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe SRS-TR group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ethe DRS-B group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.17\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134.12\u0026thinsp;\u0026plusmn;\u0026thinsp;32.56\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.672\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS scores(scores, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epre-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.821\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree days after the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.332\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt the last follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.343\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUCLA scores(scores, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epre-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.341\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree days after the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.231\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt the last follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.403\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASES scores(scores, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epre-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.612\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree days after the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.280\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt the last follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.121\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eabduction ROM (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epre-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.5\u0026thinsp;\u0026plusmn;\u0026thinsp;21.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.0\u0026thinsp;\u0026plusmn;\u0026thinsp;21.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.932\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree days after the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102.0\u0026thinsp;\u0026plusmn;\u0026thinsp;22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99.3\u0026thinsp;\u0026plusmn;\u0026thinsp;23.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.240\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt the last follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e148.2\u0026thinsp;\u0026plusmn;\u0026thinsp;23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e142.8\u0026thinsp;\u0026plusmn;\u0026thinsp;22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.795\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eanteflexion ROM (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epre-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.8\u0026thinsp;\u0026plusmn;\u0026thinsp;27.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.917\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree days after the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120.3\u0026thinsp;\u0026plusmn;\u0026thinsp;21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111.4\u0026thinsp;\u0026plusmn;\u0026thinsp;22.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.142\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt the last follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154.1\u0026thinsp;\u0026plusmn;\u0026thinsp;20.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e153.7\u0026thinsp;\u0026plusmn;\u0026thinsp;19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.242\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative re-tear (n,%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt the last follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1, 3.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2, 6.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e P\u0026lt;.05 was considered statistically significant\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003e Pearson χ\u003csup\u003e2\u003c/sup\u003etest\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ec\u003c/sup\u003e t test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAHD and number of Sugaya classified indicators (person)\u003c/h2\u003e \u003cp\u003eAt the 6-month follow-up, 2 patients in the \u003cb\u003eSRS-TR\u003c/b\u003e control group and 0 patients in the \u003cb\u003eDRS-B\u003c/b\u003e group were found to have full-thickness rotator cuff tears on MRI, with no significant tendon retraction observed. Both patients reported satisfaction with symptom relief and did not require additional intervention. The acromiohumeral distance (AHD) values in the \u003cb\u003eSRS-TR\u003c/b\u003e group at postoperative day 3 and at the final follow-up (9.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13 mm and 11.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12 mm, respectively) were significantly higher than those in the \u003cb\u003eDRS-B\u003c/b\u003e group (7.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92 mm and 9.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02 mm, respectively), with statistically significant differences (P\u0026thinsp;=\u0026thinsp;0.022 and P\u0026thinsp;=\u0026thinsp;0.043). ( Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComparison of\u003c/b\u003e AHD \u003cb\u003eand Number of Sugaya classified indicators (person)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAHD(mm, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epoint-in-time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eThe SRS-TR group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ethe DRS-B group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epre-operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6.42\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.678\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree days after the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e7.