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Abstract

Background:

All-suture anchors (ASAs) are increasingly used in arthroscopic rotator cuff repair and rely on cortical bone for strength. No study has compared ASA pullout strength in relation to bone mineral density (BMD) in the different quadrants of the supraspinatus footprint on the greater tuberosity (GT).

Hypothesis:

ASA biomechanical characteristics at each quadrant would improve with increasing regional BMD.

Study Design:

Controlled laboratory study.

Methods:

Four 2.6-mm ASAs were inserted into the anteromedial, posteromedial, anterolateral, and posterolateral quadrants of the GT supraspinatus footprint of 12 cadaveric specimens. Local measures of bone quality around each anchor were evaluated using micro-computed tomography. Afterward, each ASA was biomechanically loaded to failure to determine the ultimate pullout strength and mode of failure. Repeated measures correlations were calculated to determine the relationship between measures of bone quality and pullout strength.

Results:

The mean load to failure of ASA placed in the posterolateral GT was significantly greater than all 3 of the other quadrants (P < .01). There was no significant difference in mean pullout force in the posteromedial, anterolateral, and anteromedial quadrants. Cortical BMD and mean BMD were also significantly greater in the posterolateral corner (P < .05). The pullout force measured across all quadrants was significantly correlated with cortex mean bone density, cortex volume, mean bone mineral density, and bone volume (P < .01).

Conclusion:

ASA pullout strength is correlated with local cortical BMD. ASA fixation strength and BMD were robust in all quadrants on the GT, and were greatest in the posterolateral GT.

Clinical Relevance:

This finding expands the available geography for ASA placement by demonstrating that the lateral GT has adequate BMD to support ASAs.

Keywords

all-suture anchor biomechanical study bone mineral density rotator cuff rotator cuff repair pullout strength

Rotator cuff tears are one of the most common causes of shoulder pain and are prevalent among older adults.¹⁵ Rotator cuff pathology increases proportionally with age, with reported rates of rotator cuff tears as high as 54% in patients >60 years, and as high as 80% in patients >80 years old.^24,39,40 Currently, an estimated 250,000 rotator cuff repairs (RCRs) are performed annually in the United States.^5,22,46 As the population continues to live longer with active lifestyles, the incidence and prevalence of rotator cuff tears will likely continue to rise.⁸

RCR techniques and implant materials have evolved since the procedure was first completed with arthroscopic assistance by Levy et al.^7,20 Surgeons can choose from a variety of suture anchors, including soft all-suture anchors (ASA) and traditional hard-body anchors composed from metallic, bioabsorbable, or biocomposite materials. Advantages of ASA compared with conventional hard-body anchors include their smaller diameter, decreased footprint, ability to preserve bone, improved points of fixation, and ease of insertion.^27,31,33,43 In addition, their small size minimizes violation of the supraspinatus footprint, allowing more surface area for biologic tendon-to-bone healing while enabling the placement of more anchors.³¹ Placement of two 4.75-mm hard screw-in anchors occupies an estimated 75% of the supraspinatus footprint, which is reported to be a mean medial-to-lateral length and anterior-posterior width of 6.9 mm and 12.6 mm, respectively. Alternatively, placement of two 2.6-mm ASAs occupies only 41% of the supraspinatus footprint.^25,31 Furthermore, previous studies suggest the clinical performance of ASAs, defined as patient-reported outcomes and retear rates, is nearly equivalent to hard-body anchors.^{9,27,31,33,43,45}

