All-suture Anchors Research Articles

Rapidly destructive osteonecrosis of the humeral head after arthroscopic rotator cuff repair: a case report

BackgroundCases of rapidly destructive osteonecrosis (RDON) of the humeral head after arthroscopic rotator cuff repair (RCR) have rarely been reported, which has prevented a clear consensus on the cause of osteonecrosis.Case presentationA 63-year-old woman without a history of trauma underwent arthroscopic RCR after being diagnosed with a medium-sized full-thickness rotator cuff tear for symptoms of left shoulder pain for six months. The patient had no medical history other than hypertension, and no other potential cause was found for osteonecrosis of the left shoulder prior to surgery. Four months after surgery, pain and range of motion improved. Six months after surgery, the patient complained of an increase in shoulder pain. While follow-up ultrasonography did not show a re-tear of the repaired tendon, osteonecrosis of the humeral head could not be confirmed as plain radiography was not performed. Follow up MRI performed a year after surgery revealed RDON of the humeral head. Despite mild improvement in the shoulder pain, the Shoulder Rating Scale of the University of California at Los Angeles (UCLA) and Constant score were poor at 23 and 69, respectively. In the present case, the arthroscopic RCR was performed using two anchors; for the repair of the anterior of the supraspinatus and the rotator interval, a 2.8-mm all-suture anchor was inserted into the upper part of the intertubercular groove. The cause of RDON is presumed to be the damage to the anterolateral and intraosseous branches of the anterior humeral circumflex artery (AHCA) for anchor positioning and insertion.ConclusionsA poor outcome was obtained in the case of RDON, despite the integrity of the repaired rotator cuff tendon after arthroscopic RCR was intact. Although the cause of RDON has not been clearly established, care should be taken not to damage the anterolateral and intraosseous branches of the AHCA regarding the insertion location of the suture anchor, and to prepare the anchor in the vicinity of the intertubercular groove.

Ability to Retension Knotless Suture Anchors: A Biomechanical Analysis of Simulated Bankart Lesions.

Background:Knotless suture anchors are gaining popularity in arthroscopic glenohumeral labral repairs. The ability to retension knotless designs after initial anchor placement has been reported; however, no studies have quantified this claim or investigated the biomechanical consequence of retensioning.Purpose/Hypothesis:To determine whether knotless and knotted suture anchors have biomechanical or anatomic differences with regard to labral repairs and to determine whether retensioning of knotless suture anchors affects capsular tension, labral height, and capsular shift. We hypothesized that retensioning of knotless anchors would result in improved capsular tension compared with conventional knotted suture anchors.Study Design:Controlled laboratory study.Methods:A total of 18 fresh-frozen cadaveric shoulders with a mean age of 56 years were dissected to the capsule and disarticulated at the humeral capsular insertion. The scapula was potted and placed in a custom shoulder simulator to tension the capsule via braided sutures localized to the anteroinferior glenohumeral ligament. Specimens were randomized into 3 groups: (1) Knotted (KT), (2) Knotless with end retensioning (KLend), and (3) Knotless with stepwise retensioning (KLstepwise). All repairs were completed using all-suture anchors placed at the 5-, 4-, and 3-o’clock positions. KLstepwise was used to simulate an intraoperative technique. Resultant mean capsular tension under 5 mm of displacement (subfailure loading) was measured for each anchor placement and retensioning step. Labral height and capsular shift were measured using a MicroScribe digitizer.Results:The intact, defect, 1-anchor, 2-anchor, and 3-anchor tensions were not significantly different between the KT and KLend groups. For the latter, retensioning of all knotless anchors increased capsular tension by 2.1 N compared with its 3-anchor state, although this was not statistically significant (P = .081). The KLstepwise group explored an alternative method to retension the capsule using knotless anchors, with similar final capsular tensions compared with the other groups. All repairs had similar improvements in capsulolabral height and superior capsular shift.Conclusion:Knotted and knotless suture anchors provided similar overall restorations in anteroinferior glenohumeral ligament tension. However, knotless devices were capable of small but statistically insignificant improvements in capsular tension with retensioning.Clinical Relevance:Retensioning of knotless anchors allows the surgeon to tighten regions of the glenohumeral capsule that remain lax after repair.

