Use of suture anchors and new suture materials in the upper extremity.
ABSTRACT Suture anchors are an important tool in the orthopedist's armamentarium. Their use is prevalent in surgery of the entire upper limb. Suture anchors have mostly obviated the need for multiple drill holes when striving for secure fixation of soft tissue to bone. As with most other orthopedic products, the designs of these anchors and the materials used to fabricate them have evolved as their use increased and their applications became more widespread. It is ultimately the surgeon's responsibility to be familiar with these rapidly evolving technologies and to use the most appropriate anchor for any given surgery.
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ABSTRACT: The conventional practices used in flexor tendon repair have remained unchanged in many units. Because clinical cases vary considerably, some situations may merit more unusual methods. Here the author describes a few methods that have been used in flexor tendon repair. This article discusses a few methods that are clinically useful in treating some patients but are not commonly described. The newer tendon-bone junction methods exemplified here would likely replace the pull-out suture. Late direct repair and lengthening plasty require the accumulation of clinical experience. Allograft tendon reconstruction has shown successful midterm results, but long-term follow-up is certainly necessary.Hand clinics 05/2013; 29(2):215-21. · 0.69 Impact Factor
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Use of Suture Anchors and New
Suture Materials in the Upper
Min Jung Park, MD, MMSca, Steven S. Shin, MD, MMScb,*
Suture anchors have revolutionized the way ortho-
pedic surgeons perform upper limb surgery. They
are designed to help surgeons achieve soft
tissue–to-bone healing in cases where inadequate
soft tissue stock on bone makes it impossible to
perform a direct soft tissue–to–soft tissue repair.1
Previously open surgical procedures may now be
performed arthroscopically, thanks to the advent
of suture anchors. This is particularly notable in
the shoulder, where glenoid labrum repairs and
rotator cuff repairs are now routinely performed
arthroscopically.2–9Arthroscopic stabilization has
become the gold standard treatment of shoulder
instability, largely because of the introduction of
suture anchors. Suture anchor tenodesis of the
proximal biceps tendon is performed for the treat-
ment of proximal biceps tendonitis and rupture,10
although other techniques are also available for
Besides the shoulder, the elbow is another joint
in which the use of suture anchors has become
popular for various surgical procedures. Although
different techniques exist for ulnar collateral liga-
ment reconstruction, suture anchors have been
used for this procedure (Fig. 1).14,15They are
also used in the repair of distal biceps tendon
ruptures, conditions in which transosseous suture
repair used to be the only surgical option. Some
investigators have also described the use of the
Corkscrew anchor (Arthrex, Naples, FL) in distal
biceps tendon ruptures: implants that were origi-
nally designed for rotator cuff tendon fixation
In the wrist and hand, smaller-sized suture
anchors are used for various surgical procedures
(Fig. 3). In the wrist, suture anchors are used for
scapholunate or lunotriquetral ligament repair,
capsulodesis procedures, and triangular fibrocar-
tilage repair.21,22Suture anchors are also used in
The authors have nothing to disclose.
aDepartment of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 2501
Christian Street 103, Philadelphia, PA 19146, USA;bKerlan-Jobe Orthopedic Clinic, 6801 Park Terrace, Los
Angeles, CA 90045, USA
* Corresponding author.
E-mail address: firstname.lastname@example.org
? Suture anchors have mostly obviated the need for multiple drill holes when striving for secure fixa-
tion of soft tissue to bone.
? As with most other orthopedic products, the designs of these anchors and the materials used to
fabricate them have evolved as their use increased and their applications became more wide-
spread. It is ultimately the surgeon’s responsibility to be familiar with these rapidly evolving technol-
ogies and to use the most appropriate anchor for any given surgery.
? Besides the shoulder, the elbow is another joint in which the use of suture anchors has become
popular for various surgical procedures.
Hand Clin 28 (2012) 511–518
0749-0712/12/$ – see front matter ? 2012 Elsevier Inc. All rights reserved.
the repair of ulnar collateral ligament injuries of the
thumb, as well as collateral ligament injuries of the
finger metacarpophalangeal and interphalangeal
joints.23–25Rupturesof the flexor digitorum profun-
dus tendon are commonly repaired using suture
anchors as well.26–30
HISTORY OF SUTURE ANCHOR MATERIALS
Like many present-day suture anchors, the first
suture anchors were made exclusively of metal
and, for the most part, did quite well in facilitating
soft tissue–to-bone healing. Over time, both
product-related and surgeon-related complica-
tions of these implants were reported, such as
fracture at the site of anchor placement, anchor
pull-out, infection around the metal implant, and
errant anchor placement (extraosseous or even
intra-articular, causing chondral injury and foreign
body reactions).31–36The presence of a metal
anchor around a joint also impaired satisfactory
visualization of the joint on magnetic resonance
imaging (MRI), not to mention making revision
Fig. 1. Ulnar collateral ligament reconstruction using the biocomposite SutureTak. (Courtesy of Arthrex, Inc,
Naples, FL; with permission.)
