An Injectable Calcium Phosphate Bone Graft Substitute Improves the Pullout Strength of Various Suture Anchor Designs in an Osteoporotic Bone Model

Overview

Journal Arthrosc Sports Med Rehabil

Date 2023 Apr 27

PMID 37101877

Authors

Miguel A Diaz

Steven Munassi

David E Teytelbaum

Anthony Pipitone

Christopher E Baker

Affiliations

Soon will be listed here.

Abstract

Purpose: To compare various suture anchor designs with and without calcium phosphate (CaP) augmentation in an osteoporotic foam block model and decorticated proximal humerus cadaveric model.

Methods: This was a controlled biomechanical study, consisting of 2 parts: (1) an osteoporotic foam block model (0.12 g/cc; n = 42) and (2) a matched pair cadaveric humeral model (n = 24). Suture anchors selected were an all-suture anchor, PEEK (polyether ether ketone)-threaded anchor, and a biocomposite-threaded anchor. For each study arm, one half the samples were first filled with injectable CaP and the other half were not augmented with CaP. For the cadaveric portion, the PEEK- and biocomposite-threaded anchors were assessed. Biomechanical testing consisted of a stepwise, increasing load protocol for a total of 40 cycles, followed by ramp to failure.

Results: For the foam block model, the average load to failure for anchors with CaP was significantly greater when compared with anchor fixation augmented without CaP; the all-suture anchor was 135.2 ± 20.2 N versus 83.3 ± 10.3 N ( = .0006); PEEK was 131 ± 34.3 N versus 58.5 ± 16.8 N ( = .001); and biocomposite was 182.2 ± 64.2 N versus 80.8 ± 17.4 N ( = .004). For the cadaveric model, the average load to failure for anchors augmented with CaP was again greater than anchor fixation without CaP; PEEK anchors went from 41.1 ± 21.1 N to 193.6 ± 63.9 N ( = .0034) and biocomposite anchors went from 70.9 ± 26.6 N to 143.2 ± 28.9 N ( = .004).

Conclusions: Augmenting various suture anchors with CaP has shown to significantly increase pull-out strength and stiffness in an osteoporotic foam block and time zero cadaveric bone model.

Clinical Relevance: Rotator cuff tears are common in the elderly patients, in whom poor bone quality jeopardizes treatment success. Exploring methods that increase the strength of fixation in osteoporotic bone to improve outcomes in this patient population is important.

References

Braunstein V, Ockert B, Windolf M, Sprecher C, Mutschler W, Imhoff A . Increasing pullout strength of suture anchors in osteoporotic bone using augmentation--a cadaver study. Clin Biomech (Bristol). 2015; 30(3):243-7. DOI: 10.1016/j.clinbiomech.2015.02.002. View

Nicholson A, Estrada J, Mathew J, Finocchiaro A, Pinnamaneni S, Okeke L . Minimum 15-year follow-up for clinical outcomes of arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2022; 31(8):1696-1703. DOI: 10.1016/j.jse.2022.01.116. View

Galatz L, Ball C, Teefey S, Middleton W, Yamaguchi K . The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004; 86(2):219-24. DOI: 10.2106/00004623-200402000-00002. View

Ntalos D, Sellenschloh K, Huber G, Briem D, Puschel K, Morlock M . Conventional rotator cuff versus all-suture anchors-A biomechanical study focusing on the insertion angle in an unlimited cyclic model. PLoS One. 2019; 14(11):e0225648. PMC: 6880995. DOI: 10.1371/journal.pone.0225648. View

Sano A, Itoi E, Konno N, Kido T, Urayama M, Sato K . Cystic changes of the humeral head on MR imaging. Relation to age and cuff-tears. Acta Orthop Scand. 1998; 69(4):397-400. DOI: 10.3109/17453679808999054. View

Teunis T, Lubberts B, Reilly B, Ring D . A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014; 23(12):1913-1921. DOI: 10.1016/j.jse.2014.08.001. View