Arthroscopic Fixation of Knee Osteochondritis Dissecans With Interlinked Knotless All-Suture Anchors

Unstable, displaced, and persistently symptomatic osteochondritis dissecans of the knee typically requires surgical treatment. An arthroscopic, knotless fixation method using interlinked all-suture anchors is presented, with potential advantages over other current techniques in fixation over a broad zone, treatment versatility for a wide range of fragment types, retensioning ability after stressing, decreased risk of implant-breakage complications, and avoidance of additional surgery for implant removal.

Paper 09: Postage-Stamp Glenoid Fracture after Bankart Repair. How Many Anchors are Safe? - A Biomechanical Analysis

Objectives:Fractures of anterior glenoid rim, aka “Postage-Stamp” fractures, are potential complications of arthroscopic Bankart repairs that occur when a fracture line propagates through previous anchor sites producing a serrated edge. (Fig.1: A and J) Placing multiple anchors adjacent to glenoid rim in attempt to recreate the labral bumper was suggested to reduce the risk of recurrent dislocation after surgery, [Boileau et al 2006] as well as to create a stress riser that may predispose to fracture if another traumatic event may occur.This controlled laboratory study investigated the effect of increased number holes, and different types and sizes of suture anchors on the load necessary to create Postage-Stamp fractures. Our objective was to establish a safe number of anchors that could be inserted in the anterior glenoid rim without incurring in a substantially high risk of fracture.Hypothesis:Increasing the number of holes and anchors and their size would decrease forces necessary to break the anterior glenoid rim.Methods:We tested 46 synthetic scapulae with similar compressive strength and elastic modulus of human glenoid (4th gen. composite scapulae, Sawbones, Pacific Research Laboratories, USA) in a servohydraulic apparatus (Fig.1: B and H) following a previous published biomechanical model. [Farmer et al2014] A guide ensured holes were drilled and anchors were inserted in the same exact angle, depth and location for every specimen. (Fig.1: C to F) A metallic humeral head applied force to the anterior glenoid rim at 1mm/s until fracture occurred. (Fig. 1: G to K) Load-to-fracture of intact glenoid was compared to groups of drilling anchor holes (# 3,4,5,6 and 7) of different diameters (1.6mm and 3mm), and groups with anchors of different sizes and types (1.6mm all-suture and 3mm core anchors).(Fig.1: I to K) One-way ANOVA followed by Turkey post-hoc test compared groups to determine the number of holes necessary to weaken glenoids below 70% of intact value with a p value <0.005.Results:Intact glenoid mean load-to-fracture was 1,238 ± 74N. Drilling 3 to 7 holes of 1.6mm-diameter linearly reduced load to 93%, 89%, 74%, 56% and 52% of intact value respectively, while 3.0mm drill holes reduced load to 87%, 65%, 51%, and 40% respectively.(Fig.2) Directly comparing drill role sizes there were significant differences on the 4, 5 and 7 holes groups (p=0.045, 0.032 and 0.015, respectively), so that a glenoid could safely sustain up to 5 holes of 1.6mm, but no more than 3 holes of 3.0mm-diameter.(Fig.3)Inserting 1.6mm “all-suture” anchors in the 1.6mm-diameter holes did not change the load-to-fracture on the 4 or 5 holes groups (Fig.4A), indicating that the number of drill holes was the main determinant of anterior glenoid rim strength, so that the all-suture anchors did not act as stress risers. Thus, up to 5 “all-suture” 1.6mm anchor could be safely used on a Bankart repair.The 3.0mm “core” anchors increased the load-to-fracture when compared to the group with the same number of holes of the same diameter size. Despite 4 holes of 3.0mm-diameter decreased the load-to-fracture bellow the safety line of 70% of intact value, the group with 4 anchors of 3.0mm-diameter “core” anchors increased load-to-fracture to 85% of intact value (p=0.033).(Fig.4B) This stress shield effect of the 3.0mm core anchor was not noticed on the 5 anchors group, in which the overall strength of the construction was bellow the 70% of intact safety line.Conclusions:Our data call in that up to four 3.0mm “core” anchors or five 1.6mm-diameter “all-suture” anchors could be safely inserted in the anterior glenoid rim without incurring in increased risk of Postage-Stamp fracture. One should prefer small diameter anchors if more than 4 anchors were intended on a Bankart repair.This study contributed to important data about number, size and type of anchors that the anterior glenoid rim could safely sustain in order to avoid postage-stamp fracture in case a new traumatic dislocation episode occur after a Bankart repair, which is of clinical interest in high risk population preoperative planning and selection of implant size, type and number.

