Pietschmann - 2009 Ombro Forces Ex Vivo

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Arch Orthop Trauma Surg (2009) 129:373–379
DOI 10.1007/s00402-008-0689-4
ARTHROSCOPY AND SPORTS MEDICINE
Suture anchor Wxation strength in osteopenic versus 
non-osteopenic bone for rotator cuV repair
Matthias F. Pietschmann · Valerie Fröhlich · 
Andreas Ficklscherer · Mehmet F. Gülecyüz · 
Bernd Wegener · Volkmar Jansson · Peter E. Müller 
Received: 11 January 2008 / Accepted: 17 June 2008 / Published online: 8 July 2008
© Springer-Verlag 2008
Abstract
Introduction Rotator cuV tears are increasing with age.
Does osteopenic bone have an inXuence on the pullout
strength of suture anchors?
Materials and methods SPIRALOK 5.0 mm (DePuy
Mitek), Super Revo 5 mm and UltraSorb (both ConMed
Linvatec) suture anchors were tested in six osteopenic and
six healthy human cadaveric humeri. Incremental cyclic
loading was performed. The ultimate failure load, anchor
displacement, and the mode of failure were recorded.
Results In the non-osteopenic bone group, the absorbable
SPIRALOK 5.0 mm achieved a signiWcantly better pullout
strength (274 N § 29 N, mean § SD) than the titanium
anchor Super Revo 5 mm (188 N § 34 N, mean § SD), and
the tilting anchor UltraSorb (192 N § 34 N, mean § SD).
In the osteopenic bone group no signiWcant diVerence in the
pullout strength was found. The failure mechanisms, such
as anchor pullout, rupture at eyelet, suture breakage and
breakage of eyelet, varied between the anchors.
Conclusion The present study demonstrates that, in oste-
openic bone, absorbable suture anchors do not have lower
pullout strengths than metal anchors. In normal bone, the
bioabsorbable anchor in this study even outperformed the
non-absorbable anchor.
Keywords Shoulder · Rotator cuV tear · Suture anchor · 
Bone density
Introduction
Rotator cuV tears are more common among the elderly pop-
ulation [19–21], thus the rotator cuV tear is often associated
with osteoporotic or osteopenic bone in the proximal
humerus, in particular with female patients [21], therefore
making higher demands on the anchoring system was used.
Metal anchors are still favored in rotator cuV surgery,
especially in osteopenic bones, since they are easy to han-
dle, inexpensive, and according to some surgeons, possess
higher pullout strength. However, metal anchors interfere
with radiographic diagnostic procedures and cause prob-
lems in revision procedures [8]. In contrast, absorbable
suture anchors represent an alternative solution. They bear
the advantage of becoming absorbed after a certain time
thereby minimizing complications generated by migration,
and give less scatter on radiographic diagnostic procedure
than metal anchors.
The purpose of this study was to compare a newer absorb-
able anchor particularly developed for osteopenic bone,
SPIRALOK suture anchor (5.0 mm, DePuy Mitek, Raynham,
MA, USA), with established suture anchors. For comparison,
we chose the Super Revo 5 mm titanium suture anchor
(ConMed Linvatec, Utica, NY, USA), and the absorbable
UltraSorb tilting anchor (Linvatec, Largo, FL, USA) for the
repair of rotator cuV tears in healthy and osteopenic bone.
Materials and methods
Specimen preparation
Twelve human humeri from 12 cadavers, eight male and
four female bones, with a mean age of 57 years at the time
of death (range 27–93 years) were used (Fig. 1). 
M. F. Pietschmann · V. Fröhlich · A. Ficklscherer · 
M. F. Gülecyüz · B. Wegener · V. Jansson · P. E. Müller (&)
Department of Orthopedics, Klinikum Grosshadern, 
Ludwig-Maximilians-Universitaet Munich, 
Marchioninistr. 15, 81377 Munich, Germany
e-mail: peter.mueller@med.uni-muenchen.de; 
mpietschmann@yahoo.com
123
374 Arch Orthop Trauma Surg (2009) 129:373–379
The specimens were taken within 24 h, post mortem.