Barber F, Feder S, Burkhart S, Ahrens J . The relationship of suture anchor failure and bone density to proximal humerus location: a cadaveric study. Arthroscopy. 1997; 13(3):340-5. DOI: 10.1016/s0749-8063(97)90031-1. View

Kovacevic D, Fox A, Bedi A, Ying L, Deng X, Warren R . Calcium-phosphate matrix with or without TGF-β3 improves tendon-bone healing after rotator cuff repair. Am J Sports Med. 2011; 39(4):811-9. DOI: 10.1177/0363546511399378. View

Entezari V, Lazarus M . Surgical Considerations in Managing Osteoporosis, Osteopenia, and Vitamin D Deficiency During Arthroscopic Rotator Cuff Repair. Orthop Clin North Am. 2019; 50(2):233-243. DOI: 10.1016/j.ocl.2018.10.006. View

10.

Patel A, Savoie 3rd F, OBrien M . "Current concepts and expert practice report: Augmentation of rotator cuff repairs". J Clin Orthop Trauma. 2021; 19:118-124. PMC: 8144684. DOI: 10.1016/j.jcot.2021.05.016. View

11.

Horoz L, Hapa O, Barber F, Husemoglu B, Ozkan M, Havitcioglu H . Suture Anchor Fixation in Osteoporotic Bone: A Biomechanical Study in an Ovine Model. Arthroscopy. 2016; 33(1):68-74. DOI: 10.1016/j.arthro.2016.05.040. View

12.

Trofa D, Ruder J, Yeatts N, Peindl R, Habet N, Saltzman B . Cyclic and Load-to-Failure Properties of All-Suture Anchors in Human Cadaveric Shoulder Greater Tuberosities. Arthroscopy. 2020; 36(11):2805-2811. DOI: 10.1016/j.arthro.2020.06.010. View

13.

Couto A, Rodrigues A, Nunes B, Torres J, Gutierres M . Arthroscopic approach to simple bone cyst of the humeral head-a step toward a minimally invasive technique. JSES Open Access. 2019; 2(4):211-214. PMC: 6334867. DOI: 10.1016/j.jses.2018.08.001. View

14.

Frank J, ElAttrache N, Dines J, Blackburn A, Crues J, Tibone J . Repair site integrity after arthroscopic transosseous-equivalent suture-bridge rotator cuff repair. Am J Sports Med. 2008; 36(8):1496-503. DOI: 10.1177/0363546507313574. View

15.

Aziz K, Shi B, Okafor L, Smalley J, Belkoff S, Srikumaran U . Pullout strength of standard vs. cement-augmented rotator cuff repair anchors in cadaveric bone. Clin Biomech (Bristol). 2018; 54:132-136. DOI: 10.1016/j.clinbiomech.2018.03.016. View

16.

Barber F, Herbert M . Cyclic loading biomechanical analysis of the pullout strengths of rotator cuff and glenoid anchors: 2013 update. Arthroscopy. 2013; 29(5):832-44. DOI: 10.1016/j.arthro.2013.01.028. View

17.

Traverso A, Friedrich K, Reichert W, Bauer S . Large Footprint Bone Cyst: Arthroscopic Autologous Cylinder Press-Fit with Buddy Anchor Interference-Fit for Rotator Cuff Repairt. J Orthop Case Rep. 2022; 11(8):71-74. PMC: 8686496. DOI: 10.13107/jocr.2021.v11.i08.2372. View

18.

Tingart M, Apreleva M, Lehtinen J, Zurakowski D, Warner J . 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. 2004; 32(6):1466-73. DOI: 10.1177/0363546503262644. View

19.

Ruder J, Dickinson E, Peindl R, Habet N, Fleischli J . Greater Tuberosity Decortication Decreases Load to Failure of All-Suture Anchor Constructs in Rotator Cuff Repair. Arthroscopy. 2018; 34(10):2777-2781. DOI: 10.1016/j.arthro.2018.05.030. View

20.

Visscher L, Jeffery C, Gilmour T, Anderson L, Couzens G . The history of suture anchors in orthopaedic surgery. Clin Biomech (Bristol). 2018; 61:70-78. DOI: 10.1016/j.clinbiomech.2018.11.008. View