Arthroscopic Repair of Posterior Root Tears of the Lateral Meniscus with All-Suture Anchor

Meniscus root tears are increasingly being recognized and treated because of improved awareness and diagnostics. These injuries commonly occur in combination with knee ligament injuries. Untreated posterior meniscus root teats have been demonstrated to increase contact pressure and decrease contact area, ultimately leading to unfavorable joint loading and development of early osteoarthritis. Posterior lateral meniscus root tears (PLMRTs) also have been reported to increase anterior tibial translation and pivot shift in anterior cruciate ligament–deficient knees. Therefore, it is crucial to repair meniscal root tears when possible to restore knee joint loading and kinematics. Several techniques for repair of the PLMRT have been described. In this Technical Note, we describe our preferred technique for repair of PLMRT using an all-suture anchor. This technique is reproducible, does not need a tunnel, mitigates bungee effect of transtibial technique, and the anchor can easily be inserted on the footprint without a need for a guide.

Serial magnetic resonance imaging evaluation of the early reaction of all-suture anchors in arthroscopic rotator cuff repair.

The aim of this study was to evaluate the early reaction of all-suture anchors (ASAs) in arthroscopic rotator cuff repair. This retrospective case series comprised 23 patients (8 women, 15 men; mean age = 59.9 years, age range = 36-73 years) with medium-size rotator cuff tear who underwent arthroscopic rotator cuff repair. All patients underwent postoperative serial magnetic resonance imaging (MRI) evaluation 3 and 6 months postoperatively. Demographic and operative characteristics were recorded. MRIs were evaluated for osseous cyst formation, and tunnel volume was measured. Statistical analyses were performed to detect differences in the serial MRI follow-up observation. A total of 39 ASAs were evaluated. Osseous cyst formation was found in two ASAs (5.1%) at the 6-month follow-up. Tunnel expansion was significantly observed in both 3- and 6-month postoperative MRI evaluations (P < 0.001). The mean tunnel volume significantly increased 1.95 times at the 3-month follow-up and 2.84 times at the 6-month follow-up (P < 0.001). Evidence from this study has revealed low rates of cyst formation but significant increases in tunnel volume at the early follow-up following arthroscopic rotator cuff repair with ASAs. Level IV, Therapeutic Study.

Arthroscopic Remplissage Using Knotless, All-Suture Anchors

Glenohumeral bone loss is a significant risk factor for recurrent instability after shoulder dislocation. The Hill-Sachs lesion is an osseous defect of the posterior humeral head that is commonly recognized after anterior shoulder dislocation. Several procedures exist to address humeral-sided bone loss, including soft tissue filling procedures, osteoarticular allografts, bone plugs, rotation osteotomies, and humeral head replacements. However, among the most common of these procedures is the arthroscopic remplissage. This technique involves capsulotenodesis of the posterior shoulder capsule and infraspinatus tendon into a Hill-Sachs lesion. Previously described techniques use knotted suture anchors. In this report, we describe a modified technique for remplissage using knotless, all-suture anchors to perform capsulotenodesis of a Hill-Sachs lesion. Benefits of this technique include a single skin incision, improved bone preservation, and easier facilitation of revision surgery if required.

Subpectoral Biceps Tenodesis Using an All-Suture Anchor

Long head biceps tendon pathology is a substantial contributor to anterior shoulder pain and often requires surgical intervention to offer a return to normal functionality. Surgical treatment options consist of both open and arthroscopic tenodesis or tenotomy of the long head biceps brachii. Several techniques exist for tenodesis and tenotomy of the biceps, although current debate continues regarding which surgical approach is the optimal intervention for symptomatic bicep pathology. In this technical note, we describe a subpectoral biceps tenodesis of the long head bicep tendon using an all-suture anchor. Our technique offers the advantages of using an all-suture anchor that incorporates a self-tensioning mechanism with direct visualization of the tendon during biceps tenodesis and anchor insertion.