The soft-tissue was removed, freeing the humeral head.
Prerequisite for inclusion into the study was a macroscopi-
cally intact humeral head. Evidence of surgical intervention
or other pathologic conditions, such as prior fracture, were
taken as exclusion criteria.
Measurement of bone density
The exact bone mineral density (BMD) of the humeri was
measured by a bone density scan using a 64-slice-computed
tomography system (Siemens, Sensation 64 Somatom,
Munich, Germany). Five measurements with a layer thick-
ness of 3 mm each were accomplished in the proximal range
of the humeral head. Analysis was carried out with the use of
Osteo software (Siemens, Munich, Germany). The program
was originally used to quantify bone density in the lumbar
spine and was adapted for the humeral head. Trabecular and
cortical BMD of the humeral head were deWned [21].
Depending on the BMD the human humeri were divided into
two groups, non-osteopenic and osteopenic.
Until testing, the specimens were stored frozen at
¡21°C. The humeri were thawed carefully at 4°C over a
period of 24 h before measurement, and kept moist during
the test with 0.9% NaCl. The measurements were per-
formed at room temperature.
Suture anchors
Two screw anchors and one tilting anchor were tested
(Fig. 2):
• SPIRALOK 5.0 mm (DePuy Mitek, Raynham, MA,
USA): absorbable suture anchor, screw anchor made
from poly-L-lactic acid with Ethibond-polyamide-
sutures (USP 2)
• Super Revo 5 mm (ConMed Linvatec, Utica, NY, USA):
titanium suture anchor, screw anchor with coated non-
absorbable twisted polyester sutures (USP 2)
• UltraSorb anchor (ConMed Linvatec, Utica, NY,
USA): absorbable suture anchor, PLA, tilting anchor
with silicone-coated, non-absorbable twisted polyester
sutures (USP 2)
For the sake of comparability and to focus on the diVer-
ences in anchor design, both screw type anchors had a
diameter of 5 mm in both the osteopenic and healthy bone
groups, even though anchors with a greater diameter such
as 6.5 mm might yield better results in osteopenic bone.
Placing the suture anchors
• Three suture anchors were placed along the lateral
ridge of the greater tuberosity at intervals of approxi-
mately 10 mm as described by Meier et al. for single
row suture anchor repair technique [15]. Consequently,
there were three implantation sites: an anterior, a
medial and a posterior one (Fig. 3a). The anchor posi-
tions were regularly alternated in order to minimize the
inXuence of possible variations in bone density at the
various positions [1, 7, 18]. The diVerent suture
anchors were inserted according to the manufacturers’
instructions at a 45° angle to the diaphysis of the
humerus [5, 7, 21] (Fig. 3b). The anchors were tested
with the suture material supplied by the manufacturer.
Biomechanics
An electromechanical testing machine (model Z010/TN2A;
Zwick, Ulm, Germany) with a measuring range from 20 N
to 10 kN and an uncertainty measurement of 0.21% was
Fig. 1 Age distribution of the twelve cadaver specimen in this study
0
1
2
3
4
age
nu
m
be
r 
of
 s
pe
ci
m
en
91-10081-9071-8061-7051-6041-5031-4021-30
Fig. 2 Types of suture anchors tested in this study from left to right:
UltraSorb, Linvatec. Super Revo 5 mm, Linvatec. SPIRALOK 5.0
mm, DePuy Mitek
123
Arch Orthop Trauma Surg (2009) 129:373–379 375
used. The data evaluation was recorded with testXpert V5.0
(Zwick, Ulm, Germany).
The humeri were Wxed to a custom made mounting-
plate. The direction of pull was at 135° to the axis of the
humeral shaft. This set-up replicates the physiologic pull of
the supraspinatus tendon [18]. One anchor of each type was
tested individually.
The anchor sutures were Wxed between two clamping
jaws of the testing machine. The distance between implan-
tation site and clamping jaws was 30 mm.