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.022\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt the last follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e9.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.043\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTendon integrity (I/II/III/IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epre-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/0/0/30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0/0/0/30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree days after the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26/4/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e25/5/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.772\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt the last follow-up visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23/6/1/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e17/11/0/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.141\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e P\u0026lt;.05 was considered statistically significant\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Pearson χ\u003csup\u003e2\u003c/sup\u003etest\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ec\u003c/sup\u003e t test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most significant finding of this study is that the suture-bridge\u0026ndash;based single-row\u0026ndash;tensioned repair (SRS-TR) technique demonstrates comparable clinical efficacy to the conventional double-row suture-bridge (DRS-B) technique at intermediate-term follow-up for medium-to-large U-shaped supraspinatus tears. Although prior studies have reported no significant differences in retear rates between single-row and double-row rotator cuff repair techniques overall [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], single-row approaches may be associated with higher failure rates specifically in large or extensive tears [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In contrast, the double-row technique is widely recommended for such cases due to its superior capacity for anatomical tendon repositioning and enhanced biomechanical fixation strength [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our findings indicate that the SRS-TR technique successfully integrates key advantages of the single-row approach\u0026mdash;such as technical simplicity and reduced suture-related tendon trauma\u0026mdash;while mitigating several limitations of conventional single-row fixation, particularly with respect to fixation stability and footprint restoration. Notably, SRS-TR was associated with a significantly shorter operative duration and reduced procedural costs, attributable to lower anchor utilization. Although the DRS-B technique offers well-documented biomechanical advantages [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], it is technically demanding: conventional double-row or modified Mason\u0026ndash;Allen suture-bridge configurations typically require three to four separate suture passes per inner-row anchor\u0026mdash;performed using either a suture hook or suture passer\u0026mdash;thereby increasing surgical complexity, intraoperative time, and potential for iatrogenic tendon injury. By contrast, the SRS-TR technique achieves robust fixation with only two suture passes per anchor, resulting in improved procedural efficiency, reduced technical demand, and diminished risk of tendon trauma.\u003c/p\u003e \u003cp\u003eAccording to the Sugaya classification system [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], tendon healing integrity was superior in the SRS-TR group compared with the DRS-B group. While arthroscopic rotator cuff repair (ARCR) demonstrates long-term efficacy\u0026mdash;particularly for small and medium-sized tears\u0026mdash;over a 10-year follow-up [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], recent evidence (2019\u0026ndash;2024) indicates that retear rates after ARCR for large, high-tension tears range from 25% to 94% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Preclinical studies in rabbit models have shown that low-tension mechanical stimulation enhances healing at the tendon\u0026ndash;bone interface, whereas excessive tension impairs tissue integration and increases susceptibility to postoperative retear [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Cho et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] observed that, following double-row suture-bridge repair, recurrent tears occurred most frequently near the inner-row anchor sutures\u0026mdash;structures that pose significant technical challenges for revision surgery. In the DRS-B technique, the medial row must simultaneously achieve tension reduction and sufficient compression; however, knot-tying at this site exacerbates local soft-tissue stress, potentially compromising tendon viability [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This has led to the recognition of a distinct retear pattern\u0026mdash;termed \u0026ldquo;medial failure\u0026rdquo;\u0026mdash;characterized by rupture proximal to the reconstruction site at the musculotendinous junction, likely resulting from focal tendon strangulation and stress concentration [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. To address tension-related failure in large tendon defects, numerous modifications have been proposed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], including optimized anchor positioning and refined suture configurations [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Although traditional single-row and modified Mason\u0026ndash;Allen techniques reliably achieve tendon-to-bone apposition, their limited footprint coverage concentrates mechanical stress and increases the risk of suture cut-through [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Consequently, these techniques provide