Rotator Cuff Tears: Double Row Repair, When to Use, How to Make it Cost-Effective

Dr. Jonathan Ticker joins members of the 42nd Annual San Diego Course to discuss Rotator Cuff Tears.

This talk is titled: Double-row Rotator Cuff Repair, When You Must Use & How I Make it Cost Effective

This presentation breaks down a practical, real-world approach to Double Row Rotator Cuff Repair, covering when it works best and how to get a strong, reliable repair while avoiding common pitfalls. Dr. Ticker explains that he typically uses a double-row technique for mobile tears up to about 3 – 3.5 cm, using one medial triple-loaded anchor and one lateral knotless anchor and all six suture limbs. He avoids tying medial knots, which helps reduce stress on the tendon and lowers the risk of type-II retears. If a tear can’t be fully reduced or the tendon or bone quality isn’t good enough, he switches to a single-row repair instead.

When to use a Double-Row Rotator Cuff Repair:

Mobile, reducible tears up to 3-3.5 cm
Adequate tendon and bone quality
Full reduction achievable to the lateral edge after releases
Uses one medial and one lateral anchor with all six suture limbs

When to use a Single Row Instead, for Rotator Cuff Repair:

Tears not fully reducible over the greater tuberosity after releases
Poor tendon or bone quality
Tears where a double-row construct will not sit anatomically

Core Principles Behind Dr. Ticker’s Rotator Cuff Repair Technique:

Repair strength = Number of sutures, more than the number of anchors
More medial suture passage (~1.5cm or more) = Greater resistance to pullout
Avoid medial knots to prevent type-II retears near or at the musculotendinous junction
Use screw-in lateral anchors to improve fixation and avoid pullout
Bone quality and bone bed preparation are critical

Dr. Ticker’s Technical Steps & Pearls:

Step 1: Bone Bed Preparation

Prepares the greater tuberosity to denude the soft tissue and expose the bone for better healing
Emphasizes that “how you prepare is as important as how you repair”
Routinely releases the middle glenohumeral ligament (MGHL)

Step 2: Medial Anchor Placement

Places a central medial anchor with a straight punch
Prefers solid body screw-in anchors
Utilizes all six suture limbs without tying medial knots

Step 3: Suture Passage

Uses retrograde techniques
Identifies the anterior supraspinatus clearly before passing sutures
Passes sutures lateral to the muscle-tendon junction and medial to the cable

Step 4: Reduction Techniques

Uses oblique side-to-side sutures to reduce “L”-shaped tears
Marks lateral anchor placement (7-10 mm) inferior on greater
Abducts the arm to ensure perpendicular approach to the tuberosity

Step 5: Lateral Row Fixation

Prefers 5.5 mm or 6.5 mm screw-in anchors based on bone quality
Tensions sutures before anchor insertion for optimal compression
Usually ties lateral knots to prevent suture slippage

Managing Complex Rotator Cuff Tears:

Can combine double-row anteriorly and single-row posteriorly when tissue quality and tear pattern varies
Adjusts suture distribution to maintain anatomic footprint coverage

Technical Pearls to Avoid Complications during Rotator Cuff Repair:

Avoid medial knots to reduce type-II retears
Anchor pullout may occur with poor bone quality, so use larger screw-in anchors
Loose sutures can occur over time, and lateral knot tying helps mitigate this
Screw-in anchors offer more predictable fixation compared to push-in anchors

Conclusion: When to use a Double Row Rotator Cuff Repair

According to Dr. Ticker, an efficient two-anchor double-row rotator cuff repair can be both powerful and cost-effective when executed with:

Appropriate medial suture placement and number
Strategic tear reduction
Careful attention to bone quality and tendon mobility
Strong secure lateral fixation

Dr. Ticker’s approach emphasizes precision over hardware, demonstrating that optimal outcomes depend on technique, not the number of anchors.