Cyclic loading was performed to simulate clinical condi-
tions [6, 7, 18]. As described in Biomechanics, a preload of
20 N and a crosshead extension rate of 20 mm/min were
selected [18]. Fifty cycles with a tensile load of 75 N were
applied, and then the tensile load was increased to 100 N for
another 50 cycles. Until failure of the anchor Wxation system
(suture breakage, anchor pullout, etc.), the tensile load was
gradually increased by 25 N per 50 cycles [18]. The ultimate
failure loads, the total systemdisplacement, as well as the
system displacement after the Wrst pull with 75 N were
recorded during testing. As displacement, we deWned anchor
dislocation and irreversible suture lengthening. Additionally,
the respective modes of failure were documented.
Statistical analysis
The statistical analysis was performed with the use of
GraphPad Prism statistical software, version 3.02 (Graph-
Pad Software, San Diego, CA, USA). The analysis of the
BMD was performed with the Mann–Whitney-U-test. For
testing the signiWcance of all three anchor Wxation systems,
the Kruskal–Wallis test for multiple samples was used.
Finally, using the Dunn’s post hoc test, the experimental
groups were compared individually. All three tests are non-
parametric tests for unpaired samples. The signiWcances
were calculated on the basis of a 5% level (p 0.05).
Modes of failure
Modes of failure varied depending on BMD and anchor
design. Suture break at the eyelet occurred with the Super
Revo titanium anchor whereas, the SPIRALOK and Ultra-
Sorb anchors displayed suture breaks in places other than
the eyelet. In the osteopenic group, the number of anchor
pullouts clearly increased (Tables 1 and 2).
Ultimate failure load
The ultimate failure loads of each individual anchor Wxa-
tion system ranged from a mean of 151 N (UltraSorb, oste-
openic bone) to a mean of 274 N (SPIRALOK 5.0 mm,
non-osteopenic bone). In 12 humeri, the SPIRALOK
achieved the highest pullout strengh with 222 N (§59 N
SD), compared to the Super Revo with 169 N (§41 N SD)
and the UltraSorb with 171 N (§41 N SD).
There was a signiWcant diVerence in the pullout strength
of the SPIRALOK 5.0 mm in non-osteopenic and osteope-
nic bone (p 0.05) (Tables 1 and 2).
The statistical comparison of the pullout strength of the
diVerent anchors did not show a signiWcant diVerence
within the osteopenic bone group. The comparison of the
anchors in the non-osteopenic humeri showed signiWcantly
higher pullout strength of the SPIRALOK anchor compared
to the Super Revo 5 mm, and to the UltraSorb tilting anchor
(p 0.05).
Discussion
The ideal suture anchor should be easy to insert, provide
adequate primary strength in order to permit rehabilitation
Table 1 Summary of the results for non-osteopenic bone (n = 6)
a Ultimate failure load (N) after cyclic loading with Wfty cycles per load, beginning with 75 N, values are given as mean and standard deviation,
with the range in brackets
b Anchor displacement (mm) was measured after the Wrst cycle at 75 N, values are given as mean and standard deviation
c Failure modes of the three tested suture anchors varied, given as number of cases
Suture anchor Ultimate 
failure load (N)a
Anchor displacement 
at Wrst cycle at 75 N (mm)b
Mode of failure (number of cases)c
SPIRALOK 5.0 mm 274 § 29 (242–325) 1.81 § 1.08 Anchor pullout (1), rupture at eyelet (2), suture breakage 
(not at eyelet) (2), breakage of eyelet (1)
Super Revo 5 mm 188 § 34 (150–225) 1.53 § 1.39 Anchor pullout (1), rupture at eyelet (4), suture breakage 
(not at eyelet) (1)
UltraSorb 192 § 34 (150–250) 2.58 § 1.56 Anchor pullout (3), rupture at eyelet (1), suture breakage 
(not at eyelet) (2)
Table 2 Summary of the results for osteopenic bone (n = 6)
a Ultimate failure load (N) after cyclic loading with Wfty cycles per load, beginning with 75 N, values are given as mean and standard deviation,
with the range in brackets
b Anchor displacement (mm) was measured after the Wrst cycle at 75 N, values are given as mean and standard deviation
c Failure modes of the three tested suture anchors varied, given as number of cases
Suture anchor Ultimate 
failure load (N)a
Anchor displacement 
at Wrst cycle at 75 N (mm)b
Mode of failure (number of cases)c
SPIRALOK 5.0 mm 171 § 19 (150–200) 3.47 § 2.87 Anchor pullout (5), rupture at eyelet (1)
Super Revo 5 mm 150 § 42 (125–225) 2.06 § 1.63 Anchor pullout (3), rupture at eyelet (3)
UltraSorb 151 § 40 (90–200) 2.71 § 1.14 Anchor pullout (5), suture breakage (not at eyelet) (1)
123
Arch Orthop Trauma Surg (2009) 129:373–379 377
exercises, it should not interfere with radiographic diagnos-
tic procedures nor generate complications (e.g. osteolysis,
cartilage damage by migration, etc.). In case of a revision
surgery, the anchor should be either absorbable or easily
removable. The ideal, all-needs-fulWlling anchor for rotator
cuV repair has not yet been developed.