inadequate mechanical support for medium-to-large tears and are associated with higher retear rates [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], limiting their applicability in demanding clinical scenarios. In contrast, the SRS-TR technique employs a standard single-row foundation augmented by free lateral-row anchors, thereby improving tension distribution across the repaired tendon and enabling secure, anatomic footprint approximation. Furthermore, single-row sutures are tied under controlled low tension to achieve stable closure of the joint capsule\u0026mdash;enhancing tendon insertion contact and creating a favorable microenvironment for biological healing. This construct not only reinforces medial-row suture stability but also minimizes the risk of joint fluid ingress into the tendon\u0026ndash;bone interface [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], a known contributor to impaired healing. The absence of statistically significant differences in retear rates between groups may reflect limitations inherent to this study\u0026mdash;including its relatively short follow-up duration, single-center design, and modest sample size.\u003c/p\u003e \u003cp\u003eNeyton et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] reported that a reduction in acromiohumeral distance (AHD) following rotator cuff repair is associated with an improved structural and functional prognosis\u0026mdash;and specifically, that a postoperative decrease in AHD correlates with a lower risk of supraspinatus retear. In the present study, AHD in the SRS-TR group decreased significantly by postoperative day 3 and remained stably reduced at final follow-up, suggesting enhanced tendon healing and potentially reduced retear risk during rehabilitation. For patients with medium-to-large, high-tension supraspinatus tears, medial-row anchor pullout remains a recognized concern. Compared with the DRS-B technique, the SRS-TR group exhibited a significantly lower intraoperative anchor dislodgement rate. Moreover, SRS-TR enabled more spatially dispersed suture configurations and greater intraoperative flexibility. In this technique, traction tension was primarily borne by the lateral-row anchors\u0026mdash;decoupling reduction forces from the medial-row fixation and allowing real-time, image-guided adjustment to achieve and stabilize anatomic tendon reduction. Joint capsule closure was accomplished using a simplified single-row configuration, independent of lateral-row anchor position or tension. In contrast, the DRS-B technique relies on medial-row anchor placement with sutures passed more medially to optimize tendon footprint contact and reduction. However, limited arthroscopic visualization\u0026mdash;combined with inherent tendon elasticity\u0026mdash;makes precise intraoperative prediction of optimal medial-row suture passage points challenging, introducing procedural uncertainty. Conversely, excessively lateral or loose suture placement compromises reliable anatomical reduction [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Notably, four instances of anchor dislodgement occurred in the DRS-B group; analysis suggested contributing factors included overaggressive cortical debridement and localized stress concentration\u0026mdash;both of which may elevate mechanical load at the repair site and impair biological healing [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTendon reduction and retraction tension represent a critical determinant of postoperative retear risk [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Although supraspinatus tendon reduction tension is influenced by multiple factors\u0026mdash;including tendon quality [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and chronicity of tear [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u0026mdash;intraoperative assessment of tear morphology and precise tissue repositioning are equally essential for achieving optimal tension [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Conventionally, greater tendon retraction correlates with higher reduction tension [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and accurate intraoperative quantification of reduction tension is therefore pivotal to optimizing surgical outcomes and minimizing retear rates. However, no standardized, clinically validated threshold for defining \u0026ldquo;high tension\u0026rdquo; during rotator cuff repair currently exists, and reported measurements vary considerably across studies. Davidson et al. evaluated reduction tension in 67 rotator cuff repairs and found that tension exceeding 8 lbf (\u0026asymp;\u0026thinsp;35.6 N) was associated with suboptimal functional and structural outcomes [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In a cadaveric study simulating posterosuperior reverse L-shaped tendon defects across seven shoulder specimens, mean traction force required for anatomical reduction was 16.02 N, whereas malreduction necessitated a significantly higher mean force of 19.52 N [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Among symptomatic patients enrolled in randomized controlled trials, supraspinatus tendon tears remain the most common pathology [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In the present study, we focused on U-shaped supraspinatus tears with 2\u0026ndash;5 cm retraction; however, we did not systematically quantify reduction tension or investigate its relationship with tension-relieving suture techniques. Consequently, the optimal tension threshold at which adjunctive tension-relieving strategies\u0026mdash;such as the SRS-TR technique\u0026mdash;should be employed remains undefined and warrants further investigation in prospective, biomechanically informed studies.