All-suture anchor pullout results in decreased bone damage and depends on cortical thickness

• Published in: Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Vol. 29; no. 7; pp. 2212 - 2219
• Main Authors: Ntalos, Dimitris, Huber, G., Sellenschloh, K., Saito, H., Püschel, K., Morlock, M. M., Frosch, K. H., Klatte, T. O.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-07-2021; Springer Nature B.V
• Subjects: Aged; Biomechanical Phenomena; Biomechanics; Bone Density; Bone mineral density; Cadaver; Cancellous bone; Computed tomography; Correlation; Cortical bone; Damage; Diameters; Humans; Humerus; Humerus - physiopathology; Humerus - surgery; Hypotheses; Implantation; Mechanical properties; Medicine; Medicine & Public Health; Middle Aged; Morphology; Orthopedics; Rotator cuff; Rotator Cuff - surgery; Shoulder; Sports Medicine; Surgery; Suture Anchors; Suture Techniques; Sutures; Thickness; Shoulder surgery; Arthroscopy; Cortical thickness; Bone mass density; Pullout; Suture anchor; Micro-CT; All suture; Rotator cuff
• DOI: 10.1007/s00167-020-06004-6
• EISSN: 1433-7347
• ISSN: 0942-2056

Purpose
To evaluate the influence of cortical and cancellous bone structure on the biomechanical properties of all-suture and conventional anchors and compare the morphological bone damage after their failure. The hypothesis of the study is that all-suture anchor pullout is less invasive and that the pullout force is influenced by the cortical thickness.
Methods
Thirty human humeri were biomechanically tested as follows: starting with a load cycle from 20 to 50 N, a stepwise increase of the upper peak force by 0.05 N for each cycle at a rate of 1 Hz was performed. Analysis included maximum pullout strength for three different anchor implantation angles (45°, 90°, 110°) of the two anchor types. After anchor pullout, every sample underwent micro-CT analysis. Bone mineral density (BMD) and cortical thickness were determined at the anchor implantation site. Furthermore, the diameter of the cortical defect and the volume of the bone cavity were identified.
Results
The maximum pullout strength of all-suture anchors demonstrates a strong correlation to the adjacent cortical thickness (
r
 = 0.82,
p
 ≤ 0.05) with at least 0.4 mm needed to withstand 200 N. No correlation could be seen in conventional anchors. Moreover, no correlation could be detected for local BMD in both anchors. All-suture anchors show a significantly narrower cortical defect as well as a smaller bone cavity following pullout (4.3 ± 1.3 mm vs. 5.3 ± 0.9 mm,
p
 = 0.037; 141 mm
3
vs. 212 mm
3
;
p
 = 0.009). The cortical defect is largest if the anchors are placed at a 45° angle.
Conclusion
In contrast to conventional anchors, the pullout force of all-suture anchors depends on the thickness of the humeral cortex. Furthermore, all-suture anchors show a significantly smaller cortical defect as well as decreased bone damage in the case of pullout. Therefore, the clinical implication of this study is that all-suture anchors are advantageous due to their bone preserving ability. Also, intraoperative decortication should not be performed and cortical thickness should be preoperatively evaluated to decrease the risk of anchor failure.