Abstract
Purpose
To evaluate the incidence of intraoperative anchor pullout during arthroscopic rotator cuff repair, to compare the outcomes of different methods of managing anchor pullout, and to introduce a new technique for anchor pullout.
Methods
1076 patients who underwent arthroscopic rotator cuff repair using a single-row repair technique were included. In 483 patients, rotator cuff repair was performed using a screw-in type anchor, and in 593 patients, soft anchors were used. When intraoperative anchor pullout occurred, it was managed by buddy screwing, anchor insertion in a different location, cement augmentation, or by bar anchoring using a threaded Steinmann pin. Plain radiography and sonography were used to check anchor locations and healing.
Results
Fifty-two patients experienced anchor pullout intra- or postoperatively (48 and four patients, respectively). Anchor pullouts were more frequently observed for larger tears, women, older patients, and in patients with preoperative stiffness (limitations of both active and passive movements of the affected shoulder joint). For screw-in type anchors, pullout during surgery occurred in 16 patients (3.3%, 16/483), and all were managed using the buddy screwing technique. For soft anchor cases, pullout occurred in 32 patients (5.4%, 32/593) and was managed by anchor insertion in a different location (17 patients), cement augmentation (two patients), or bar anchoring using a threaded Steinmann pin (13 patients). Three patients managed by buddy screwing and two patients managed by anchor insertion in a different location had anchor failure after repair. Tendon healing at 6 months was observed in 12/16 patients treated by buddy screwing, 11/17 treated by anchor insertion in a different location, 2/2 treated by cement augmentation, and 12/13 treated by bar anchoring with a threaded Steinmann pin.
Conclusion
Intraoperative anchor pullout during arthroscopic rotator cuff repair is an uncommon but cumbersome complication. There are some techniques already introduced to deal with this complication. In comparison, not one technique is overwhelmingly superior to others; however, our new technique which is bar anchoring with a threaded Steinmann pin could be another solution, since it could utilize primary anchor sites and results appear to be acceptable.
Level of evidence III.
Similar content being viewed by others
References
Aziz KT, Shi BY, Okafor LC, Smalley J, Belkoff SM, Srikumaran U (2018) Pullout strength of standard vs. cement-augmented rotator cuff repair anchors in cadaveric bone. Clin Biomech 54:132–136
Barber FA, Herbert MA (2013) Cyclic loading biomechanical analysis of the pullout strengths of rotator cuff and glenoid anchors: 2013 update. Arthroscopy 29(5):832–844
Barber FA, Herbert MA, Hapa O, Rapley JH, Barber CA, Bynum JA, Hrnack SA (2011) Biomechanical analysis of pullout strengths of rotator cuff and glenoid anchors: 2011 update. Arthroscopy 27(7):895–905
Benson EC, MacDermid JC, Drosdowech DS, Athwal GS (2010) The incidence of early metallic suture anchor pullout after arthroscopic rotator cuff repair. Arthroscopy 26(3):310–315
Bilsel K, Yildiz F, Kapicioglu M, Uzer G, Elmadag M, Pulatkan A, Esrefoglu M, Bozdag E, Milano G (2017) Efficacy of bone marrow-stimulating technique in rotator cuff repair. J Shoulder Elbow Surg 26(8):1360–1366
Brady PC, Arrigoni P, Burkhart SS (2006) What do you do when you have a loose screw? Arthroscopy 22(9):925–930
Braunstein V, Ockert B, Windolf M, Sprecher CM, Mutschler W, Imhoff A, Postl LK, Biberthaler P, Kirchhoff C (2015) Increasing pullout strength of suture anchors in osteoporotic bone using augmentation—a cadaver study. Clin Biomech 30(3):243–247
Cadet ER, Hsu JW, Levine WN, Bigliani LU, Ahmad CS (2008) The relationship between greater tuberosity osteopenia and the chronicity of rotator cuff tears. J Shoulder Elbow Surg 17(1):73–77
Chung SW, Oh JH, Gong HS, Kim JY, Kim SH (2011) Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors. Am J Sports Med 39(10):2099–2107
Curtis AS (2018) Editorial commentary: anchors away! reflections on anchor placement and number in rotator cuff repair. Arthroscopy 34(2):386–388
Denard PJ, Burkhart SS (2011) Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair. Arthroscopy 27(10):1409–1421
Dezaly C, Sirveaux F, Philippe R, Wein-Remy F, Sedaghatian J, Roche O, Mole D (2011) Arthroscopic treatment of rotator cuff tear in the over-60s: repair is preferable to isolated acromioplasty-tenotomy in the short term. Orthop Traumatol Surg Res 97(6 Suppl):S125–130
Entezari V, Lazarus M (2019) Surgical considerations in managing osteoporosis, osteopenia, and vitamin D deficiency during arthroscopic rotator cuff repair. Orthop Clin North Am 50(2):233–243
Er MS, Altinel L, Eroglu M, Verim O, Demir T, Atmaca H (2014) Suture anchor fixation strength with or without augmentation in osteopenic and severely osteoporotic bones in rotator cuff repair: a biomechanical study on polyurethane foam model. J Orthop Surg Res 9:48
Ficklscherer A, Loitsch T, Serr M, Gulecyuz MF, Niethammer TR, Muller HH, Milz S, Pietschmann MF, Muller PE (2014) Does footprint preparation influence tendon-to-bone healing after rotator cuff repair in an animal model? Arthroscopy 30(2):188–194