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations that warrant careful consideration. First, tensioned external fixation and knot-tying in single-row repair techniques may reduce the subacromial space, and the inherently limited visualization associated with such approaches can complicate suture management. Preemptive subacromial synovectomy, subacromial release, and acromioplasty may therefore be indicated to improve arthroscopic exposure and enhance surgical precision. Second, single-row repair concentrates suture ends at a localized site, potentially increasing the risk of foreign-body reaction; prolonged mechanical irritation and friction may further promote subacromial cortical bone resorption, with possible implications for long-term clinical durability. Third, tensioned external fixation may be suboptimal for patients with massive rotator cuff tears or advanced fatty degeneration of the supraspinatus\u0026mdash;conditions associated with diminished tissue quality and higher failure risk. In such cases, augmenting the number of lateral-row anchors may improve load distribution and construct stability. Finally, osteoporosis of the humeral greater tuberosity may compromise anchor fixation strength, predisposing to early loosening or pullout and thereby undermining initial biomechanical integrity [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Notably, this study did not systematically assess greater tuberosity bone quality or its impact on fixation integrity\u0026mdash;representing a potential source of unmeasured confounding.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that the SRS-TR technique achieves favorable safety and efficacy outcomes at intermediate-term follow-up for medium-to-large U-shaped supraspinatus tendon tears. Compared with the conventional DRS-B technique, SRS-TR offers several advantages: enhanced technical simplicity, significantly shorter operative time, lower intraoperative anchor dislodgement rates, and comparable retear rates. Nevertheless, definitive conclusions regarding optimal tension management remain limited by the absence of standardized, quantitative intraoperative tension measurement. Large-scale, high-quality multicenter randomized controlled trials are therefore warranted\u0026mdash;incorporating rigorous stratification by tear size, quantitative assessment of reduction tension, and standardized biomechanical reporting\u0026mdash;to elucidate the most effective tension-mitigating strategies and inform evidence-based surgical recommendations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSRS-TR single-row suture combined with tension-reducing\u003c/p\u003e\n\u003cp\u003eDRS-B double-row suture bridge\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRCTs rotator cuff tears\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eARCR arthroscopic rotator cuff repair\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRI Magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eVAS pain visual analogue scale\u003c/p\u003e\n\u003cp\u003eUCLA university of California Los Angeles\u003c/p\u003e\n\u003cp\u003eASES American Shoulder and Elbow Surgeon\u0026apos;s Form\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAHD acromiohumeral distance\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was approved by The Ethics Committee of China Three Gorges University. All methods were carried out in accordance with relevant guidelines and regulations (protocol 20254801).\u003c/p\u003e\n\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eYes, I have research data to declare.\u003c/p\u003e\n\u003cp\u003e\u0026quot;If you require the raw data, please contact the corresponding author at\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eZhangsheng Dai [email protected].\u0026quot;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo, I declare that the authors have no competing interests as defined by\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBMC, or other interests that might be perceived to influence the results\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eand/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYW carried out the studies, participated in collecting data, and drafted the manuscript. CX and ZS performed the statistical analysis and participated in its design. ZD helped to draft the manuscript and performed the data acquisition \u0026amp; analysis. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elb Surg. 2010;19(1):116\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClinker C, Soule S, Presson AP, Zhang C, Joyce C, Tashjian RZ, et al. Does dynamically tensioning suture alter outcomes after rotator cuff repair? J Shoulder Elb Surg. 2025;34(10):2378\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZuo J, Chen C, Guo J, Lin J, You T, Chen P, et al. Efficacy of rotator cuff suture and arthroscopic 360\u0026deg; capsular release in patients with rotator cuff tear with limited shoulder movement. BMC Surg. 2023;23(1):379.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamamura K, Mikami Y, Irii A, Nishimoto H, Mukaihara S, Yoshikawa T, et al. A novel therapy using fish scale collagen scaffold for rotator cuff healing in a rat model. J Shoulder Elb Surg. 2022;31(12):2629\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKilicoglu IO, Zukor DJ, Adeeb N, Park T, Menendez ME, Denard PJ. Determining the minimal clinically important difference and patient acceptable symptom state after isolated subscapularis repair in arthroscopic shoulder surgery. JSES Int. 2024;8(3):472\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFox MA, Hughes JD, Drain NP, Wagala N, Patel N, Nazzal E, et al. Knotted and knotless double row transosseous equivalent repair techniques for arthroscopic rotator cuff repair demonstrate comparable post-operative outcomes. Knee Surg sports Traumatol arthroscopy:official J ESSKA. 