The fixation strength of ASAs is dependent on the integrity of the surrounding cortical bone, which tends to decrease in middle-aged and elderly populations.^29,42 Reduced bone mineral density (BMD) in the greater tuberosity (GT) has been identified as a risk factor for RCR failure due to decreased suture anchor pullout strength.^{3,18,19,29,35,44} Previous studies have detailed the distribution of proximal humeral bone density and indicate that the highest density of bone on the GT is on the supraspinatus footprint.^{2,29,30,41,42} This location is medial to the lateral “drop-off,” where the bone is reportedly weaker.^2,42 Despite these known differences in bone quality, some RCR techniques, such as the transosseous-equivalent repair, rely on anchors placed over this lateral “drop-off.”³² Suture anchor fixation on the supraspinatus footprint has been limited by the relatively large size of traditional hard-body anchors.²⁷ However, the relatively smaller size of ASA may allow more anchors to be placed into the denser bone located on the supraspinatus footprint, thus avoiding suture anchor placement into the suboptimal bone over the lateral “drop-off.” Studies have evaluated ASA pullout in humeral cadaveric specimens.^{11,27,28,36,41} However, there are limited data on ASA pullout strength and bone quality in the different regions of the supraspinatus footprint on the GT.^13,26 Therefore, this study aimed to evaluate and compare the ASA pullout strength and the regional bone quality of 4 quadrants of the supraspinatus footprint on the GT. We hypothesized that the ASA biomechanical characteristics at each quadrant would improve with increasing regional BMD. Clinically, these results will help surgeons optimize RCR strategies utilizing suture anchor fixation.

Methods

Specimen Preparation

Institutional review board approval was not required for this laboratory investigation, which utilized de-identified cadaveric specimens. Twelve shoulder specimens (6 male and 6 female specimens), with a mean age of 65 ± 6.37 years (range, 52-74 years), with no signs of deformity or previous shoulder surgeries were procured from an institute-approved tissue bank (Science Care) and stored at −30^oC. Before testing, each shoulder was dissected to remove all soft tissue, the clavicle, and the scapula to isolate the humerus.

Anchor Selection and Insertion

Anchors were placed into the anteromedial, posteromedial, anterolateral, and posterolateral aspects of the supraspinatus footprint on the GT (Table 1 and Figure 1). All measurements were taken via a digital caliper. A 2.6-mm FiberTak (Arthrex, Inc) all-suture soft anchor, double-loaded with sliding 1.3-mm SutureTape (Arthrex, Inc), was placed into each location according to the manufacturer's recommendations. The circumferential teeth drill guide was placed at a 45° angle to the humerus, as confirmed using a goniometer. The 2.6-mm drill bit was inserted through the guide and used to predrill a socket for anchor insertion. The drill bit was removed, and the 2.6-mm FiberTak all-suture anchor was inserted through the drill guide and malleted into the bone. The drill guide and anchor inserter were removed. Gentle tension was then applied to the sutures to set each anchor on the deep aspect of the humeral cortex. All anchors were confirmed to be appropriately set by tactile feel. The sliding sutures were then hand-tied 3 cm from the humerus with 10 alternating half-hitches.

Table 1

Anchor Insertion Locations and Testing Characteristics

Anchor Location	Specific Anchor Location
Anteromedial greater Tuberosity	5 mm posterior to the bicipital groove and just along the articular Margin of the humeral head
Posteromedial greater tuberosity	12.5 mm posterior to the anteromedial anchor and also along the articular margin
Anterolateral greater tuberosity	5 mm posterior to the bicipital groove, 12.5 mm lateral to the articular margin of the humeral head, along the lateral edge of the greater tuberosity
Posterolateral greater tuberosity	12.5 mm posterior to the anterolateral anchor, 12.5 mm lateral to the articular margin of the humeral head, along the lateral edge of the greater tuberosity

Figure 1.

(A) The marked points indicate the insertion locations for the anteromedial, posteromedial, anterolateral, and posterolateral anchors into the right cadaveric humerus greater tuberosity. (B) A 2.6-mm FiberTak all-suture soft anchor was inserted into each marked location. Two additional anchors were placed into the bicipital groove for later analysis. (C) The medial anchors were placed just lateral to the articular margin, the posterior anchors were placed 12.5 mm posterior to the anterior anchors, and the lateral anchors were placed 12.5 mm lateral to the medial anchors. (D) Anchors were placed at a 45° angle in relation to the humeral axis. AL, anterolateral; AM, anteromedial; PL, posterolateral; PM, posteromedial.