Fig. 2. (Left) A 3.5 x 10 mm Corkscrew FT. (Right) The Corkscrew anchor in distal biceps tendon repair. (Courtesy of
Arthrex Inc, Naples, FL; with permission.)
Park & Shin
surgery even more difficult when anchor removal
was necessary. The idea of a bioabsorbable,
radiolucent device that lastsonly aslong as neces-
sary for soft tissue healing to bone to occur and
then was hydrolyzed was attractive to many
surgeons. Just as bioabsorbable suture materials
were developed as suture material technology
advanced, so too were bioabsorbable suture
anchors. The Suretac bioabsorbable device (Smith
and Nephew, Andover, MA) was one of the first
such implants; since its introduction, its tack
design was replaced by a suture anchor design,
as was its nonscrew-to-screw design.37Early clin-
ical and animal data of bioabsorbable implants
were promising38; however, as with the earlier
metal implants, reports of complications, such as
exuberant inflammatoryreactionleading to
osteolysis and implant breakage surfaced as
long-term follow-up data became available and
the indications for these devices increased.38–47
Although the material that was used to manufac-
ture these initial bioabsorbable anchors was
usually some variant of poly-lactic acid (PLA) or
co-polymer of PLA and polyglycolic acid, it is
unclear as to which factors (eg, material composi-
tion, isomer configuration, or implant design)
contributed to the reported complications.48,49
Surgeon technical error may also have played
a role in some of the reports of bioabsorbable
anchor failure.50Some suture anchors are now
made of “biocomposite” materials (ie, a combina-
tion of tricalcium phosphate [TCP] and PLA deriv-
atives), with the goals of decreasing inflammatory
reaction in bone and faster implant-to-bone
surgeons have advocated a move away from bio-
absorbable suture anchors and back to traditional
metal anchors, bioabsorbable anchors are still
The mechanical properties and material compo-
sitions of suture anchors may contribute to the
differences in potential clinical and/or mechanical
failure, owing to premature anchor breakdown,
loss of fixation, or osteolysis.52,53In a study by
Park and colleagues,54a highly significant relation-
ship was observed between failure of a superior
labrum repair and the use of bioabsorbable poly-
compared with nonabsorbable metallic or polye-
therether ketone (PEEK) anchors. Although patient
factors, such as workers compensation claim and
smoking status, contributed to the reoperation
rate, the strongest association was made with
the use of bioabsorbable suture anchors. Even
subtle differences in the manufacturing processes
of PLDLA, oxidative degradation after or during
manufacturing, and varying isomer compositions
between anchors from different manufacturers
may contribute to the different chemical properties
of the final products.
With the development of new anchor materials
and designs, Barber and colleagues37,55–62have
been periodically reporting in vitro as well as
anatomic site-specific biomechanical data on the
performance of various suture anchors. Although
Fig. 3. The use of suture anchors for procedures at the
hand and wrist: (thin arrow) repair of thumb ulnar
collateral ligament, (arrowhead) repair of scapholu-
nate interosseous ligament, (thick arrow) repair of
Arthrex, Inc, Naples, FL; with permission.)
Fig. 4. Examples of suture anchors made from various materials. (Courtesy of Arthrex, Inc, Naples, FL; with
New Suture Materials in the Upper Extremity
the data are an important guide for potential
clinical performance, literature is scarce in terms
of actual clinical performance of the individual
anchor materials, design, and their modes of
failure in vivo.
EVOLVING ANCHOR TECHNOLOGIES AND
Owing to some of the complications mentioned
previously, many device manufacturers have
been introducing new materials and designs for
suture anchors. PEEK is a material that has gained
popularity inrecentyearsasanalternative toprevi-
ously available suture anchor materials. Although
not bioabsorbable, PEEK is a highly specialized
plastic that currently has wide industrial applica-
tions because of its high material strength.
For osteoporotic bone, some investigators
advocate the augmentation of suture anchors
with either polymethylmethacrylate cement or bio-
absorbable TCP cement, based on cadaveric
study data.63It is unclear, however, whether this
technique is clinically relevant. The recent devel-
opment of biocomposite materials in the manufac-
ture of suture anchors is a technically simpler and
therefore more attractive option. As stated previ-
ously, biocomposite materials are made of some
combination of TCP and PLA derivatives and
were introduced to theoretically minimize the
host reaction and enhance bony integration of
the suture anchors. BioComposite SutureTak (Ar-
threx) and Biocryl Rapide (Depuy Mitek, Raynham,
MA) are 2 examples of such products. Although
internal manufacturer data exist showing various
levels of material resorption and bony integration,
as of the time of this review, no peer-reviewed
publication is available regarding the use of bio-
composite materials in a clinical setting.
