Cyclic Load Testing and Ultimate Failure Strength of Suture

Anchors in the Acetabular Rim

Michell Ruiz-Suarez, M.D., M.S., Jorge Aziz-Jacobo, M.D., and F. Alan Barber, M.D.

Purpose: To determine the resistance to cyclic stress and load-to-failure strength of several suture
anchors suitable for hip arthroscopy. Methods: Ten polyetheretherketone (PEEK) PushLock, PEEK
SutureTak, and Bio-SutureTak anchors (Arthrex, Naples, FL); Lupine Loop BR anchors (DePuy
Mitek, Norwood, MA); Bio-Mini Revo anchors (ConMed Linvatec, Largo, FL); and BioRaptor 2.9
AB anchors (Smith & Nephew, Andover, MA) were inserted in rotation into different locations on
the rim of 4 matched pairs of potted acetabula clamped to the base of a servohydraulic testing
machine. The anchors’ sutures were cyclically pulled in line with the insertion angle. Displacement
at 100 and 500 cycles, yield load, ultimate failure load, and failure mode were recorded. Statistical
analysis was performed. Results: Most of the displacement observed during cyclic loading occurred
in the first 100 cycles, except for the BioRaptor 2.9 AB, which showed twice as much displacement
at 500 cycles as at 100 cycles. The Lupine Loop BR cyclic displacement was greater than that of the
PEEK PushLock (at 100 cycles also), Bio-SutureTak, and PEEK SutureTak at 500 cycles (P ⬍ .05).
The BioRaptor 2.9 AB cyclic displacement was significantly greater at 100 and 500 cycles than that
of the PEEK PushLock and Bio-SutureTak (P ⬍ .05). The mean ultimate failure loads for these
anchors ranged from 154 N (PEEK SutureTak) to 255 N (Bio-Mini Revo) and was statistically
equivalent (P ⫽ .139). Correlation analysis showed no significant associations between anchor
stiffness, cyclic load displacement, or failure load. Conclusions: Anchors with specific indications
for hip arthroscopy showed very little displacement and had consistent failure loads under cyclic
conditions in the acetabular rim. All hip anchors except the BioRaptor 2.9 AB showed less than 2.0
mm of displacement after 500 cycles. Clinical Relevance: Biomechanical testing of suture anchors
designated for hip arthroscopy should be performed in the acetabular rim before their use. Suture
anchors used for shoulder arthroscopy may not perform as well in the hip.

S uture anchors are commonly used for shoulder

capsulolabral repairs1-4 and offer advantages over
older suture fixation techniques.5 Many of the same
arthroscopic techniques developed for use in the gle-
nohumeral joint are now being applied to the hip. Hip
labral tears can be repaired with suture anchors in
From the Instituto Nacional de Rehabilitación (M.R.-S.), Mexico
City, Mexico; and Plano Orthopedic Sports Medicine and Spine
Center (J.A.-J., F.A.B.), Plano, Texas, U.S.A.
Supported by Arthrex, Smith & Nephew Endoscopy, ConMed Lin-
vatec, and DePuy Mitek. Research was performed at Arthrex, Naples,
FL.
Received April 12, 2009; accepted October 22, 2009.
Address correspondence and reprint requests to F. Alan Barber,
M.D., Plano Orthopedic Sports Medicine and Spine Center, 5228 W
Plano Pkwy, Plano, TX 75093, U.S.A.
© 2010 by the Arthroscopy Association of North America
0749-8063/9206/$36.00
doi:10.1016/j.arthro.2009.10.013
much the same way as shoulder glenoid surgery.
Whereas single-pull load-to-failure strength testing
provides one element of an anchor’s properties, the
anchors used in these labral repairs are actually sub-
jected to multiple submaximal cyclic loads. In the
glenoid labral repair, a displacement of 5 mm after
cyclic loading would constitute a clinical failure.6,7
Currently, there are no data available for hip labral
repairs to suggest how much displacement would con-
stitute a clinical failure.
Although many similarities exist, the acetabular rim
is different from the glenoid. Anchors placed in the
acetabular rim may show different failure profiles than
anchors placed in the glenoid rim. The number of
suture anchors approved by the Food and Drug Ad-
ministration for use in the acetabulum is limited. Test-
ing of these anchors in the acetabulum with submaxi-
mal cyclic loads should provide a test environment

