Is the Modified TOE Technique a Viable Alternative to Classical Knotted Repair for Rotator Cuff Tears? A Comparative Study

Purpose: The purpose of this study is to compare the clinical and radiological outcomes of classical knotted transosseous-equivalent (TOE) rotator cuff repair versus a modified knotless TOE technique. It aims to determine whether eliminating medial-row knots influences tendon healing and functional recovery. Methods: Patients who underwent arthroscopic rotator cuff repair between 2021 and 2023 were retrospectively reviewed. Patients were divided into two groups based on the surgical technique used: classical knotted TOE repair and modified TOE repair. Functional outcomes were evaluated preoperatively and at final follow-up using the American Shoulder and Elbow Surgeons (ASES) Score, University of California Los Angeles (UCLA) Shoulder Score, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) Score, and Modified Constant Score. Range of motion (ROM) was assessed in forward flexion, abduction, and external rotation. Rerupture was assessed by postoperative MRI in symptomatic patients. Results: A total of 89 patients (45 in the classical TOE group and 44 in the modified TOE group) were included. Both groups demonstrated significant improvements in clinical scores and ROM compared to preoperative values (p < 0.001 for all). No significant differences were observed between groups regarding postoperative ASES, UCLA, QuickDASH, and Modified Constant Scores (p > 0.05 for all comparisons). Forward flexion, abduction, and external rotation also improved similarly in both groups without statistically significant differences (p > 0.05). Rerupture was detected in 8.9% (4/45) of patients in the classical TOE group and 6.8% (3/44) in the modified TOE group, with no significant difference between groups (p > 0.05). Conclusion: The modified TOE repair technique provided clinical and radiological outcomes comparable to those of the classical knotted TOE technique. Given its potential advantages in reducing medial-row tension and facilitating technical application, the modified TOE technique may represent a reliable alternative in arthroscopic rotator cuff repair. Level of evidence: Level III—retrospective comparative series.