Arthroscopic Bankart revision using all suture anchor in recurrent anterior shoulder dislocation: A case report

IntroductionArthroscopic Bankart revision after recurrent shoulder dislocation is still a matter of discussion. Several factors are contributing to this injury. Recently the development of all suture anchors has grown in popularity in arthroscopic stabilization. It was proven to preserve bone stock, smaller in size thus more anchors can be made.Presentation of caseWe presented a case of 27-year-old woman with recurrent anterior dislocation after seven years of arthroscopic Bankart repair. Seven years before, we performed Bankart repair using three 2.8 mm fiber-wire anchor (FASTak® (Arthrex, Karsfield Germany)). For the revision surgery we performed arthroscopic revision using four all suture anchor technique (Y-Knot® Flex All-Suture Anchor, 1.3 mm – One strand of #2 Hi-Fi® (Conmed, New York)).DiscussionFrom preoperative and intraoperative assessment, we found no anchor failure and no massive bony lesion. To preserve the bone stock we insert four all suture anchors between the old anchor. One year post-operative follow up showed that patient could gain normal range of movement. No early or late complications were observed.ConclusionCompared to the conventional metallic anchor, all suture anchor has the same biomechanical strength. Moreover due to its relatively small size, it can reserve bone stock and more anchors can be made thus adding more stability to the shoulder.     

Failure of anterior shoulder instability repair caused by eyelet cutout of absorbable suture anchors

Repair of soft tissue to bone is increasingly frequently performed using absorbable suture anchors. If a repair fails clinically, it is often impossible to identify the cause of failure at repeat surgery. We report on 2 cases of recurrence of instability after arthroscopic Bankart repair. In reoperation in these cases, all sutures were correctly knotted around the labrum but were intact and torn out of the anchor eyelets. No sign of anchor displacement (3 anchors in each patient) was seen. This is the first clinical report of unambiguous structural suture anchor failure. These observations emphasize the sensitivity of Bankart repair to weak links in the repair chain, which must be avoided.     

Editorial Commentary: Anchor Position Affects Glenoid Resorption Rates After Arthroscopic Bankart Repair: Shoulder Stabilization Surgery Is a Game of Millimeters

The technical nuances of arthroscopic Bankart repair cannot be overstated. Previous literature has identified a number of risk factors for failure of arthroscopic stabilization procedures, and the implications of glenoid bone loss is widely recognized as a critical driver of postoperative outcomes. However, other technical considerations (inadequate number of suture anchors, improper position of suture anchors) have been acknowledged as risk factors for the failure of arthroscopic stabilization procedures. More recently, concerns have been raised regarding the observed rates of glenoid bone resorption following arthroscopic Bankart repair, which theoretically may predispose higher rates of clinical failure. Furthermore, certain techniques for placing anchors on the glenoid during arthroscopic Bankart repair may accelerate these resorptive changes. Precise measures of poststabilization surgery glenoid resorption coupled with comprehensive assessments of clinical outcomes are required to determine the optimal technique for anchor insertion during arthroscopic Bankart repair.     

A comparison of lateral ankle ligament suture anchor strength

BackgroundLateral ankle ligament repairs increasingly use suture anchors instead of bone tunnels. Our purpose was to compare the biomechanical properties of a knotted and knotless suture anchor appropriate for a lateral ankle ligament reconstruction.MethodsIn porcine distal fibulae, 10 samples of 2 different PEEK anchors were inserted. The attached sutures were cyclically loaded between 10 N and 60 N for 200 cycles. A destructive pull was performed and failure loads, cyclic displacement, stiffness, and failure mode recorded.ResultsPushLock 2.5 anchors failed before 200 cycles. PushLock 100 cycle displacement was less than Morphix 2.5 displacement (p < 0.001). Ultimate failure load for anchors completing 200 cycles was 86.5 N (PushLock) and 252.1 N (Morphix) (p < 0.05). The failure mode was suture breaking for all PushLocks while the Morphix failed equally by anchor breaking and suture breakage.ConclusionsThe knotted Morphix demonstrated more displacement and greater failure strength than the knotless PushLock. The PushLock failed consistently with suture breaking. The Morphix anchor failed both by anchor breaking and by suture breaking.     

