Clinical Orthopaedics and Related Research®

, Volume 468, Issue 12, pp 3406–3412

Bioabsorbable Tricalcium Phosphate Bone Cement Strengthens Fixation of Suture Anchors

  • Rayshad Oshtory
  • Derek P. Lindsey
  • Nicholas J. Giori
  • Faisal M. Mirza
Basic Research



Failure of suture anchor fixation in rotator cuff repair can occur at different interfaces. Prior studies show fixation at the bone-anchor interface can be augmented using polymethylmethacrylate (PMMA) cement, and screw fixation into bone can be strengthened using bioabsorbable tricalcium phosphate cement.


We wished to determine whether augmentation of suture anchor fixation using bioabsorbable tricalcium phosphate cement would increase pullout strength of suture anchors from bone and the number of cycles to failure, to determine the mode of failure after cement augmentation, and to compare strength and mode of failure with those after augmentation with PMMA.


We used 10 matched pairs of cadaveric proximal humeri and implanted a metal screw-type suture anchor in one side and on the other side injected tricalcium phosphate cement into the anchor holes before anchor placement. We tested all specimens to failure using a ramped cyclic loading protocol.


Tricalcium phosphate cement augmentation increased the final load to failure by 29% and the number of cycles to failure by 20%. Visual inspection confirmed that failure occurred at the cement-bone interface.


Tricalcium phosphate cement appears to augment suture anchor fixation into bone, reducing the risk of anchor pullout and failure.

Clinical Relevance

When relying on suture anchor fixation in bone of questionable quality, we suggest considering augmentation of suture anchor fixation with bioabsorbable cement. This method also provides potential for bioabsorbability and may be more amenable to arthroscopic application.


  1. 1.
    Bishop J, Klepps S, Lo IK, Bird J, Gladstone JN, Flatow EL. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg. 2006;15:290–299.CrossRefPubMedGoogle Scholar
  2. 2.
    Calvert PT, Packer NP, Stoker DJ, Bayley JI, Kessel L. Arthrography of the shoulder after operative repair of the torn rotator cuff. J Bone Joint Surg Br. 1986;68:147–150.PubMedGoogle Scholar
  3. 3.
    Collinge C, Merk B, Lautenschlager EP. Mechanical evaluation of fracture fixation augmented with tricalcium phosphate bone cement in a porous osteoporotic cancellous bone model. J Orthop Trauma. 2007;21:124–128.CrossRefPubMedGoogle Scholar
  4. 4.
    Cook SD, Salkeld SL, Stanley T, Faciane A, Miller SD. Biomechanical study of pedicle screw fixation in severely osteoporotic bone. Spine J. 2004;4:402–408.CrossRefPubMedGoogle Scholar
  5. 5.
    Cummins CA, Murrell GA. Mode of failure for rotator cuff repair with suture anchors identified at revision surgery. J Shoulder Elbow Surg. 2003;12:128–133.CrossRefPubMedGoogle Scholar
  6. 6.
    Djurasovic M, Marra G, Arroyo JS, Pollock RG, Flatow EL, Bigliani LU. Revision rotator cuff repair: factors influencing results. J Bone Joint Surg Am. 2001;83:1849–1855.PubMedGoogle Scholar
  7. 7.
    Elder S, Frankenburg E, Goulet J, Yetkinler D, Poser R, Goldstein S. Biomechanical evaluation of calcium phosphate cement-augmented fixation of unstable intertrochanteric fractures. J Orthop Trauma. 2000;14:386–393.CrossRefPubMedGoogle Scholar
  8. 8.
    Favus MJ, ed. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. Ed 4. Philadelphia, PA: Lippincott, Williams & Wilkins; 1999.Google Scholar
  9. 9.
    Giori NJ, Sohn DH, Mirza FM, Lindsey DP, Lee AT. Bone cement improves suture anchor fixation. Clin Orthop Relat Res. 2006;451:236–241.CrossRefPubMedGoogle Scholar
  10. 10.
    Jang JS, Lee SH, Rhee CH, Lee SH. Polymethylmethacrylate-augmented screw fixation for stabilization in metastatic spinal tumors: technical note. J Neurosurg. 2002;96(1 suppl):131–134.PubMedGoogle Scholar
  11. 11.
    Klepps S, Bishop J, Lin J, Cahlon O, Strauss A, Hayes P, Flatow EL. Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs. Am J Sports Med. 2004;32:1716–1722.CrossRefPubMedGoogle Scholar
  12. 12.
    Magee T, Shapiro M, Hewell G, Williams D. Complications of rotator cuff surgery in which bioabsorbable anchors are used. AJR Am J Roentgenol. 2003;181:1227–1231.PubMedGoogle Scholar
  13. 13.
    Meyer DC, Fucentese SF, Koller B, Gerber C. Association of osteopenia of the humeral head with full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2004;13:333–337.CrossRefPubMedGoogle Scholar
  14. 14.
    Meyer DC, Jacob HA, Pistoia W, von Roll A, Gerber C. The use of acrylic bone cement for suture anchoring. Clin Orthop Relat Res. 2003;410:295–302.CrossRefPubMedGoogle Scholar
  15. 15.
    Moore DC, Frankenburg EP, Goulet JA, Goldstein SA. Hip screw augmentation with an in situ-setting calcium phosphate cement: an in vitro biomechanical analysis. J Orthop Trauma. 1997;11:577–583.CrossRefPubMedGoogle Scholar
  16. 16.
    Moore DC, Maitra RS, Farjo LA, Graziano GP, Goldstein SA. Restoration of pedicle screw fixation with an in situ setting calcium phosphate cement. Spine (Phila PA 1976). 1997;22:1696–1705.Google Scholar
  17. 17.
    Motzkin NE, Chao EY, An KN, Wikenheiser MA, Lewallen DG. Pull-out strength of screws from polymethylmethacrylate cement. J Bone Joint Surg Br. 1994;76:320–323.PubMedGoogle Scholar
  18. 18.
    Renner SM, Lim TH, Kim WJ, Katolik L, An HS, Andersson GB. Augmentation of pedicle screw fixation strength using an injectable calcium phosphate cement as a function of injection timing and method. Spine (Phila PA 1976). 2004;29:E212–E216.Google Scholar
  19. 19.
    Rohmiller MT, Schwalm D, Glattes RC, Elalayli TG, Spengler DM. Evaluation of calcium sulfate paste for augmentation of lumbar pedicle screw pullout strength. Spine J. 2002;2:255–260.CrossRefPubMedGoogle Scholar
  20. 20.
    Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg Am. 2007;89:953–960.CrossRefPubMedGoogle Scholar
  21. 21.
    Tingart MJ, Apreleva M, Zurakowski D, Warner JJ. Pullout strength of suture anchors used in rotator cuff repair. J Bone Joint Surg Am. 2003;85:2190–2198.CrossRefPubMedGoogle Scholar
  22. 22.
    Wittenberg RH, Lee KS, Shea M, White AA III, Hayes WC. Effect of screw diameter, insertion technique, and bone cement augmentation of pedicular screw fixation strength. Clin Orthop Relat Res. 1993;296:278–287.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  • Rayshad Oshtory
    • 1
  • Derek P. Lindsey
    • 2
  • Nicholas J. Giori
    • 2
    • 3
  • Faisal M. Mirza
    • 2
    • 3
  1. 1.Department of Orthopedic SurgeryPost Street Orthopaedics and Sports MedicineSan FranciscoUSA
  2. 2.VA Bone and Joint Rehabilitation Research and Development CenterPalo AltoUSA
  3. 3.Department of Orthopedic SurgeryStanford University Medical CenterStanfordUSA

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