2023;31(5):1919\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristoforetti JJ, Krupp RJ, Singleton SB, Kissenberth MJ, Cook C, Hawkins RJ. Arthroscopic suture bridge transosseus equivalent fixation of rotator cuff tendon preserves intratendinous blood flow at the time of initial fixation. J Shoulder Elb Surg. 2012;21(4):523\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImam M, Sallam A, Ernstbrunner L, Boyce G, Bardakos N, Abdelkafy A, et al. Three-year functional outcome of transosseous-equivalent double-row vs. single-row repair of small and large rotator cuff tears: a double-blinded randomized controlled trial. J Shoulder Elb Surg. 2020;29(10):2015\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee KW, Moon KH, Ma CH, Lee GS, Yang DS, Choy WS. Clinical and radiologic outcomes after medializing and not medializing rotator cuff tendon attachment site on chronic retracted rotator cuff tears. Arthroscopy. 2018;34(8):2298\u0026ndash;307.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzar M, Vandermeijden O, Pireau N, Chelli M, Gonzalez JF, Boileau P. Arthroscopic revision cuff repair: do tendons have a second chance to heal? J Shoulder Elb Surg. 2022;31(12):2521\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHao B, Li H, Liang A. Effects of early exercise and immobilization after arthroscopic rotator cuff repair surgery: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2025;26(1):254.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuan X, Wu J, Liu Z, Li X, Xiao Y, Shu H, et al. Outcomes after Double-Layer repair versus En masse repair for delaminated rotator cuff injury: A systematic review and Meta-analysis. Orthop J Sports Med. 2023;11(10):23259671231206183.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Benedetto P, Mancuso F, Tosolini L, Buttironi MM, Beltrame A, Causero A. Treatment options for massive rotator cuff tears: a narrative review. Acta Biomed. 2021;92(S3):e2021026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlachel F, Siegert P, R\u0026uuml;ttershoff K, Thiele K, Akg\u0026uuml;n D, Moroder P, et al. Long-term Results of Arthroscopic Rotator Cuff Repair: A Follow-up Study Comparing Single-Row Versus Double-Row Fixation Techniques. AM J SPORT MED. 2021;48(7):1568\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoser M, Lund G, Selj\u0026oslash;e US, Haldorsen B, Svege IC, Hennig T, et al. At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears. The Journal of bone and joint surgery. Am volume. 2019;101(12):1050\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee BG, Cho NS, Rhee YG. Modified Mason-Allen suture bridge technique:a new suture bridge technique with improved tissue holding by the modified Mason-Allen stitch. Clin Orthop Surg. 2012;4(3):242\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained? Am J Sports Med. 2011;39(10):2108\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNie S, Qin H, Tan H, Zhao P, Yan W, Zhou A, et al. Suture tape anchors for enhancing healing in rotator cuff tears: a retrospective cohort study. BMC Musculoskelet Disord. 2025;26(1):470.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHonda H, Gotoh M, Mitsui Y, Nakamura H, Tanesue R, Shimokobe H, et al. Clinical and structural outcomes after arthroscopic rotator cuff repair: a comparison between suture Bridge techniques with or without medial knot tying. J Orthop Surg Res. 2018;13(1):297.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eL\u0026auml;dermann A, Christophe FK, Denard PJ, Walch G. Supraspinatus rupture at the musclotendinous junction: an uncommonly recognized phenomenon. J Shoulder Elb Surg. 2012;21(1):72\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaillot C, Martellotto A, Demezon H, Harly E, Le Huec JC. Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis. Clin J Sport Med. 2021;31(6):501\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDierckman BD, Wang DW, Bahk MS, Burns JP, Getelman MH. Vivo Measurement of Rotator Cuff Tear Tension:Medial Versus Lateral Footprint Position. American journal of orthopedics. (Belle Mead NJ). 2016;45(3):E83\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Chen M, Xu T, Tian Z, Xu L, Zhou Y. Functional results of modified Mason-Allen suture versus horizontal mattress suture in the arthroscopic Brostr\u0026ouml;m-Gould procedure for chronic ankle instability. J Orthop Surg Res. 2022;17(1):459.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZafra M, Uceda P, Mu\u0026ntilde;oz-Luna F, Mu\u0026ntilde;oz-L\u0026oacute;pez RC, Font P. Arthroscopic repair of partial-thickness articular surface rotator cuff tears: single-row transtendon technique versus double-row suture bridge (transosseous equivalent) fixation: results from a prospective randomized study. Arch Orthop Trauma Surg. 2020;140(8):1065\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLo IKY, Burkhart SS. Transtendon arthroscopic repair of partial-thickness, articular surface tears of the rotator cuff. Arthroscopy. 2004;20(2):214\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArrigoni P, Brady PC, Burkhart SS. The double-pulley technique for doublerow rotator cuff repair. Arthroscopy. 2007;;23(6):675.e1-4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeyton L, Goden\u0026egrave;che A, Nov\u0026eacute;-Josserand L, Carrillon Y, Cl\u0026eacute;chet J, Hardy MB. Arthroscopic suture-bridge repair for small to medium size supraspinatus tear: healing rate and retear pattern. Arthroscopy. 2013;29(1):10\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePastor MF, Kraemer M, Schwarze M, Hurschler C, Smith T, Wellmann M. The effect of rotator cuff malreduction on tendon tension: an evaluation of a custom-made digital tensiometer clamp. Arch Orthop Trauma Surg. 2018;138(2):219\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung SW, Kim JY, Kim MH, Kim SH, Oh JH. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med. 2013;41(7):1674\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo SWL. Repair of Massive Rotator Cuff Tear With Medialization and Balloon Spacer Insertion. Arthrosc Tech. 2023;13(1):102821.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLowry V, Lavigne P, Zidarov D, Matifat E, Cormier AA, Desmeules F. A Systematic Review of Clinical Practice Guidelines on the Diagnosis and Management of Various Shoulder Disorders. Arch Phys Med Rehabil. 