762 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 6 (June), 2010: pp 762-768
 SUTURE ANCHORS IN ACETABULAR RIM
more consistent with the in vivo situation. The pur-
pose of this study was to determine the resistance to
cyclic stress and load-to-failure strength of several
suture anchors suitable for hip arthroscopy. The hy-
pothesis was that new suture anchors indicated for hip
arthroscopy would show different biomechanical
characteristics in the acetabulum than anchors not
designed for that location.
METHODS
Four matched pairs of fresh-frozen acetabula (all
male specimens; age range, 53 to 65 years) were
thawed and stripped of all soft tissue after removal of
the femur. The pelvis was cut approximately 3 inches
from the acetabulum to isolate it. Drywall screws were
inserted into the pelvis around each separated acetab-
ulum and then potted in quick-setting resin with care
taken to keep the rim free of resin. Six different suture
anchors were inserted in rotation into different loca-
tions on the rim of each acetabulum to decrease the
effect of bone quality and density variations in the
different locations (Fig 1). Because different locations
of acetabular labral injuries have been reported,8 we
tested the topographic areas that have been previously
described as being affected by these kinds of lesions.
The anchors were inserted at the 9-, 10:30-, 12-, 1:30-,
3-, and 7:30-o’clock positions in left hips and 9-,
10:30-, 12-, 1:30-, 3-, and 4:30-o’clock positions in
right hips. The anchors were inserted at a safe angle9
FIGURE 1. Six different suture anchors were inserted in rotation into
different locations on each acetabulum rim to decrease the effect of
bone quality and density variations. © 2010 F. Alan Barber, used by
permission.
763
FIGURE 2. The PEEK hip PushLock anchor is a radiolucent, non-
absorbable PEEK 5.5-mm anchor with a closed 2-mm distal PEEK
“eyelet” that can hold several sutures and the PushLock threads.
© 2010 F. Alan Barber, used by permission.
relative to the surface of the acetabulum to allow the
best introduction into the acetabular bone and to avoid
cutting out of the anchor. The anchors were also
spaced 10 mm apart to leave spacing between anchors
to avoid crack propagation during the cyclic and de-
structive testing. All the anchors were rotated in po-
sition to place them an equal number of times at the
different insertion sites. The polyetheretherketone
(PEEK) PushLock anchors (Arthrex, Naples, FL)
were provided with 2 sutures. One of these sutures
was removed so that the PEEK PushLock anchors
tested were threaded with a single suture to be con-
sistent with the other anchors.
The anchors tested were PEEK PushLock, PEEK
SutureTak, and Bio-SutureTak (Arthrex); Lupine
Loop BR (DePuy Mitek, Norwood, MA); Bio-Mini
Revo (ConMed Linvatec, Largo, FL); and BioRaptor
2.9 AB (Smith & Nephew, Andover, MA). All an-
chors were inserted according to the manufacturers’
instrumentation and recommended techniques.
The PEEK PushLock anchor is a radiolucent, non-
absorbable PEEK 5.5-mm anchor with 2 separate
components (Fig 2). These are the PushLock eyelet
and the PushLock threads, which are premounted and
physically separate on a driver shaft. The closed distal
PEEK “eyelet” is 2 mm wide and can hold several
sutures, a segment of FiberChain (Arthrex), or a single
2-mm FiberTape (Arthrex). The tested version appli-
cable to the hip held a single No. 2 FiberWire suture.
The FiberWire suture is made of a core of multiple
strands of ultrahigh–molecular weight polyethylene
(UHMWPE) surrounded by a braided polyester cov-
ering. The main body of the anchor is PEEK and has
a series of 9 ridges with a hollow core through which
the driver shaft passes. After inserting the distal PEEK
764 M. RUIZ-SUAREZ ET AL.
FIGURE 3. The PEEK SutureTak is a 3.0-mm-diameter radiolu-
cent, nonabsorbable PEEK push-in suture anchor with a series of 7
ridges instead of screw threads. © 2010 F. Alan Barber, used by
permission.
eyelet containing a suture into the hole in the acetab-
ular rim created using the appropriate punch, we ad-
vanced the PushLock threads down the driver shaft
until flush with the bone to secure the suture in the
bone.
The PEEK SutureTak is a 3.0-mm-diameter radi-
olucent, nonabsorbable PEEK push-in suture anchor
with a series of 7 ridges instead of screw threads (Fig
3). The single eyelet is located in a traditional post
situated at the anchor top through which a single No.
2 FiberWire suture is passed. A step drill with differ-
ent diameters is used to prepare the insertion site. This
anchor should not be confused with the similarly sized