Single-Portal Proximal Biceps Tenodesis Using an All-Suture Anchor

The long head of the biceps is an important pain generator of the shoulder joint. Pathologies of the long head of the biceps involve superior labrum anterior to posterior lesions, pulley lesions, partial tears of the biceps tendon, biceps tendonitis, and medial biceps subluxation caused by full-thickness subscapularis tendon tears. Treatment of an inflamed or injured long head of the biceps by either tenotomy or tenodesis is often mandatory during shoulder arthroscopy to avoid persisting pain and possible revision procedures. In comparison with a tenotomy of the biceps tendon, a biceps tenodesis preserves the tension, anatomy, and cosmesis of the biceps muscle. The presented technique demonstrates a single portal technique for a proximal biceps tenodesis in the bicipital groove using an all-suture anchor.

Using a modified J-shaped Y-knot all-suture anchor to pass a suture under the coracoid process in coracoclavicular stabilization.

IntroductionThe distal clavicle fracture is a common shoulder injury. There are several treatment methods which can achieve good outcomes, of which coracoclavicular (CC) stabilization is one of the most popular surgical options. In CC stabilization, the step of passing a suture under the coracoid base is the most difficult step because the standard surgical tool is not designed for passing a suture under the coracoid process. To solve this problem, there are commercial tools for use in this step but all of them are expensive, and thus of limited availability in developing or low-resource settings. We propose a modified J-shaped Y-knot all-suture anchor for use in passing a suture under the coracoid process.Case presentationA 45-year-old Thai male who had a left distal clavicle fracture was scheduled for CC stabilization. We modified a sterile Y-knot all-suture anchor to loop underneath the coracoid base which was easy to use and can design individually.DiscussionIn CC stabilization, there are many specialized commercial tools specially designed to easily pass the suture under the coracoid base but they are very expensive. The surgeon can use this technique to modify J-shaped Y-knot all-suture anchor for use in CC stabilization, recycling a Y-knot all-suture anchor normally discarded after use.ConclusionA modified J-shaped Y-knot all-suture anchor can use in passing a suture under the coracoid process.

Arthroscopic Single-Portal Suprapectoral Biceps Tenodesis With All-Suture Anchor

Tenodesis of the long head of the biceps tendon can be performed through arthroscopic and open techniques with various fixation methods and at different locations on the humerus. Many techniques have been described, with controversy surrounding the advantages and disadvantages of each. In this Technical Note, we describe an all-arthroscopic, intra-articular, single-portal, suprapectoral biceps tenodesis with an all-suture anchor. This technique also allows for suture passage through the biceps tendon before tenotomy to ensure proper maintenance of the length–tension relationship of the biceps musculotendinous unit.

The effect of the number of anchors used in the medial row on clinical outcomes in arthroscopic double row repair of rotator cuff tears: retrospective evaluation of patients with 3 to 7 years of follow-up

Aim: Arthroscopic double row (DR) suture anchor repair is one of the most frequently applied methods in the surgical treatment of rotator cuff tear (RCT). Various modifications have been tried to eliminate some of the disadvantages of this technique such as operation time, high cost, and the high risk of retearing. In this study, we aimed to investigate whether placing a single or double suture anchor in the medial row affects clinical and functional outcomes and retear rates in patients with RCT who were operated with the DR suture anchor technique.&#x0D; Material and Method: A retrospective study including 58 patients aged 18-65 years who underwent DR suture anchor repair due to medium-sized RCT and had a minimum follow-up period of 3 years was conducted. One knotless anchor was placed in the lateral row in all patients. In the medial row, we placed 1 all suture anchor (ASA) in group 1 and 2 ASAs in group 2. Visual pain scale (VAS), University of California Los Angeles Score (UCLA), American shoulder and elbow score (ASES) scales were used for preoperative and postoperative clinical and functional evaluation, and complications and retears were recorded.&#x0D; Results: When the preoperative and postoperative VAS, UCLA and ASES scores were compared within groups, there were significant difference from pre- to post-operative findings in both groups (p 0.05). Operation time in Group 1 was significantly shorter than in Group 2 (p