Micro-Computed Tomography

Bone quality around each anchor was assessed via micro-computed tomography (micro-CT) (µCT, vivaCT 40; Scanco Medical AG) before biomechanical testing. Microtomographic slices were acquired using a 55 kVp potential and reconstructed at a voxel size of 35 μm. Each anchor location was identified, and a spherical volume of interest with a radius of 5 mm was defined for evaluation (Figure 2). Bone microarchitecture was analyzed via image processing software (Analyze 14.0) to determine the following outcome measures: mean BMD (mg/cm³), cortical BMD, bone, cortex and trabecular volume (mm³), bone surface area (mm²), bone volume fraction (BV/TV, %), and surface to volume ratio (BS/BV), and porosity (number and density in mm³).

Figure 2.

(A) 3-dimensional reconstruction and (B) coronal microtomographic slide of the proximal humerus demonstrating the 5-mm spherical volume of interest around the posteromedial anchor location.

Biomechanical Testing

The distal humerus was potted and attached to the frame of a mechanical testing system (370.02 Bionix Testing System; MTS Systems Corp) in a custom jig. Specimens were positioned to accommodate a 45° angle of pull relative to the humeral axis, to simulate the physiological traction of the supraspinatus tendon (Figure 3). The suture ends of each anchor were secured to a hook attached to the actuator of the mechanical testing system machine for load application. After an initial 2N preload, cyclic loading of 5 to 20 N was applied for 10 cycles. The anchors were then pulled to failure at a rate of 1 mm/sec, with failure defined as either anchor disengagement from the bone-anchor interface or suture breakage. Ultimate load at failure and mode of failure were recorded for each anchor.

Figure 3.

Biomechanical testing setup with a left humerus. Sutures were pulled 45° from the humeral axis to simulate the physiologic traction of the supraspinatus.

Data Analysis

A sample size of 10 was determined based on previously reported means and standard deviations for RCR comparing BMD and metal versus biodegradable sutures,⁴¹ with an α error of .05 and power (1-β error probability) of 0.80 (G*Power 3.1.97). A mixed linear model with a random effect was used to account for multiple readings from the same specimen and determine differences in pullout strength and measures of bone quality between anchor locations, followed by a Tukey pairwise comparison. Repeated measures correlations were calculated to determine the relationship between measures of bone quality and pullout strength.

Results

Micro-Computed Tomography

The mean total volume and bone volume measured around each ASA were not significantly different in any of the 4 quadrants. Mean bone BMD and mean cortical BMD were both significantly greater around the ASAs placed in the posterolateral GT quadrant compared with all other 3 quadrants (P < .01) (Table 2). There were no statistical differences in mean BMD or cortical BMD between the AM, PM, and AL quadrants. Mean cortical volume (m³) was significantly greater in the lateral GT quadrants (anterolateral [AL] and posterolateral [PL]) compared with the medial quadrants (anteromedial [AM] and posteromedial [PM], P < .05). Bone volume fraction (BV/TV, %) was not significantly different between the 3 quadrants, although bone surface density (BS/BV) was considerably lower in the PL quadrant compared with AM, PM and GT quadrants (P < .01).

Table 2

Quantitative Measures of Bone Quality and ASA Fixation Strength for Each Quadrant of the Greater Tuberosity ^a