关节镜下生物骨锚钉修复肩关节Bankart损伤

目的：探讨关节镜下采用生物骨锚钉固定缝合治疗肩关节Bankart损伤的方法及疗效。方法：自2010年1月至2017年6月收治23例肩关节复发性脱位患者,诊断为单纯肩关节Bankart损伤,男20例,女3例;年龄19~34（23.4±3.9）岁;右肩14例,左肩9例;军事训练伤17例,运动损伤5例,摔伤1例。受伤至手术时间3~36（10.9±5.8）个月。使用双线生物骨锚钉行关节盂前方肩关节囊-韧带-盂唇复合体提拉紧缩缝合术。采用肩关节Rowe评分评价临床疗效。结果：23例均获随访,时间18~39（24.5±3.7）个月,末次随访时,患侧肩关节无再发脱位,均恢复正常运动及工作。肩关节Rowes评分术前（53.91±11.67）分,术后（91.74±12.30）分,评价分级术前优0例、良0例、可9例、差14例,术后优16例、良4例、可3例、差0例（P<0.01）。结论：关节镜下生物骨锚钉缝合修复肩关节Bankart损伤是一种可靠有效、性价比高的治疗方法,适用于Bankart损伤翻修手术。     

A Knotless Suture Anchor: Technique for use in arthroscopic Bankart repair

Arthroscopic Bankart repair performed using suture anchors most closely mimics open repair techniques. One of the challenges with the arthroscopic technique is tying consistent, good-quality arthroscopic knots. The unique Knotless Suture Anchor (Mitek Products, Westwood, MA) and method of use for arthroscopic Bankart repair is described. The Knotless Suture Anchor has a short loop of suture secured to the tail end of the anchor. A channel is located at the tip of the anchor that functions to capture the loop of suture after it has been passed through the ligament. The ligament is tensioned as the anchor is inserted into bone to the appropriate depth. The doubled suture configuration that is created with the loop increases the suture strength in the Knotless Suture Anchor compared with standard suture anchors with the same size suture. To my knowledge, this article describes the first knotless suture anchor. A secure, low-profile repair can be created without arthroscopic knot tying.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 2 (February), 2001: pp 213–218     

Knotless suture anchor: arthroscopic bankart repair without tying knots

Arthroscopic Bankart repair done using suture anchors most closely mimics open repair techniques. The challenge with the arthroscopic technique is tying consistent, good quality arthroscopic knots. A unique knotless suture anchor and method of use for arthroscopic Bankart repair is described. The Knotless Suture Anchor has a short loop of suture secured to the tail end of the anchor. A channel is located at the tip of the anchor that functions to capture the loop of suture after it has been passed through the ligament. The ligament is tensioned as the anchor is inserted into bone to the appropriate depth. Mechanical testing showed increased suture strength in the Knotless Suture Anchor compared with standard suture anchors. This is attributable to the doubled suture configuration that is created with the Knotless Suture Anchor loop. To the author's knowledge, the current study describes the first knotless suture anchor. A secure, low-profile repair can be created without arthroscopic knot tying.     

Mode of failure for rotator cuff repair with suture anchors identified at revision surgery

Rotator cuff tears are a common cause of shoulder pain and dysfunction. After surgical repair, there is a significant re-tear rate (25%-90%). The aim of this study was to determine the primary mode of mechanical failure for rotator cuffs repaired with suture anchors at the time of revision rotator cuff repair. We prospectively followed 342 consecutive torn rotator cuffs, repaired by a single surgeon using suture anchors and a mattress-suturing configuration. Of those shoulders, 21 (6%) subsequently underwent a revision rotator cuff repair by the original surgeon, and 1 underwent a second revision repair. Intraoperative findings, including the mode of failure, were systematically recorded at revision surgery and compared with the findings at the primary repair. In addition, 81 primary rotator cuff repairs had a radiographic and fluoroscopic evaluation at a mean of 37 weeks after repair to assess for any loosening or migration of the anchors. At revision rotator cuff repair, the predominant mode of failure was tendon pulling through sutures (19/22 shoulders) (P <.001). Two recurrent tears occurred in a new location adjacent to the previous repair, and one anchor was found loose in the supraspinatus tendon. The mean size of the rotator cuff tear was larger at the revision surgery (P =.043), the tendon quality ranked poorer (P =.013), and the tendon mobility decreased (P =.002), as compared with the index procedure. The radiographs and fluoroscopic examination showed that all 335 anchors in 81 patients were in bone. Rotator cuff repairs with suture anchors that underwent revision surgery failed mechanically by three mechanisms, the most common of which was tendon pulling through sutures. This suggests that the weak link in rotator cuff repairs with suture anchors and horizontal mattress sutures, as determined at revision surgery, is the tendon-suture interface.     