3.0-mm biodegradable Bio-SutureTak (Fig 4), which
FIGURE 4. The Bio-SutureTak has an insert-molded suture eyelet
of braided, nonabsorbable polyester suture and a body of molded
poly-L-lactide– co-D,L-lactide. © 2010 F. Alan Barber, used by
permission.
FIGURE 5. The Lupine Loop BR suture anchor is an absorbable
anchor made of Biocryl Rapide (70% poly-lactide co-glycolide and
30% ␤-tricalcium phosphate) and threaded with a single strand of
No. 2 Orthocord. © 2010 F. Alan Barber, used by permission.
has an entirely different eyelet design (an insert-
molded suture eyelet of braided, nonabsorbable poly-
ester suture) and is molded from poly-L-lactide– co-
D,L-lactide. A single No. 2 FiberWire suture was
passed through the internal suture eyelet.
The Lupine Loop BR suture anchor (Fig 5) is an
absorbable anchor made of Biocryl Rapide (70% poly-
lactide co-glycolide and 30% ␤-tricalcium phosphate).
Of the poly-lactide co-glycolide in the Biocryl Rapide
material, 85% is poly-L-lactic acid and 15% is poly-
glycolic acid. This triangular-shaped anchor is 3.9 mm
at the widest part and 9 mm long and is inserted into
a 2.9-mm drill hole. The distal anchor has a slot and
the body a hole. A short knotted suture loop passes
through the hole to hook the slot. This creates an
eyelet through which the single attached suture is
passed. The suture is No. 2 Orthocord (DePuy Mitek)
made from braided absorbable polydioxanone (62%)
and nonabsorbable UHMWPE (38%). The partially
absorbable suture is coated with a copolymer of 90%
caprolactone and 10% glycolide.
Bio-Mini Revo anchor (Fig 6) is a blue, bioabsorbable
3.1-mm-diameter (outer diameter) screw anchor made
from self-reinforced 96L/4D poly-lactic acid. The anchor
is pre-threaded with a single No. 2 Hi-Fi suture (ConMed
Linvatec) made from braided pure UHMWPE. We in-
serted the anchor by first using a 2.1-mm punch to create
a hole in the acetabulum and then a 2.4-mm tap to create
threads for anchor insertion.
The BioRaptor 2.9 AB hip suture anchor (Fig 7) is
an absorbable anchor composed of poly-L-lactic acid
 SUTURE ANCHORS IN ACETABULAR RIM
FIGURE 6. The Bio-Mini Revo anchor is a blue, bioabsorbable
3.1-mm-diameter screw anchor made from self-reinforced 96L/4D
poly-lactic acid with a No. 2 Hi-Fi suture. © 2010 F. Alan Barber,
used by permission.
material. It has a series of raised ridges that are press
fit into a 3.0-mm drilled hole. Four ridges are located
proximal and three distal to a single transverse suture
eyelet. The anchor contains a single No. 2 Ultrabraid
suture (Smith & Nephew) made from uncoated,
braided UHMWPE. For hip arthroscopy, this anchor
comes with a 4.0-mm ⫻ 6-inch drill guide and a
4.0-mm obturator.
Biomechanical testing began the same day as an-
chor insertion. The potted acetabula were clamped by
an adjustable angle fixture secured to the base of the
Instron 8871 machine (Instron, Canton, MA), and the
FIGURE 7. The BioRaptor 2.9 AB hip suture anchor is composed
of poly-L-lactic acid and has 4 ridges located proximal to and 3
distal to a single transverse suture eyelet containing a single No. 2
Ultrabraid suture. © 2010 F. Alan Barber, used by permission.
765
FIGURE 8. The acetabula were positioned in the Instron machine
so that the sutures of the inserted anchors were pulled in line with
the angle of anchor insertion. © 2010 F. Alan Barber, used by
permission.
fixture was positioned to create a pull for testing that
was in line with the angle of anchor insertion (Fig 8).
A 1-kN load cell was attached to the Instron machine.
The sutures from the anchors were secured by use of
a pneumatic suture clamp attached to the upward
actuator arm for testing. The clamp was positioned to
create a suture gauge length of 30 mm. All anchors
were threaded with their own single UHMWPE-
containing suture.
The constructs were preloaded to 10 N at 1 N/s, and
this preload was held for 5 seconds. After preloading,
the constructs were cycled from 10 to 60 N at 1 Hz for
500 cycles.7,10 After cycling, those anchors that sur-
vived the cycling were subjected to a single pull to
failure conducted at 33 mm/s. The data were plotted in
Origin Scientific Graphing and Analysis Software
(OriginLab, Northampton, MA). Cyclic displacement
at 100 and 500 cycles, yield load (start point at fail-
ure), ultimate load, and mode of failure were recorded.
Statistical Analysis
A 1-way analysis of variance test was used to com-
pare means of the data, with significance set at P ⬍
.05. A Pearson correlation analysis was performed to
investigate the association between stiffness of the
suture anchor and the cyclic load failure characteris-
tics for each anchor.
766 M. RUIZ-SUAREZ ET AL.