Knotted all-suture anchors and knotted titanium suture anchors are not clinically superior to each other in isolated type II slap tear repair: A minimum 2-year follow-up

Knotted all-suture anchors and knotted titanium suture anchors are not clinically superior to each other in isolated type II slap tear repair: A minimum 2-year follow-up

Distal Triceps Tendon Injury

Background: Triceps tendon ruptures typically result from a forceful elbow eccentric contraction. The goal of a distal triceps tendon repair is to reattach the torn tendon back to the olecranon. Surgery is indicated for patients with complete rupture of the triceps tendon or symptomatic partial tears with failed conservative management. The complication rate occurs in 22% of patients postoperatively; however, only 0% to 4% of patients suffer a re-rupture of the tendon. Indications: We present a case of a highly active 38-year-old right-hand dominant man with acute onset of left posterior elbow pain following 1-handed pushup resulting in a complete distal triceps avulsion with 1.5 cm retraction. Technique: The distal triceps avulsion was repaired in a double row fashion using 2 double-loaded all-suture anchors in the medial row and anchor in the lateral row through a posterior approach. Results: Full anatomic footprint coverage was able to be achieved intraoperatively, and gentle range of motion from 0 to 90 degrees of flexion did not result in gap formation. Discussion/Conclusion: Successful outcomes with full anatomic footprint coverage of the distal triceps tendon can be achieved through a double row repair configuration.

Post-Traumatic Hallux Valgus: A Modified Surgical Technique

Post-traumatic hallux valgus, a turf toe variant, is a rare, yet limiting injury. According to the literature, the deformity has been associated with acute medial collateral ligament tears, turf toe variant injuries, Lisfranc injury patterns, and first metatarsal fractures. There have been few documented cases of post-traumatic hallux valgus secondary to medial collateral ligament tears, and the treatment has been variable. Some authors have described direct end-to-end repair of the ligament to address the deformity, while others have described a modified McBride bunionectomy involving a Silver bunionectomy, lateral soft tissue release, and medial capsular and ligamentous repair. We propose a modified technique similar to the modified McBride bunionectomy, however, with the use of an all-suture anchor in the medial capsular and ligamentous repair. Our belief is that the all-suture anchor will allow for a stronger repair that will meet the physical demands of everyday ambulation and athletic participation. We used this technique in an individual who had evidence of a medial ligamentous complex injury of the hallux on MRI and failed conservative management. Postoperatively, the patient is immobilized until they can begin working on range of motion, strengthening, and finally to achieve return to full activity and sports.

Arthroscopic Iliac Crest Bone Graft Augmentation Using All-Suture Anchors for Shoulder Instability Caused by Glenoid Bone Loss

Augmentation of the anterior glenoid with bone graft is an established treatment for recurrent anterior instability due to critical glenoid bone loss. Both open and arthroscopic techniques have been described. Fixation with metal screws through an open approach is the most common technique, but the risk of metal screw–related complications remains a concern. A variety of arthroscopic techniques using suspensory fixation or suture anchors have been described in the literature. However, they all require a posterior incision to insert a targeting device or to manage sutures. We describe a technique for arthroscopic bone grafting of the anterior glenoid via a purely anterior approach with 2 linked knotless suture anchors, thereby avoiding posterior suture management and glenoid metalwork complications.

All-Suture Anchors in Orthopaedic Surgery: Design, Rationale, Biomechanical Data, and Clinical Outcomes

All-suture anchors (ASAs) are a relatively new alternative to traditional suture anchors, comprised of sutures, suture tapes, or ribbons woven through a soft sleeve. These novel anchors are typically smaller than traditional anchors, allowing for more anchors to be used in the same amount of space or for use when bone stock is limited, for example, in revision settings. They can be inserted through curved guides to reach more challenging locations, and they have thus far had similar loads to failure during biomechanical testing as traditional anchors. However, these benefits must be weighed against new challenges. When using ASAs, care must be taken to fully deploy and seat the anchor against cortical bone for optimal fixation and to prevent gap formation. Furthermore, decortication, often performed to enhance the biologic environment for soft-tissue healing, may weaken the cortical bone on which ASA fixation depends on. The purpose of this article is to provide insight on the designs, advantages, and potential disadvantages associated with ASAs, as well as review the available biomechanical and clinical data.