Increasing the insertion depth of suture anchors for rotator cuff repair does not improve biomechanical stability

The purpose of this study was to evaluate whether deeper-than-recommended insertion of a suture anchor within the rotator cuff footprint of human cadaveric humeri affects fixation characteristics. Metallic 5-mm screw-in anchors loaded with a single No. 2 suture were placed in the infraspinatus footprint of 8 human cadaveric humeri at standard and deep depths. Specimens were cyclically loaded from 10 to 45 N for 500 cycles and then loaded to failure. Cylic displacement, failure load, and failure mode were compared. All deep anchors became flush within a few cycles, and both anchor depths displaced and rotated at the bone surface. Displacement of the deep anchors was significantly greater than that of standard anchors. There was no difference in failure load. Cyclic testing showed significant displacement, regardless of anchor position, possibly leading to gap formation of the repair. Deep placement of suture anchors for increased purchase caused greater displacement and is not recommended.     

Can capsular plication compensate the lack of one suture anchor in an arthroscopic three suture anchor Bankart repair? A comparative study

ObjectiveThe aim of this study was to compare the complication rates and clinical results of labral repair with two suture anchors and capsular plication, and labral repair with three suture anchor fixation in artroscopic Bankart surgery.MethodsSixty-nine patients (60 males, 9 females; mean age: 28.2 ± 7.8 years (range: 16–50)) who had undergone arthroscopic repair of a labral Bankart lesion were evaluated. Group A underwent an arthroscopic Bankart repair with three knotless suture anchors, while group B underwent a modified arthroscopic Bankart repair with two knotless suture anchors and an additional capsular plication procedure. The mean follow-up was 52.5 months. Constant Shoulder Score (CSS), Rowe Score (RS), modified UCLA Shoulder Score (mUSS) and range of motion (ROM) were used as outcome measures.ResultsIn both groups, a significant improvement was detected in functional outcomes at postoperative last follow-up compared to the preoperative period. No statistically significant difference was found (p > 0.05) in clinical scores (CSS; Group A: 89.7, Group B: 80.2) (RS; Group A: 88.2, Group B: 80.2) (mUSS; Group A: 26.3, Group B: 25.7) external rotation loss (At neutral; Group A: 4.5°, Group B: 5.2°. At abduction; Group A: 4.3°, Group B: 5.7°) and recurrence rates (Group A: 13.3%, Group B: 20.8%). Although the difference was not statistically significant, the recurrence rate was higher in group B (20.8%), compared to group A (13.3%), despite the shorter average follow-up time of group B (p = 0.417).ConclusionsArthroscopic repair of labral Bankart lesions with both techniques showed good functional outcomes and stability at the latest follow-up. Higher recurrence rate despite the shorter average follow-up of group B suggests that two anchor usage might not be sufficient for Bankart repair in terms of better stability and less recurrence risk.Level of evidenceLevel III, Therapeutic Study.     

锚钉固定位置与角度对肩关节前关节囊修复效果影响

目的探讨不同锚钉位置及角度对关节镜治疗复发性肩关节前向不稳临床疗效的影响。 方法回顾性分析85例于2018年1月至12月因复发性肩关节前向不稳在南部战区总医院接受肩关节镜手术治疗的患者排除严重骨缺损、翻修等其他损伤。使用术后肩关节CT测量锚钉位置及插入角度，采用视觉模拟评分系统(VAS评分)及Rowe评分系统对患者术后关节疼痛程度、稳定性、活动度及功能进行综合评价。不同锚钉位置及角度与VAS评分及Rowe评分的关系使用独立样本t检验分析。 结果在85例患者中，有57例患者的所有锚钉均在肩胛盂关节面上，28例患者的锚钉部分在肩胛盂关节面上，部分在肩胛盂边缘。两组的比较中，VAS评分差异无统计学意义(t ＝－0.829，P>0.05)；所有锚钉均在肩胛盂关节面上的患者Rowe评分较高(t＝－4.072，P<0.05)。通过术后Rowe评定分级对锚钉打入角度的反向比较中，2点、3点、4点和5点钟4个位点对应锚钉角度之间的比较均无统计学差异(t＝0.312、0.885、0.775、0.934，均为P>0.05)。 结论肩关节镜下缝合锚钉在合理插入角度范围内固定于肩胛盂边缘稍内侧的关节面上可以使复发性肩关节前向不稳的患者获得更好的近期疗效，而远期疗效需要进一步深入研究。     