These days, most studies for suture anchors rather
approach physiologic conditions in vivo. Contrary to previ-
ous studies in which the single-pull to failure technique was
used, today we prefer cyclic loading since it is a more accu-
rate mode of testing. This new technique simulates the sta-
bility of the system in relation to repetitive load [7, 9, 16].
If one compares the maximum failure strength of both test
models, the single-pull to failure provides a higher ultimate
pullout strength which, however, does not represent the in
vivo situation with regard to repetitively occurring loads
and the physiologic strength level of the rotator cuV [1, 12,
16].
A successfulrotator cuV repair depends on at least three
factors: the condition of the tendon, the anchor material and
design, and the bone density at the greater tuberosity [20].
We applied the BMD measurement, which is standard-
ized for the lumbar spine, to the humeral head. The results
obtained from the humerus cannot be used to diVerentiate
the bones with regard to osteoporosis, since no standardized
data for the humerus exist. The humeri were only graded
according to their bone mineral density into “healthy” and
“osteopenic”. The osteopenic bones were all found in the
older age group which is consistent with the clinical situa-
tion. Many patients with chronic rotator cuV tears are of
older age.
Various studies to determine the inXuence of bone den-
sity at the greater tuberosity and the ultimate failure load
of suture anchors have been conducted, but have yielded
inconsistent results. For instance, Barber et al. [1] found
higher pullout strength (approximately 40%) in the poster-
ior area of the greater tuberosity whereas, Tingart et al.
[21] reports higher pullout strength in the proximal, ante-
rior, and middle area of the greater tuberosity. However,
Tingart et al. did not Wnd a correlation of higher pullout
strength with an accordingly higher trabecular bone den-
sity in the middle and anterior tuberosity, but only with
the cortical bone density within the middle range. These
Wndings must be seen critically, because the suture
anchors used are by default anchored in trabecular bone,
not in cortical bone [13]. No diVerence in the ultimate fail-
ure load as a function of the implantation position at the
greater tuberosity could be detected in our study, which
might be due to the limited number of tested anchors at the
diVerent positions.
In reXecting the correlations between pullout strength
and trabecular bone density, signiWcances could be found
with the SPIRALOK anchor and with the Super Revo
anchor. This permits the conclusion that the tested screwing
anchors are the better choice when operating on healthy tra-
becular bone, because their ultimate failure load, other than
that of the tilting anchor UltraSorb, shows a positive corre-
lation between non-osteopenic and osteopenic trabecular
bone.
Studies, reporting osteolysis by absorbable suture
anchors, pertain primarily to PGA polymers [3, 4, 8, 11].
PLA polymers, such as the SPIRALOK 5.0 mm, dissolve
more slowly than PGA polymers [8, 10], and therefore bear
a smaller risk of foreign body reaction with osteolysis [3,
8]. Yet it still needs to be clariWed whether the radiographic
evidence of osteolysis has a correlation with a poor clinical
outcome or if it is rather an insigniWcant radiological
change without any clinical function.