All-Suture and Solid Medial Row Anchors Produce Similar Clinical Outcomes for Double Row Suture Bridge Rotator Cuff Repair (227)

Objectives:All-suture anchor use for rotator cuff repair is increasing. Potential benefits of these anchors include less bone loss from anchor hole drilling and decreased injury to the chondral surface with anchor pullout. Minimal evidence exists comparing clinical outcomes of all suture to solid medial row anchor fixation in double row suture bridge rotator cuff repair. The purpose of this study was to compare patient-reported outcomes for rotator cuff tears treated with all-suture medial row anchors to those treated with more traditional solid anchors. The null hypothesis was that there is no difference in outcomes between the all-suture and solid anchor rotator cuff repairs.Methods:Three sports medicine fellowship trained surgeons performed rotator cuff repairs using the double row suture bridge technique with minimum 3 years of follow up. Patients were separated into two groups based on whether or not they received all-suture or solid anchor fixation for the medial row of their repair. All lateral row fixation was performed with solid anchors. Primary outcomes were evaluated with telephone follow-up and included the American Shoulder and Elbow Surgery Score (ASES), Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale (VAS). The Rehabilitation protocol was the same for all subjects in the study.Results:3 sports medicine fellowship trained orthopaedic surgeons performed 153 rotator cuff repairs. 91 of these subjects had all-suture fixation of the medial row and 62 received solid anchor fixation. Follow up was 3.6 years ± 0.6 for the all-suture group and 3.7 years ± 0.6 in the solid anchor group (p= 0.28). ASES scores were 92 ± 16 in the all-suture group and 90 ± 17 in the solid group (p =0.35). SANE scores were 91 ± 13 in the all-suture and also 91 ± 13 in the solid anchor cohort (p = 0.97). VAS scores were 1.1 ± 2.0 in the all-suture and 0.7± 1.8 in the solid anchor group (p=0.17). There were no significant differences between groups with regards to re-operation rate or anchor configuration.Conclusions:All suture anchors used in medial row fixation for double row suture bridge rotator cuff repairs have similar clinical outcomes to rotator cuff tears treated in similar fashion with solid medial row anchors.

Arthroscopic Biological Augmentation for Massive Rotator Cuff Tears: The Biceps-Cuff-Bursa Composite Repair

Surgical repair of massive and chronic rotator cuff tears is difficult due to tendon retraction and severe atrophy, and the resultant retear rate in the structurally weak tendons is high. Commercially available patches and bioinductive scaffolds have been used to provide strength and superior healing environment in partial and complete rotator cuff tears. Biological biceps autograft has been used for superior capsular reconstruction, and the subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing. We describe our technique for combined use of the long biceps tendon (LBT) and vasculature-preserved subacromial bursa as autografts in rotator cuff repair augmentation. The technique involves obtaining a LBT graft of sufficient length using a “traction and tenodesis” technique. The subacromial bursa is mobilized as a continuous layer (vascular bursal duvet) by maintaining its medial and lateral vascularity. All-suture anchors are used to minimize the insertion apertures (3 mm) in tuberosity. The bursa is advanced laterally, and the mobilized cuff is repaired together as a biceps-cuff-bursa composite unit. Combined use of the biceps and bursa as biological autografts has the advantage of structural and regenerative augmentation, and the autografts are easily accessible without added cost.

Circumferential and Segmental Arthroscopic Labral Reconstruction of the Hip Utilizing the Knotless Pull-Through Technique with All-Suture Anchors

Appropriate labral tear management is one of the principal priorities of hip-preservation surgery. The labrum’s role in the stability and biomechanics of the hip and preservation of the suction seal has been thoroughly demonstrated. Favorable patient-reported outcomes with labral reconstruction and, more recently, labral augmentation have shown that these are viable reconstructive procedures in the setting of irreparable labra. A wide variety of grafts have been used for these advanced labral restoration techniques. The present Technical Note will describe a detailed arthroscopic circumferential labral reconstruction using the pull-through technique with knotless all-suture anchors. The benefits of such can be applied to both segmental and circumferential labral reconstruction procedures, as well as labral augmentation, based on the intraoperative findings and preference of the surgeon.