Arthroscopic revision Bankart repair: a preliminary evaluation

Arthroscopic stabilization of primary, recurrent anterior shoulder instability has become the procedure of choice with infrequent exceptions. Failures of stabilization can and do occur. This is a Level IV retrospective analysis of arthroscopic revision Bankart surgery performed on 15 non-consecutive patients over a 4-year period with an average 22-month follow-up. The average patient age was 27.5 with 12 men and 3 women. Four of the 15 failures were from the senior author's (R.K.N.R.) practice with the remaining 11 referred for treatment. Four of the 15 failures resulted from open surgery while the remaining 11 failed an arthroscopic stabilization procedure. Four contact/collision athletes were included, and significant bone loss was recorded in 5 patients. Operative findings included 10 recurrent Bankart lesions while 9 patients were felt to demonstrate capsular attenuation. Fourteen of the 15 had a Hill-Sachs lesion while chondromalacic change involving the anterior glenoid was noted in 13 of the 15 patients. A suture anchor technique was used with an average of 2.5 double-loaded suture anchors. In this series, 4 failures occurred after revision arthroscopic stabilization (27%) with an average SANE score of 86 (range, 65-100). One of the 5 patients with significant bone loss sustained a recurrence while 1 of 4 contact athletes failed the revision arthroscopic stabilization. Two of the 4 failures in this study subsequently underwent an open bone block procedure. Arthroscopic revision Bankart repair can be an effective alternative, but should only be considered in the properly selected patient.     

Infected suture anchors in the shoulder

Symptomatic anterior glenohumeral instability secondary to a Bankart lesion may require surgical reconstruction and repair of labral pathology. In this report, a Bankart repair was performed using metallic suture anchors. An infection developed around the anchors necessitating their removal. To our knowledge, this is the first report of an infection associated with a suture anchor device.     

The twist-lock concept of tissue transport and suture fixation without knots: observations along the Hong Kong skyline

Purpose:To evaluate the load to failure and the mode of failure of a novel suture anchor construct that does not require knots (the “twist-lock” construct) and to compare it with a standard suture anchor construct (Corkscrew; Arthrex, Naples, FL).Type of Study:Biomechanical single-pull load-to-failure study comparing the twist-lock construct to the Corkscrew suture anchor construct.Methods:The twist-lock construct is a suture anchor system that does not use knots, instead using 3 consecutive twists between suture limbs to enhance internal interference between the suture limbs. This system maximizes internal interference by 2 mechanically verifiable friction-multiplier mechanisms: the cable friction effect and the wedge effect. After theoretically verifying the strength characteristics of the twist-lock system, the authors tested and compared its strength in vitro to that of a standard screw-type suture anchor system (Corkscrew). Unicellular polyurethane, which has been shown to accurately mimic the properties of cancellous bone, was used for implantation of suture anchors for the purpose of comparing the load to failure of 10 identical constructs in each of the 2 anchor systems. Axial single-pull loading to failure was performed with an Instron 5565 testing machine (Instron, Canton, MA).Results:The average load to failure for the twist-lock group was 137.2 N, and the average for the Corkscrew group was 123.0 N, a difference of 14.2 N. This study shows that the twist-lock anchors failed at a load that was 12% higher than that of the Corkscrew group (P = .02).Conclusion:The twist-lock system is a suture anchor system that achieves suture fixation of soft tissue to bone without the need to tie knots. It shows single-pull loads to failure that are significantly higher than those of a standard suture anchor system.     

Novel ultrasound assisted suture anchor system using the BoneWelding® technology yields a comparable primary stability in osteopenic and healthy human humeri as a benchmark anchor

Introduction

The aim of this biomechanical study was to evaluate the primary stability of the SportWelding® Sombrero 3.6 mm suture anchor system in osteopenic and healthy cadaveric humeri.

Use of Mitek anchoring for Bankart repair: A comparative, randomized, prospective study with traditional bone sutures

The most common type of shoulder instability is posttraumatic anterior instability. Treatment is surgical. Of the several procedures used, the standard one is Bankart repair. However, this procedure is technically demanding. To simplify it a suture anchor such as Mitek anchors may be used. A prospective randomized study was conducted to compare Mitek anchors with bone sutures. The results showed that Mitek anchors shorten surgical time by making reattachment of the capsule easier. Shoulder muscle strength, range of motion, and frequency of recurrence were equally good in the anchor group and bone suture group. A roentgenographic method allowed exact measurement of placement of the anchors. This method showed at 2-year follow-up evaluation that the anchors were still in the anterior glenoid. No metal-related complications are found at the 2-year follow-up evaluation.     

The “Bony Bankart Bridge” Procedure: A New Arthroscopic Technique for Reduction and Internal Fixation of a Bony Bankart Lesion

Arthroscopic treatment of bony Bankart lesions can be challenging. We present a new easy and reproducible technique for arthroscopic reduction and suture anchor fixation of bony Bankart fragments. A suture anchor is placed medially to the fracture on the glenoid neck, and its sutures are passed around the bony fragment through the soft tissue including the inferior glenohumeral ligament complex. The sutures of this anchor are loaded in a second anchor that is placed on the glenoid face. This creates a nontilting 2-point fixation that compresses the fragment into its bed. By use of the standard technique, additional suture anchors are used superiorly and inferiorly to the bony Bankart piece to repair the labrum and shift the joint capsule. We call this the “bony Bankart bridge” procedure.     