Horoz L, Hapa O, Barber FA, Husemoglu B, Ozkan M, Havitcioglu H (2017) Suture anchor fixation in osteoporotic bone: a biomechanical study in an ovine model. Arthroscopy 33(1):68–74
Hyatt AE, Lavery K, Mino C, Dhawan A (2016) Suture anchor biomechanics after rotator cuff footprint decortication. Arthroscopy 32(4):544–550
Kawakami J, Yamamoto N, Nagamoto H, Itoi E (2018) Minimum distance of suture anchors used for rotator cuff repair without decreasing the pullout strength: a biomechanical study. Arthroscopy 34(2):377–385
Kim KC, Rhee KJ, Shin HD (2009) Revision of a pull-out suture anchor in the lateral row during the suture-bridge technique: technical note. Knee Surg Sports Traumatol Arthrosc 17(12):1463–1465
Kim SH, Kim DY, Kwon JE, Park JS, Oh JH (2015) Perianchor cyst formation around biocomposite biodegradable suture anchors after rotator cuff repair. Am J Sports Med 43(12):2907–2912
Kim SH, Kim YH, Lee HR, Choi YE (2015) Short-term effects of high-intensity laser therapy on frozen shoulder: a prospective randomized control study. Man Ther 20(6):751–757
Kirchhoff C, Braunstein V, Milz S, Sprecher CM, Fischer F, Tami A, Ahrens P, Imhoff AB, Hinterwimmer S (2010) Assessment of bone quality within the tuberosities of the osteoporotic humeral head: relevance for anchor positioning in rotator cuff repair. Am J Sports Med 38(3):564–569
Leppala J, Kannus P, Sievanen H, Jarvinen M, Vuori I (1998) Adhesive capsulitis of the shoulder (frozen shoulder) produces bone loss in the affected humerus, but long-term bony recovery is good. Bone 22(6):691–694
Milano G, Saccomanno MF, Careri S, Taccardo G, De Vitis R, Fabbriciani C (2013) Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study. Arthroscopy 29(5):802–810
Miller BS, Downie BK, Kohen RB, Kijek T, Lesniak B, Jacobson JA, Hughes RE, Carpenter JE (2011) When do rotator cuff repairs fail? Serial ultrasound examination after arthroscopic repair of large and massive rotator cuff tears. Am J Sports Med 39(10):2064–2070
Nagra NS, Zargar N, Smith RD, Carr AJ (2017) Mechanical properties of all-suture anchors for rotator cuff repair. Bone Joint Res 6(2):82–89
Oshtory R, Lindsey DP, Giori NJ, Mirza FM (2010) Bioabsorbable tricalcium phosphate bone cement strengthens fixation of suture anchors. Clin Orthop Relat Res 468(12):3406–3412
Pietschmann MF, Frohlich V, Ficklscherer A, Gulecyuz MF, Wegener B, Jansson V, Muller PE (2009) Suture anchor fixation strength in osteopenic versus non-osteopenic bone for rotator cuff repair. Arch Orthop Trauma Surg 129(3):373–379
Postl LK, Ahrens P, Beirer M, Cronlein M, Imhoff AB, Foehr P, Burgkart R, Braun C, Kirchhoff C (2016) Pull-out stability of anchors for rotator cuff repair is also increased by bio-absorbable augmentation: a cadaver study. Arch Orthop Trauma Surg 136(8):1153–1158
Putnam JG, Chhabra A, Castañeda P, Walker JB, Barber CC, Lendrum JA, Hartigan DE (2018) Does greater trochanter decortication affect suture anchor pullout strength in abductor tendon repairs? A biomechanical study. Am J Sports Med 46(7):1668–1673
Rolvien T, Milovanovic P, Schmidt FN, von Kroge S, Wolfel EM, Krause M, Wulff B, Puschel K, Ritchie RO, Amling M, Busse B (2020) Long-term immobilization in elderly females causes a specific pattern of cortical bone and osteocyte deterioration different from postmenopausal osteoporosis. J Bone Miner Res. https://doi.org/10.1002/jbmr.3970
Ruder JA, Dickinson EY, Peindl RD, Habet NA, Fleischli JE (2018) Greater tuberosity decortication decreases load to failure of all-suture anchor constructs in rotator cuff repair. Arthroscopy 34(10):2777–2781
Skaliczki G, Paladini P, Merolla G, Campi F, Porcellini G (2015) Early anchor displacement after arthroscopic rotator cuff repair. Int Orthop 39(5):915–920
Tingart MJ, Apreleva M, Lehtinen J, Zurakowski D, Warner JJ (2004) Anchor design and bone mineral density affect the pull-out strength of suture anchors in rotator cuff repair: which anchors are best to use in patients with low bone quality? Am J Sports Med 32(6):1466–1473
Waldorff EI, Lindner J, Kijek TG, Downie BK, Hughes RE, Carpenter JE, Miller BS (2011) Bone density of the greater tuberosity is decreased in rotator cuff disease with and without full-thickness tears. J Shoulder Elbow Surg 20(6):904–908
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
None of the authors have any conflicts of interest in relation to this work.
Funding
No funding in any form have been received from a commercial party related directly or indirectly to the subject of this article.
Ethical approval
All patients provided informed consent for the use of their data for research and the review board of Seoul National University Hospital affiliated to Seoul National University College of Medicine approved this retrospective study (IRB no.1901-113-100).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary file1 (MOV 70106 kb)
Rights and permissions
About this article
Cite this article
Jung, W., Kim, D.O., Kim, J. et al. Novel and reproducible technique coping with intraoperative anchor pullout during arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 29, 223–229 (2021). https://doi.org/10.1007/s00167-020-05935-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-020-05935-4