The advantages of using titanium suture anchors, over
using absorbable anchors, are the possibility to obtain
radiographic evidence of anchor dislocation [13, 16], and
the simplicity of the implantation procedure, which does
not necessitate pre-drilling and tapping. The titanium
anchor is pivoted directly after granulating the bone, without
Fig. 5 a Ultimate failure loads 
of the three tested suture anchors 
in non-osteopenic bone. 
b Ultimate failure loads 
of the three tested suture 
anchors in osteopenic bone
ultimate failure load in healthy bone
(n=6)
0
100
200
300
400
*
**
Dunn´s Multiple Comparison test:
 SPIRALOK vs. UltraSorb p 0,05
F m
ax
 [N
]
UltraSorb SuperRevoSPIRALOK 
p 0,05SuperRevo vs. UltraSorb 
UltraSorbSuperRevoSPIRALOK
a b
123
378 Arch Orthop Trauma Surg (2009) 129:373–379
pre-drilling and tapping. The SPIRALOK anchor, however,
needs drilling with tapping. After pre-drilling, the UltraSorb
tilting anchor is placed in the bone and blocked with a
proportioned pull.
The titanium anchor Super Revo, has sharper edges than
absorbable anchors which results in the occurrence of fre-
quent suture tears at the eyelet as shown in several other
studies [8, 16]. These tears led consequently to earlier sys-
tem failure at a slighter pull. The abrasion of the suture at
the sharp edges of the metal plays an important role here.
Therefore a stronger suture material such as, ultra high
molecular weight (UHMW) suture, that is more resistant to
breakage, at the eyelet should be used in order to optimize
the performance of the anchor. Abrasion is less pronounced
in absorbable anchor material due to the softer material [2,
14, 17]. Further, disadvantages of titanium anchors are
problems caused in case of revision surgery and interfer-
ence with postoperative imaging studies such as magnetic
resonance imaging (MRI).
The new SPIRALOK anchor had particularly been
developed for soft bones. Its four threads, surrounding a
solid, non-cannulated tapered inner core, Wx the anchor
Wrmly in the trabecular bone. An important aspect in
anchor design when it comes to better bone anchorage is
the broad and Xat rising threads with large distances
between the individual threads. The SPIRALOK anchor’s
pullout strength in the total evaluation (non-osteopenic
and osteopenic bones) was by 31% higher than that of the
Super Revo, and by 30% higher than that of the Ultra-
Sorb anchor. The best pullout performance, both on
healthy and on osteopenic bones was conducted by the
SPIRALOK anchor. However, no signiWcantly higher
pullout strength in the osteopenic bones could be
detected. It has to be mentioned, that the tested titanium
anchor Super Revo has only three threads anchoring in
the trabecular bone. It seems likely that other titanium
anchors with more threads might yield better results. There-
fore, it can be assumed that the design of the anchor plays
a greater role in the primary stability than the materials
used.
Conclusion
The data of our study suggest that the SPIRALOK anchor
appears to be of equal dependability in osteopenic bone to
the other two anchors tested, and perhaps of even better
dependability in non-osteopenic bone. The use of UHMW
sutures also contributes to higher system stability, since
several anchor failures with the Super Revo were caused by
suture breakage. The design of the anchor seems to play a
greater role than the materials used, regarding the primary
stability.
Considering the advantages of absorbable suture
anchors, such as better acceptance by patients, minimized
interference with postoperative imaging, less complicated
revision surgery and comparable pullout strength, absorb-
able suture anchors should be given precedence over non-
absorbable ones.
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123
	Suture anchor Wxation strength in osteopenic versus non-osteopenic bone for rotator cuV repair
	Introduction
	Materials and methods
	Specimen preparation
	Measurement of bone density
	Suture anchors
	Placing the suture anchors
	Biomechanics
	Statistical analysis
	Results
	Bone density measurements
	Alternating anchor implantation sites
	System stability: displacement after the Wrst pull with 75 N
	Modes of failure
	Ultimate failure load
	Correlation between bone mineral density and pullout strength
	Discussion
	Conclusion
	References
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