	Anchor Location on the Greater Tuberosity
	AM	PM	AL	PL	P
Micro-CT
Bone mean BMD, mm³	886.17 (255.09)	889.78 (253.43)	932.52 (294.26)	1031.87 (268.64)	<.0001
Cortical bone mean BMD, mm³	1245.52 (173.43)	1195.35 (166.28)	1187.60 (216.30)	1348.12 (131.58)	.0001
Bone volume, mm³	197.60 (69.17)	191.19 (57.98)	217.49 (66.01)	208.96 (68.01)	.1549
Cortical volume, mm³	75.42 (27.72)	81.39 (34.39)	114.06 (36.47)	116.36 (32.35)	.0004
Trabecular volume, mm³	504.33 (58.42)	471.30 (64.59)	448.81 (55.46)	459.64 (39.01)	.0661
Whole volume, mm³	579.75 (41.84)	552.70 (44.87)	562.87 (35.98)	576 (25.81)	.252
Total volume, mm³	583.53 (41.41)	557.12 (44.09)	569.28 (35.08)	581.13 (26.48)	.2487
Bone surface area, mm²	1361.84 (401.10)	1245.62 (323.73)	1284.57 (372.45)	1125.17 (388.75)	.0012
Bone volume fraction, %	34.33 (13.42)	34.58 (10.94)	38.38 (11.83)	36.25 (12.48)	.316
Bone surface density, mm²/mm³	2.35 (0.73)	2.24 (0.56)	2.27 (0.68)	1.95 (0.69)	.0015
Cortical porosity, %	4.15 (2.44)	4.00 (3.34)	4.91 (2.19)	4.01 (1.92)	.4488
Pore number, n	99.08 (59.12)	98.33 (66.41)	151.33 (79.83)	125.42 (65.52)	.0191
Pore density, mm⁻³	1.19 (0.53)	1.06 (0.44)	1.22 (0.47)	1.00 (0.35)	.0554
Biomechanics
Ultimate load, N	158.68 (44.15)	156.70 (72.43)	209.57 (85.06)	307.45 (131.69)	<.0001

AL, anterolateral; AM, anteromedial; BMD, bone mineral density; CT, computed tomography; PL, posterolateral; PM, posteromedial.

Biomechanical Testing

All ASAs failed by pulling out of the bone with no suture breakage. The mean ultimate load to failure for all quadrants was 208.1 ± 106.1 N. Ultimate load to load for each quadrant is included in Table 2. The ultimate load to failure of ASAs placed in the posterolateral quadrant of the GT was significantly stronger than all 3 other quadrants (P < .01). There were no significant differences in load to failure among anchors placed in the anteromedial, posteromedial, and anterolateral GT quadrants. Ultimate load to failure was significantly and positively correlated with BMD (P < .0001), bone volume (P = .033), cortical BMD (P < .001), and cortical volume (P < .01), and negatively correlated with bone surface density (P = .04) (Figure 4).

Figure 4.

(A) Overall bone mineral density and (B) cortical bone mineral density were both significantly correlated with ultimate load to failure. BMD, bone mineral density.

Discussion

The key finding of this study was that cortical BMD and fixation strength of ASAs were both greatest in the posterolateral quadrant of the supraspinatus footprint. The hypothesis that ASA biomechanical characteristics at each quadrant would improve with increasing regional BMD was validated. Clinically, this suggests that the posterolateral supraspinatus footprint is a suitable location for ASA placement if warranted by the rotator cuff tear configuration.

ASAs are increasingly used in RCR as a successful alternative to hard-body screw-in anchors.⁴³ Previous studies have evaluated the pullout strength of rotator cuff anchors—including metal,^12,34,41 biodegradable,^16,35 and all-suture anchors.^1,11 In addition, studies have compared ASA with non-ASAs in cadaveric humerus models.^9,11,26,28 Overall, results have demonstrated that ASAs have similar biomechanical properties to hard-body anchors.^9,45 The mean load to failure of ASA's sized 1.3 to 2.9 mm and hard-body screw anchors sized 4.5 to 6.5 mm, when tested in human proximal humerus specimens, ranges from 104 to 331 N.^10,26,27,41 The load to failure in the present study ranged from 155 to 322 N, which is consistent with previously reported values.

