Knot-induced glenoid erosion after arthroscopic fixation for
unstable superior labrum anterior-posterior lesion:
Case report
Yong Girl Rhee, MD, and Jeong Han Ha, MD, Seoul, Korea
A rthroscopic reconstruction of the shoulder joint is com-
monly performed with suture anchors. Most of the arthro-
scopic procedures for shoulder instability or rotator cuff
tears require the use of suture materials, unless tacks are
used. It is recommended that all stacked half-hitch knots
be locked with 3 RHAPs (reversing half-hitch on alternate
posts) to prevent knot failure by slippage and to maxi-
mize knot-holding capacity.2 A knot tied with nonab-
sorbable braided sutures gives a stronger knot-holding
capacity than a knot tied with absorbable monofilament
sutures.2 Thus, a bulky knot formation may catch on the
humeral head or rub on the glenoid after arthroscopic
surgery for a detached labrum. To our knowledge, this
report documents for the first time that the mechanical
locking of a nonabsorbable suture knot can be related to
the failure of a superior labrum anterior-posterior (SLAP)
lesion repair and gave rise to shoulder pain after arthro-
scopic reconstruction was performed with suture materi-
als.
CASE REPORT
A 34-year-old, right hand– dominant man had had right
shoulder pain for 6 months. No discrete injury had pre-
ceded the pain. The pain had not improved with 5-month-
long conservative treatment including physical therapy, in-
traarticular injection, and medication at a local clinic. On
initial examination, severe pain was provoked with the
compression-rotation test and the O’Brien test. The appre-
hension test and the impingement sign were negative, and
the range of motion was normal. Magnetic resonance im-
aging showed a detachment of the superior glenoid labrum
and the biceps tendon from the glenoid labrum. The initial
diagnosis was a SLAP lesion, and arthroscopy was per-
formed.
From the Shoulder & Elbow Clinic, Department of Orthopaedic
Surgery, School of Medicine, Kyung Hee University.
Reprint requests: Yong Girl Rhee, MD, Department of Orthopedic
Surgery, Kyung Hee University, 1 Hoiki-dong, Dongdaemoon-
ku, Seoul 130-702, Republic of Korea (E-mail: shoulderrhee@
hanmail.net).
J Shoulder Elbow Surg 2006;15:391-393.
Copyright © 2006 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2006/$32.00
doi:10.1016/j.jse.2005.03.010
At arthroscopy, the anterior type of a SLAP II lesion
was present with intact glenoid cartilage, labrum, and
rotator cuff. The SLAP lesion was fixed with 2 metallic
mini-Revo (Linvatec, Largo, FL) suture anchors with
braided No. 2 Ethibond (Ethicon, Somerville, NJ). A
Duncan sliding knot was locked with 3 RHAPs (Figure 1).
Routine postoperative immobilization and rehabilitation
were done.
The shoulder pain was improving postoperatively, but
sharp pain developed and shoulder motion was limited 2
months after surgery. Unfortunately, the patient had pain
with a clicking sensation at extreme motions even with
well-programmed conservative treatment. Nine months af-
ter surgery, the pain was exacerbated while driving without
any trauma. He also had a marked deficit in activities of
daily living because of pain. On physical examination, he
complained of severe pain on the compression– external
rotation test. Plain radiographic findings were unremark-
able.
A second arthroscopic surgery for evaluation of the
shoulder joint was done. On arthroscopy of the shoulder
joint, mild synovitis was seen with generalized congestion
around the capsule and the undersurface of the supraspi-
natus and especially on the biceps and the superior labrum.
One of the two suture materials was found to be torn and
floating in the joint. The nonabsorbable knot had rubbed
against the glenoid and created a flatfish-like lesion be-
tween the humeral head and the glenoid. The humeral head
was softened and glistened like chondromalacia (Figure 2).