Jonathan B Ticker, MD

Average rating:

40 reviews

Sharon

Dec 4, 2025

by Sharon on Jonathan B Ticker, MD

Exceptional Care from Start to Finish – 5/5 Stars

Exceptional Care from Start to Finish – 5/5 Stars
ATHROSCOPIC Left Shoulder Surgery Multiole Procedures

"I am so grateful for Dr. Jonathan B. Ticker and his team — Anne Marie Lamneck, PA, Laura Brady, Kaylan Dimodugno, and surgical coordinator Denise Katsaros. From consultation to recovery, the care was professional, compassionate, and seamless. Dr. Ticker explained everything clearly, and the surgical team made me feel safe and supported throughout. My recovery has been smooth, and I am feeling much better. I highly recommend Dr. Ticker and his amazing staff to anyone in need of expert surgical care!"

SHARON S M

Nov 24, 2025

by SHARON S M on Jonathan B Ticker, MD

Exceptional Care from Start to Finish

"I am incredibly grateful for the outstanding care I received from Dr. Jonathan B. Ticker, the entire surgical team, and the office medical staff who work closely with him — Anne Marie Lamneck, PA, Laura Brady, and Kaylan Dimodugno. From my very first consultation through my post-operative recovery, the entire experience was seamless, reassuring, and made even better by having the same team consistently involved in my care.

A special shout-out to Denise Katsaros, his surgical coordinator. She was professional, patient, and supportive while handling all my questions and concerns.

The office team was consistently professional, friendly, and efficient. Scheduling was easy, wait times were minimal, and they were always helpful when answering my questions about appointments and the overall process. I felt valued and well-informed every step of the way — never like a number.

Dr. Ticker is an exceptionally talented, skilled, and compassionate surgeon. He explained my condition and the surgical procedure in clear, understandable terms, ensuring I fully understood my options and the recovery process. His expertise and attentive bedside manner instilled a strong sense of calm and trust, which meant a great deal to me going into major surgery.

The surgical team — Dr. Flaum, Anne Marie Lamneck, PA, and the nurses — were also fantastic. Their coordination and professionalism in the operating room and during recovery made me feel safe and comfortable. The level of excellence in their care and attention to detail was truly top-notch.

Thanks to this wonderful team, my recovery has been smooth. I am no longer feeling the pre-surgical pain — only normal post-surgical discomfort, which is expected — and I am already feeling so much better.

I highly recommend Dr. Ticker and the entire staff to anyone in need of exceptional surgical care. He is not only a highly skilled surgeon but also an expert, scholar, and author. The whole team truly puts patients first and works together with dedication and compassion. Having worked in the medical field myself, I can confidently say I will recommend him to everyone.

Thank you all for everything you do!"

Marcelo Riffaud

Aug 27, 2024

by Marcelo Riffaud on Jonathan B Ticker, MD

The Quality of Care -- Dr. Ticker

In July 2023, Dr. Ticker performed arthroscopic surgery to correct a full tear of my supraspinatus tendon (as well as, among other issues, removal of a bone spur on my acromion, performing a biceps tenodesis) in my left shoulder.

I had heard and read about the very challenging and difficult experiences of others who had experienced similar trauma and surgery. I was braced for the worst, which apparently would be during the first 2 weeks post-op. But I had no idea how fortunate I was to be in the care of the best hands possible for the surgery. The first 1-2 days post-op I was absolutely pain free due to a nerve block that was administered during surgery. After this wore off, I experienced only minimal discomfort over the next 2 weeks. I was able to rest and sleep on a recliner, my soreness easily managed by the prescribed meds. At 2 weeks post-op I started PT. I took my meds throughout but only as needed, and I ended up taking less than the prescribed amounts after the first week. I wasn't being a hero or toughing it out -- I just didn't need them. I was back to full range of motion and full activity since the 5th month post-op.

I am fully convinced that my amazing experience -- from the low level of discomfort to the speed of my recovery -- had everything to do with Dr. Ticker's significant experience, amazing talent, and care-giving approach. I am a beneficiary of his many years of dedication and hard work to his calling. He is also funny and approachable, with a great bedside manner, but he is also direct and serious about his work and about what I needed to do (and not do) to increase my chances for a full recovery. I could not recommend him more highly. Thank you, Dr. Ticker!