2024;105(2):411\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAraya-Quintanilla F, Guti\u0026eacute;rrez-Espinoza H, Gana-Hervias G, Cavero-Redondo I, \u0026Aacute;lvarez-Bueno C. Association between type of rotator cuff tear and functional outcomes in patients with massive and irreparable rotator cuff tear: A pre-post intervention study. J Shoulder Elbow Surg. 2021;;30(6):1393\u0026ndash;1401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavidson PA, Rivenburgh DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elb Surg. 2000;9(6):502\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnger M, Schmidt M, Nordsletten L, Moosmayer S, Pripp AH, Melhuus K, et al. Physical examination tests in the acute phase of shoulder injuries with negative radiographs: a diagnostic accuracy study. BMC Musculoskelet Disord. 2025;26(1):546.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer DC, Fucentese SF, Koller B, Gerber C. Association of osteopenia of the humeral head with full-thickness rotator cuff tears. J Shoulder Elb Surg. 2004;13(3):333\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Arthroscopy, Double-row suture bridge, Single-row suture with tension reduction, Supraspinatus tendon tear, U-shaped tear, Acromiohumeral distance, Tendon healing","lastPublishedDoi":"10.21203/rs.3.rs-9022014/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9022014/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDouble-row suture bridge (DRS-B) repair is widely used for medium-to-large U-shaped supraspinatus tendon tears and yields satisfactory clinical outcomes. However, it is associated with higher surgical complexity, increased anchor, and potential complications\u0026mdash;including stiffness, chondral injury, and hardware-related issues. Single-row suture repair combined with tension-reducing (SRS-TR) is an emerging alternative designed to simplify fixation while preserving tendon biology and reducing mechanical stress. This study aimed to compare the early-to-midterm clinical and radiographic outcomes of SRS-TR versus DRS-B for medium-to-large U-shaped supraspinatus tears.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePrimary endpoints included A retrospective cohort study was conducted on 60 patients diagnosed with medium-to-large (2\u0026ndash;5 cm in maximal width) U-shaped supraspinatus tears, who underwent arthroscopic repair between January 2020 and January 2025. Patients were allocated to either the SRS-TR group (n\u0026thinsp;=\u0026thinsp;30) or the DRS-B group (n\u0026thinsp;=\u0026thinsp;30) based on surgeon preference and intraoperative decision-making (no randomization). Evaluation indicators included intraoperative anchor usage, and acromiohumeral distance (AHD),length of hospital stay, follow-up duration, postoperative shoulder range of motion (ROM), visual analogue scale (VAS) for pain, UCLA Shoulder Rating Scale, American Shoulder and Elbow Surgeons (ASES) score, patient-reported surgical satisfaction, tendon integrity (Sugaya classification on MRI at \u0026ge;\u0026thinsp;6 months), and retear rate. All assessments were performed at standardized intervals: baseline, 3 days, 3 months, 6 months, 12 months,24 monthsand final follow-up.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe SRS-TR group demonstrated significantly shorter operative time (mean difference: \u0026minus;49.6 min, P\u0026thinsp;=\u0026thinsp;0.033), lower anchor usage (mean 3 vs.4 anchors, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and reduced incidence of intraoperative anchor revision (0% vs. 13.3%, P\u0026thinsp;=\u0026thinsp;0.038) compared with the DRS-B group. AHD was significantly greater in the SRS-TR group both at 3 days postoperatively (mean 9.91 mm vs. 7.12 mm, P\u0026thinsp;=\u0026thinsp;0.022) and at final follow-up (mean 11.81 mm vs. 9.12 mm, P\u0026thinsp;=\u0026thinsp;0.043), suggesting improved superior tendon reduction and less superior migration of the humeral head. No postoperative complications (infection, neurovascular injury, stiffness, or anchor-related adverse events) occurred in either group. There were no statistically significant differences between groups in hospital stay, follow-up duration,ROM,VAS,UCLA, ASES, surgical satisfaction, or retear rate (Sugaya Type IV\u0026ndash;V: 3.3% in SRS-TR vs. 6.6% in DRS-B; P\u0026thinsp;=\u0026thinsp;0.141).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAt a mean follow-up of 23.1 months, both SRS-TR and DRS-B achieved comparable functional outcomes, pain relief, and patient satisfaction in patients with medium-to-large U-shaped supraspinatus tears. However, SRS-TR offered significant procedural advantages\u0026mdash;including shorter operative time, reduced anchor burden, lower intraoperative revision rates, and superior maintenance of AHD\u0026mdash;suggesting potentially enhanced biological healing and reduced mechanical strain on the repaired tendon. These findings support SRS-TR as a safe, efficient, and cost-effective alternative to DRS-B for selected U-shaped tears.\u003c/p\u003e\u003ch2\u003eLevel of evidence\u003c/h2\u003e \u003cp\u003eLevel III, comparative study\u003c/p\u003e","manuscriptTitle":"Single-Row Suture with Tension-Reducing Augmentation Versus Double-Row Suture Bridge Repair for Medium-to-Large U-Shaped Supraspinatus Tears: A Retrospective Cohort Study with 2-Year Follow-Up","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 12:59:19","doi":"10.21203/rs.3.rs-9022014/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"64b0da8c-33ca-4d0f-9357-21d206492df1","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T22:38:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 12:59:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9022014","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9022014","identity":"rs-9022014","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}