With regard to suture anchor design, knotless
anchor designs have become an attractive alter-
native to the traditional suture anchor design,
where knots are tied down close to the anchor
and may be prominent and potentially impinge or
cause intra-articular cartilage damage. Recently,
an all-suture anchor concept was introduced in
the JuggerKnot implant (Biomet, Warsaw, IN;
Fig. 5), in which the “anchor” is made of a suture
material instead of the typical metal or bio-
absorbable material of traditional anchors. The
suture is secured into the bone using a 1-cm
strand of suture that encases the regular suture
material; as the surgeon pulls on the suture
strands, the central portion of the all-suture anchor
bunches up as it contacts the cortical rim, thereby
“anchoring” it within the bone. The JuggerKnot
design allows for smaller drill holes compared
with the designs of more traditional suture anchors
that have comparable pullout strength. More data
are needed to determine the long-term clinical
benefits of this unique implant.
Of note, metal anchors have been widely used in
hand surgery, with relatively few reported hard-
ware complications. This is likely because of the
generally open nature of the surgeries that allows
for direct visualization of anchor placement and
the relatively smaller size of the anchors used in
hand and wrist procedures; however, errant
Fig. 5. (Top left) JuggerKnot soft anchor 1.4; (top right) JuggerKnot soft anchor 1.0 mini; (bottom left) Jugger-
Knot soft anchor 2.9; (bottom right) JuggerKnot soft anchor 1.5. (Courtesy of Biomet, Warsaw, IN; with
Park & Shin
anchor placement or preloaded suture breakage
can prevent surgeons from achieving satisfactory
anchor fixation and/or repair. Although relatively
uncommon, preloaded suture breakage may be
salvaged by putting an additional PDS suture
through the anchor eyelet.64As the materials
used for sutures and anchors evolve, the incidence
of suture breakage after anchor insertion is
unlikely. With the help of small Mitek anchors
(Depuy Mitek), surgeons have reported successful
collateral ligament reconstruction at the meta-
carpophalangeal joint and proximal interphalan-
geal joint with return to activities of daily living in
5 weeks and preinjury activities in 12 weeks
Promising cadaveric study data exist for stain-
less steel anchors used for flexor digitorum pro-
fundus tendon repair.27Although bioabsorbable
suture anchors are also widely used in hand and
wrist procedures, they have not been shown to
have a significant advantage over the well-
tolerated metal anchors.
NEW SUTURE MATERIAL
Braided polyester sutures (Ethibond, Ethicon,
Sommerville, NJ) were widely used in the past,
but improved, stronger suture materials, such as
Fiberwire (Arthrex), made of ultra–high molecular
weight polyethylene (UHMWPE), are now avail-
able. The Orthocord suture (Depuy Mitek) is
made of a UHMWPE sleeve and a polydioxanone
(PDS) core with polyglactin 910 coating. The intro-
duction of the stronger suture material changed
the mode of failure of the anchor/suture construct.
Instead of suture breakage, the metal anchor failed
by pulling out of bone, whereas the bioabsorbable
anchor failed at the level of the anchor eyelet.67,68
Suture knot configuration has been studied as
well, as it is an essential part of the fixation con-
struct. Although a static surgeon’s knot provides
knot with the addition of 3 reversing half-hitches
on alternating posts can also provide adequate
fixation for clinical use.69Sliding knots without
reversing half-hitches on alternating posts should
not be used.
Monofilament stainless steel sutures have been
advocated in the past for flexor tendon repairs,
but difficulties in handling the material (eg, kinking
and plastic deformation) caused interest to fade
quickly in this suture material. There have been
ament stainlesssteel sutures,however, with prom-
ising data reflecting its nonviscoelastic properties
of the previously described handling problems of
the monofilament stainless steel suture, along
with overcoming the shortcomings of stress relax-
ation and creep, as seen with polymer sutures,
could make stainless steel suture material relevant
again in flexor tendon repair.70Another theoretical
advantage of the multifilament stainless steel
suture is the option of using a crimp mechanism
instead of suture knots during the tendon repair,
thereby ensuring simultaneous
tensioning of the suture limbs (Fig. 7). Clinical
Fig. 6. The Microfix bio-absorbable suture anchor
with Orthocord suture. (Courtesy of Depuy Mitek,
Raynham, MA; with permission.)
Fig. 7. (A) Multifilament stainless steel suture used in flexor tendon repair. (B) Multifilament stainless steel suture
with crimp mechanism for securing the sutures and pretensioning. (Courtesy of Dr Leonard Gordon.)
New Suture Materials in the Upper Extremity
data are still lacking, however, with regard to
whether or not the use of this suture material leads
to improved functional outcome.
Suture anchors have been available since the early
1990s and are now an essential tool in the ortho-
pedic surgeon’s armamentarium. As with any
other implant, the surgeon should be thoroughly
educated on the characteristics of the anchor
being used and the technique necessary for
correct insertion of the anchor. With so many
different types of new anchors and sutures avail-
able, the surgeon must take care in choosing the
device that is most appropriate for the procedure
and body part in question. Upper extremity
surgical techniques will continue to be revisited,
revised, and perhaps even reinvented, in no small
part because of the introduction of new technolo-
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Park & Shin