The BMD was greatest in the posterior and lateral aspects of the supraspinatus footprint on the proximal GT. Previous studies have reported the distribution of the BMD in the GT, both on the proximal supraspinatus footprint and over the lateral drop-off for placement of lateral anchors for a transosseous-equivalent RCR. Tingart et al^41,42 and Barvencik et al² both reported that BMD was greater on the proximal GT between the articular margin and the tip of the GT compared with the distal GT lateral to the tip of the GT. Regarding specific subregions on the proximal GT, Tingart et al^41,42 reported that trabecular BMD was higher in the posterior region than in the middle and anterior regions, while cortical BMD was higher in the middle region compared with the anterior and posterior regions. Sakamoto et al³⁸ and Kirchhoff et al¹⁷ both independently performed CT studies comparing medial GT bone adjacent to the articular surface with bone along the lateral edge of the supraspinatus footprint. They both reported that the medial bone had higher BMD than the lateral bone, with the highest BMD in the posteromedial aspect of the GT. It must be noted, however, that the regions of interest scanned and analyzed were set 5 mm under the surface of the cortical bone to intentionally omit the cortical bone artifact. Inclusion of cortical bone is essential when evaluating BMD in the context of inserting ASAs that rely on cortical bone for fixation. Our finding that the posterior bone is stronger than the anterior bone is in agreement with previous studies. However, our finding that bone on the lateral supraspinatus footprint was stronger than bone on the medial supraspinatus footprint conflicts with existing literature. This discrepancy may be due to differences in the regions of interest on the supraspinatus footprint and the inclusion of cortical bone in our BMD measurements.

Few studies have specifically evaluated soft ASAs in relation to BMD in humeral cadaveric specimens.^27,28,36,41 Ntalos et al²⁷ showed that ASA pullout force depends on humeral cortical thickness, and is not correlated with cancellous BMD.²⁷ Oh et al²⁸ concluded that higher ultimate load to failure of ASAs was recorded in bone with greater density, although this was using a synthetic bone model. Ruder et al³⁶ showed that GT decortication significantly decreased ASA load to failure, highlighting the importance of cortical bone for ASA fixation strength.

Rotator cuff healing after surgical repair remains unpredictable, with failure rates reported^4,18,23 to range from 11% to 94%. Kwon et al¹⁸ published their Rotator Cuff Healing Index, designed to predict rotator cuff healing after repair. Patient and tear characteristics found to influence rotator cuff healing included BMD, age, anteroposterior tear size, tear retraction, fatty infiltration, and work activity. In their study, BMD was measured using dual-energy X-ray absorptiometry (DEXA) scans, which were completed at the proximal femur and lumbar spine. Chung et al⁴ also identified BMD, as measured on DEXA scans of the proximal femur and lumbar spine, as an independent factor affecting postoperative rotator cuff healing.⁴ Multiple studies^14,21 have reported a correlation between BMD of the proximal femur and lumbar spine measured on DXA scans and BMD of the proximal humerus measured on either DXA scans¹⁴ or standard anteroposterior shoulder radiographs.²¹ Femoral and lumbar spine BMD may be an accurate predictor of proximal humerus BMD, and may be a reliable metric influencing rotator cuff healing. Patients with low BMD on conventional DEXA scan may be counseled on lower fixation strength and decreased healing rates, which may affect postoperative rehabilitation.

A unique strength of our study was the comparison of ASA pullout strength with µCT measures of bone quality between different subregions of the supraspinatus footprint of the GT. ASA fixation strength and measures of bone quality were robust in all quadrants on the GT. This finding may have implications for future implant designs and repair constructs. Historically, double-row RCR constructs required the placement of medial and lateral rows of knotted suture anchors onto the supraspinatus footprint. The lateral row of traditional screw in-anchors occupied a prohibitively large portion of the supraspinatus footprint because of their size. As a result, the lateral row anchors were placed further distally over the lateral humeral drop-off. However, unlike traditional large screw in-anchors, ASAs are small and strong enough to be placed in the lateral GT bone without occupying a large percentage of the supraspinatus footprint and possibly impeding biologic tendon-to-bone healing. Our findings suggest that this lateral region of GT bone may be suitable for ASA placement. This presents an opportunity to optimize future RCR strategies and other procedures that require secure GT fixation, including superior capsular reconstruction, biological tuberoplasty, and lower trapezius transfer.

