BACKGROUND: Rotator cuff tears can be addressed using various repair techniques. This study sought to compare the clinical and radiologic outcomes and costs after arthroscopic single-row anchor repair and arthroscopic transosseous repair for small to medium-sized tears. METHODS: The study was a prospective randomized clinical trial (registered as trial number PACTR202404475835971 in the Pan African Clinical Trial Registry, Apr 04, 2024) that included 62 patients, randomized into two equal groups. Group A: single-row anchor repair (n = 31) and Group B: transosseous repair (n = 31). Patients were clinically evaluated using the American Shoulder and Elbow Surgeons (ASES) score and Oxford Shoulder Score (OSS), in addition to evaluation of range of motion (ROM) of forward flexion, external rotation (ER), and internal rotation (IR). Total implant costs were calculated and compared. RESULTS: In both groups, the ROM increased significantly, P <
0.001. The mean differences between preoperative and postoperative forward flexion, ER, and IR were comparable in both groups, P = 0.933, 0.817, and 0.151, respectively. The mean ASES score and OSS improved significantly in both groups at last follow-up, P <
0.001. The mean follow-up ASES score was 91.1 ± 3.5 in Group A and 90.8 ± 2.7 in Group B, P = 0.818. The mean follow-up OSS was 42.4 ± 2.1 in Group A and 41.5 ± 1.9 in Group B, P = 0.214. The average financial cost of operation was significantly lesser in the transosseous group than the anchors group, P <
0.001. CONCLUSION: Anchorless transosseous rotator cuff repair can achieve similar excellent functional outcomes as the single-row anchor repair, with equivalent tendon healing results. However, the transosseous technique has substantially lower costs.