A biomechanical comparison of EndoButton versus suture anchor repair of distal biceps tendon injuries

The purpose of this study was to compare suture anchor and EndoButton repair of distal biceps injuries in a human bone-tendon model. Right and left arm repairs were alternately performed with either the EndoButton or 2 single-loaded 5-mm suture anchors. Each construct was cyclically loaded by use of a servohydraulic materials testing machine. Initial and final displacements were recorded. All repairs were then loaded to ultimate failure. Ten millimeters of displacement was designated the clinical failure point. The EndoButton group had more stiffness than the suture anchor group during initial cyclic loading (P = .01). There were no differences in final displacement measured after cyclic loading (2.06 mm for suture anchors and 2.58 mm for EndoButton). The EndoButton group had a 16% greater ultimate tensile load than the suture anchor group (274.77 N vs 230.06 N). The EndoButton group also had a 16% higher load to clinical failure (249.95 N vs 209.56 N). These differences were not statistically significant. The EndoButton and suture anchors provide comparable fixation strength for the repair and rehabilitation of distal biceps tendon ruptures.     

Suture anchor failure strength—An in vivo study

Suture anchors are increasingly used to secure tendons or ligaments to bone. These devices are applicable for arthroscopic shoulder stabilization and rotator cuff repair. This study reports the in vivo characteristics of four anchors, including one absorbable anchor composed of poly-L-lactic acid. Failure strength and method of failure were recorded for these anchors as a function of time. Samples of four anchors [Mitek G2, Zimmer Statak, Acufex TAG wedge, and the absorbable Arthrex expanding suture plug (ESP)] were implanted into ram femurs and harvested at intervals. Each bone-anchor-suture system was stressed to failure. The failure force and failure method was recorded. Mitek G2 and Statak suture anchors failed consistently at 30 pounds by suture breakage. They had no implantation difficulties. The TAG wedge exhibited suture pull-out and implant flipping at insertion. The TAG wedge failed by suture cut-out, anchor pull-out, and suture breakage. Its average failure strength was initially 16 pounds, but increased to 28 pounds at 2 weeks and reached the 30-pound level by 4 weeks. The ESP poly-L-lactic acid anchors experienced implantation breakage in 20% because of their greater length and composition. At pull-out testing, the ESP failed by suture cut-out, anchor pull-out, and suture breakage. Failure strength was initially 27 pounds, was 17 pounds at 2 weeks, and increased to 30 pounds by 6 weeks. The absorbable ESP does not have initial pull-out strength comparable with the Mitek and Statak suture anchors but does achieve this strength by 6 weeks. This information should provide insight about the suitability of these suture anchors in the clinical setting.     

Mechanical testing of absorbable suture anchors

Purpose: Absorbable suture anchors offer great advantages but are made of mechanically weak material. The weakest link in the fixation of soft tissue to bone may therefore be the anchor itself. In this study, several commercially available anchors were mechanically tested in vitro. Type of study: Biomechanical bench study. Methods: Twelve absorbable suture anchor models were implanted into an artificial test bone according to the recommended technique. Testing temperature was 37°C ± 1°C. The anchors were loaded with an Instron testing machine with the suture material (USP No. 2, Ethibond, Ethicon, Somerville, NJ) in line with the anchor axis, with and without previous abrasion of the suture at the eyelet. Tensile load at failure and failure mode were recorded. To test creep behavior, a permanent load of 100 N was applied to the anchors, and time to failure was recorded. Suture anchor weight and crystallinity were analyzed. Results: Mean failure load on tensile testing using a cross-head speed of 60 mm/min ranged from 124 to 244 N. Failure modes were eyelet failure in 5 cases, suture failure in 6 cases, and anchor pullout in 1 case. In creep testing, eyelet failure occurred in 8 anchor models after a mean duration of 0.5 to 99 hours; 3 anchor models remained intact after 300 hours, and 1 anchor model failed by pullout of the test sample. Crystallinity ranged from 0% (amorphous) to 57.2%; anchor weight ranged from 0.036 to 0.161 g. Mechanical properties did not correlate with crystallinity but with anchor weight. Abrasion of the suture material at the eyelet had little effect on failure load. Conclusions: At 37°C, structural failure (breaking) of absorbable suture anchors may occur if loaded to the mechanical limit. Absorbable anchors are particularly sensitive to static, long-term loading.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp 188–193