Limitations

Like all biomechanical cadaveric studies, our study had several limitations. The reported fixation strength and bone quality are measured at time zero after surgery and do not account for healing or postoperative changes. Furthermore, the elongation of the construct under cyclic loading, which may occur postoperatively and carry clinical relevance, was not evaluated. In addition, when inserting the lateral GT anchors, a distance of 12.5 mm from the articular margin was selected based on previous anatomic studies.^6,37 This set distance was used to standardize anchor insertion and BMD analysis. However, the relative location of the lateral anchor in each supraspinatus footprint was likely more variable. When treating patients with a smaller humerus and supraspinatus footprint, lateral footprint anchors may be placed where clinically appropriate, which may be <12.5 mm from the articular margin. In addition, our study did not evaluate fixation strength in the lesser tuberosity, which may be clinically relevant if a subscapularis repair is indicated. Finally, there were limitations in comparing our biomechanical and µCT results with those of previous studies because of differences in testing protocols and acquisition methods. Despite these differences, our anchor pullout data were within the previously reported values.

Conclusion

ASA pullout strength was robust in all 4 quadrants of the GT and was significantly correlated with local cortical BMD. ASA fixation strength and bone quality were greatest in the posterolateral GT. Our findings suggest the available geography for ASA placement may also include the lateral GT. These findings present an opportunity to optimize future repair constructs based on individual characteristics of rotator cuff tears.

Footnotes

Acknowledgements

The authors thank Arthrex, Inc for supporting this research.

Final revision submitted June 27, 2025; accepted July 21, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: Funding for this study was provided by an Arthrex Investigator-Initiated Research grant (Study ID IIRR-01696). O.L. has received consulting fees and a grant from Arthrex, Inc. M.F.M. has received a grant from Arthrex, Inc, and ConMed. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was waived by the Institutional Review Board at Cedars-Sinai (Protocol ID: STUDY00003094).

ORCID iDs

Andrew D. Posner

Andrew Nakla

Ajith Malige

Melodie F. Metzger

References

Barber

Herbert

MA.

Cyclic loading biomechanical analysis of the pullout strengths of rotator cuff and glenoid anchors: 2013 update. Arthroscopy. 2013;29(5):832-844.

Barvencik

Gebauer

Beil

, et al. Age- and sex-related changes of humeral head microarchitecture: Histomorphometric analysis of 60 human specimens. J Orthop Res. 2010;28(1):18-26.

Chen

Giambini

Ben-Abraham

Nassr

Zhao

Effect of bone mineral density on rotator cuff tear: an osteoporotic rabbit model. PLoS One. 2015;10(10):e0139384.

Chung

Gong

Kim

SH.

Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors. Am J Sports Med. 2011;39(10):2099-2107.

Colvin

Egorova

Harrison

Moskowitz

Flatow

EL.

National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227-233.

Curtis

Burbank

Tierney

Scheller

Curran

AR.

The insertional footprint of the rotator cuff: an anatomic study. Arthroscopy. 2006;22(6):609.e1.

Dey Hazra

Ernat

Rakowski

Boykin

Millett

PJ.

The evolution of arthroscopic rotator cuff repair. Orthop J Sports Med. 2021;9(12):23259671211050899.

Ensor

Kwon

Dibeneditto

Zuckerman

Rokito

AS.

The rising incidence of rotator cuff repairs. J Shoulder Elbow Surg. 2013;22(12):1628-1632.

Ergün

Akgün

Barber

Karahan

The clinical and biomechanical performance of all-suture anchors: a systematic review. Arthrosc Sport Med Rehabil. 2020;2(3):e263-e275.

10.

Galland

Airaudi

Gravier

Le Cann

Chabrand

Argenson

JN.