There was a chondral defect of 5 ⫻ 5 mm in size on the
superior equator of the glenoid due to repeated rubbing by
the bulky knot, and the glenoid was severely eroded and
fibrillated around the chondral defect (Figure 3). The previ-
ous fixation of the unstable SLAP lesion showed stability
without any anchor protrusion, and the leading edge of the
subscapularis was partially torn. The bursal tissue was
thickened in the subacromial space. The floating suture
material was removed, and arthroscopic debridement was
performed. The retrieved suture material was 1.5 ⫻ 1 cm in
size (Figure 4). Immediately after surgery, the patient felt
much better than before. He was pain-free during shoulder
motions but reported some discomfort at the extreme ranges
of forward flexion and external rotation. A hypersensitivity
test for suture materials was negative. The patient returned
to daily activities immediately after the surgery and started
to work a week later. At 8 months after the second opera-
tion, he resumed his previous activities and reported no
shoulder pain.
391
392 Rhee and Ha
Figure 1 Arthroscopic view of advancing a sliding knot by push-
ing it forward and taking up the slack in the loop by pulling on the
post limb.
Figure 2 A flatfish type of knot was floating in the glenohumeral
joint. The humeral head was softened and glistened like
chondromalacia.
DISCUSSION
Good results have been reported for arthroscopic and
other shoulder surgeries with suture anchors, and anchors
have been increasingly used in shoulder surgery. Accord-
ingly, authors have described more anchor-related compli-
cations than before. These complications include a foreign-
body reaction to a bioabsorbable suture device,1,5 a
material reaction to a suture anchor,3 an infected suture
anchor,7 and loosening, misplacement, and glenohumeral
arthropathy resulting from anchor protrusion.6 The literature
has documented complications of suture anchors, but no
report has been made on the complications of knot-tying.
Whether a sliding knot or a nonsliding knot is used
during arthroscopic surgery, additional half-hitch knots are
required to avoid knot failure. These knots can be bulky in
a limited space. In practice, suture knots left on the upper
surface of the tendon can catch on the coracoacromial arch
and rub under this arch when the torn cuff is repaired
arthroscopically.4 However, the fibrous tissue that covers
J Shoulder Elbow Surg
May/June 2006
Figure 3 Arthroscopic view of a chondral defect on the glenoid
through an anterior portal.
Figure 4 A flatfish type of knot was retrieved.
the knots after surgery is a common finding at a second
look, and it is extremely rare that patients complain of pain
resulting from knot formation after arthroscopic stabilization
of the shoulder or rotator cuff repair. In this case, the knot
was partially torn and attached at the original site. The
head of the knot floated into the space between the humeral
head and the glenoid.
We assume that the bulky knot was reshaped into a
flatfish type of knot in the narrow space and scratched the
cartilage of the glenoid during repeated daily motion.
Nonetheless, it still remains unknown why the knot was
lodged in the narrow space and how the knot, which was
made of a soft material, could scratch the glenoid. If a metal
suture anchor is loose or misplaced after arthroscopic sur-
gery, a plain radiograph can help detect it. In our study,
laboratory and radiographic studies, as well as physical
examination, failed to provide a specific diagnosis, and
glenoid erosion from knot formation was not expected
before the second-look arthroscopy. We suspect that a knot
may have played a role in the development of post-arthro-
scopic shoulder pain and the erosion of the glenoid.
J Shoulder Elbow Surg Rhee and Ha 393
Volume 15, Number 3

REFERENCES
1. Burkhart A, Imhoff AB, Roscher E. Foreign-body reaction to the
bioabsorbable Suretac device: case report. Arthroscopy 2000;
16:91-5.
2. Chan KC, Burkhart SS, Thiagarajan P, Goh CH. Optimization of
stacked half-hitch knots for arthroscopic surgery. Arthroscopy
2001;17:752-9.
3. Chow JCY, Gu Y. Material reaction to suture anchor: case report.
Arthroscopy 2004;20:314-6.
4. Matsen FA, Lippitt SB. Shoulder surgery. In: Principles of glenohu-
meral strength. Philadelphia: Saunders; 2004. p. 302-3.
5. Menche DS, Phillips GI, Pitman MI, Steiner GC. Inflammatory
foreign-body reaction to an arthroscopic bioabsorbable meniscal
arrow repair. Arthroscopy 1999;15:770-2.
6. Rhee YG, Lee DH, Chun IH, Bae SC. Glenohumeral arthropathy
after arthroscopic anterior shoulder stabilization. Arthroscopy
2004;20:402-6.
7. Ticker JB, Lippe RJ, Barkin DE, Carroll MP. Infected suture anchors
in the shoulder: a case report. Arthroscopy 1996;12:613-5.