Pullout strength of all suture anchors in the repair of rotator cuff tears: a biomechanical study. Int Orthop. 2013;37(10):2017-2023.

11.

Goschka

Hafer

Reynolds

, et al. Biomechanical comparison of traditional anchors to all-suture anchors in a double-row rotator cuff repair cadaver model. Clin Biomech. 2015;30(8):808-813.

12.

Hecker

Shea

Hayhurst

Myers

Meeks

Hayes

WC.

Pull-out strength of suture anchors for rotator cuff and Bankart lesion repairs. Am J Sports Med. 1993;21(6):874-879.

13.

Hong

Hsu

Kuan

Lin

Yeh

WR.

Biomechanical evaluation of a transtendinous all-suture anchor technique versus interference screw technique for suprapectoral biceps tenodesis in a cadaveric model. Arthroscopy. 2018;34(6):1755-1761.

14.

Kamiyama

Shitara

Tajika

, et al. Reliability of measuring the proximal humeral bone mineral density using dual-energy x-ray absorptiometry. Osteology. 2024;4(2):88-97.

15.

Keener

Patterson

Orvets

Chamberlain

AM.

Degenerative rotator cuff tears: refining surgical indications based on natural history data. J Am Acad Orthop Surg. 2019;27(5):156-165.

16.

Kim

Kwon

Park

JH.

Perianchor cyst formation around biocomposite biodegradable suture anchors after rotator cuff repair. Am J Sports Med. 2015;43(12):2907-2912.

17.

Kirchhoff

Braunstein

Milz

, et al. Assessment of bone quality within the tuberosities of the osteoporotic humeral head: relevance for anchor positioning in rotator cuff repair. Am J Sports Med. 2010;38(3):564-569.

18.

Kwon

Kim

Lee

Kim

JH.

The rotator cuff healing index: a new scoring system to predict rotator cuff healing after surgical repair. Am J Sports Med. 2019;47(1):173-180.

19.

Lee

Hwang

Lee

Kim

TY.

Greater tuberosity bone mineral density and rotator cuff tear size are independent factors associated with cutting-through in arthroscopic suture-bridge rotator cuff repair. Arthroscopy. 2021;37(7):2077-2086.

20.

Levy

Uribe

Delaney

LG.

Arthroscopic assisted rotator cuff repair: preliminary results. Arthroscopy. 1990;6(1):55-60.

21.

Mather

MacDermid

Faber

Athwal

GS.

Proximal humerus cortical bone thickness correlates with bone mineral density and can clinically rule out osteoporosis. J Shoulder Elbow Surg. 2013;22(6):732-738.

22.

Mather

Koenig

Acevedo

, et al. The societal and economic value of rotator cuff repair. J Bone Joint Surg Am. 2013;95(22):1993-2000.

23.

McElvany

McGoldrick

Gee

Neradilek

Matsen

FA.

Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome. Am J Sports Med. 2015;43(2):491-500.

24.

Milgrom

Schaffler

Gilbert

van Holsbeeck

Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br. 1995;77(2):296-298.

25.

Mochizuki

Sugaya

Uomizu

, et al. Humeral insertion of the supraspinatus and infraspinatus. New anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg Am. 2008;90(5):962-969.

26.

Nagra

Zargar

Smith

RDJ

Carr

AJ.

Mechanical properties of all-suture anchors for rotator cuff repair. Bone Joint Res. 2017;6(2):82-89.

27.

Ntalos

Huber

Sellenschloh

, et al. All-suture anchor pullout results in decreased bone damage and depends on cortical thickness. Knee Surg Sports Traumatol Arthrosc. 2021;29(7):2212-2219.

28.

Jeong

Yang

, et al. Pullout strength of all-suture anchors: effect of the insertion and traction angle—a biomechanical study. Arthroscopy. 2018;34(10):2784-2795.

29.

Song

Kim

, et al. The measurement of bone mineral density of bilateral proximal humeri using DXA in patients with unilateral rotator cuff tear. Osteoporos Int. 2014;25(11):2639-2648.

30.

Song

Lee

YS.

Measurement of volumetric bone mineral density in proximal humerus using quantitative computed tomography in patients with unilateral rotator cuff tear. J Shoulder Elbow Surg. 2014;23(7):993-1002.

31.

Pak

Menendez

Hwang

Ardebol

Ghayyad

Denard

PJ.

Soft anchors for rotator cuff repair. JBJS Rev. 2023;11(2).

32.

Park

Tibone

ElAttrache

Ahmad

Jun

Lee

TQ.

Part II: biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007;16(4):469-476.

33.

Rhee

Kim

, et al. All-suture anchor settling after arthroscopic repair of small and medium rotator cuff tears. Am J Sports Med. 2019;47(14):3483-3490.

34.

Rosso

Weber

Dietschy

de Wild

Müller

Three anchor concepts for rotator cuff repair in standardized physiological and osteoporotic bone: a biomechanical study. J Shoulder Elbow Surg. 2020;29(2):e52-e59.

35.

Rossouw

McElroy

Amis

Emery

RJ.

A biomechanical evaluation of suture anchors in repair of the rotator cuff. J Bone Joint Surg Br. 1997;79(3):458-461.

36.

Ruder

Dickinson

Peindl

Habet

Fleischli

JE.

Greater tuberosity decortication decreases load to failure of all-suture anchor constructs in rotator cuff repair. Arthroscopy. 2018;34(10):2777-2781.

37.

Sahu

Phadnis

Revisiting the rotator cuff footprint. J Clin Orthop Trauma. 2021;21:101514.

38.

Sakamoto

Kido

Inoue

, et al. In vivo microstructural analysis of the humeral greater tuberosity in patients with rotator cuff tears using multidetector row computed tomography. BMC Musculoskelet Disord. 2014;15:351.

39.

Sher

Uribe

Posada

Murphy

Zlatkin

MB.

Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10-15.

40.

Tempelhof

Rupp

Seil

Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296-299.

41.

Tingart

Apreleva

Lehtinen

Zurakowski

Warner

JJP

. 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):1466-1473.

42.

Tingart

Bouxsein

Zurakowski

Warner

Apreleva

Three-dimensional distribution of bone density in the proximal humerus. Calcif Tissue Int. 2003;73(6):531-536.

43.

Trofa

Bixby

Fleischli

Saltzman

BM.

All-suture anchors in orthopaedic surgery: design, rationale, biomechanical data, and clinical outcomes. J Am Acad Orthop Surg. 2021;29(19):e950-e960.

44.

Waldorff

Lindner

Kijek

, et al. Bone density of the greater tuberosity is decreased in rotator cuff disease with and without full-thickness tears. J Shoulder Elbow Surg. 2011;20(6):904-908.

45.

Yang

Shih

Fang

, et al. Biomechanical comparison of different suture anchors used in rotator cuff repair surgery-all-suture anchors are equivalent to other suture anchors: a systematic review and network meta-analysis. J Exp Orthop. 2023;10(1):45.

46.

Yanik

Chamberlain

Keener

JD.

Trends in rotator cuff repair rates and comorbidity burden among commercially insured patients younger than the age of 65 years, United States 2007-2016. JSES Rev Rep Tech. 2021;1(4):309-316.

The Relationship Between Bone Quality and Biomechanical Strength of All-Suture Anchors Utilized in Rotator Cuff Repairs

Abstract

Background:

Hypothesis:

Study Design:

Methods:

Results:

Conclusion:

Clinical Relevance:

Keywords

Methods

Specimen Preparation

Anchor Selection and Insertion

Micro-Computed Tomography

Biomechanical Testing

Data Analysis

Results

Micro-Computed Tomography

Biomechanical Testing

Discussion

Limitations

Conclusion

Footnotes

Acknowledgements

ORCID iDs

References