TABLE 1. Biomechanical Testing

Anchor Displacement at 100 Cycles (mm) Displacement at 500 Cycles (mm) Ultimate Load (N) Stiffness (N/mm)

Lupine Loop BR 5.2 ⫾ 3.3 5.4 ⫾ 3.3 196 ⫾ 99 28 ⫾ 13

PEEK PushLock 1.0 ⫾ 0.3 1.1 ⫾ 0.4 201 ⫾ 46 112 ⫾ 24
Bio-SutureTak 1.0 ⫾ 0.1 1.1 ⫾ 0.2 177 ⫾ 37 117 ⫾ 16
PEEK SutureTak 1.3 ⫾ 0.8 1.4 ⫾ 0.9 153 ⫾ 26 120 ⫾ 27
BioRaptor 2.9 AB 1.6 ⫾ 1.3 3.4 ⫾ 1.7 166 ⫾ 76 109 ⫾ 33
Bio-Mini Revo 1.6 ⫾ 0.6 1.8 ⫾ 0.6 255 ⫾ 84 78 ⫾ 7

RESULTS 05). The stiffness of the Bio-Mini Revo anchor was

Most of the displacement observed during cyclic
loading occurred in the first 100 cycles, except for the
BioRaptor 2.9 AB, which showed twice as much
displacement at 500 cycles as at 100 cycles. The mean
cyclic displacement at both 100 cycles and 500 cycles,
ultimate load-to-failure strength, and stiffness re-
corded for the anchors tested are listed in Table 1. The
cyclic displacement of the Lupine Loop BR anchor at
100 cycles was significantly higher than that of the
PEEK PushLock (P ⬍ .05). The cyclic displacement
of the BioRaptor 2.9 AB anchor at 100 cycles was
significantly greater than that of the PEEK PushLock
and Bio-SutureTak (P ⬍ .05). No other statistical
differences between cyclic displacements at 100 cy-
cles exist.
The cyclic displacement for the Lupine Loop BR
at 500 cycles was significantly greater than that of
the PEEK PushLock, Bio-SutureTak, and PEEK
SutureTak (P ⬍ .05). The cyclic displacement of the
BioRaptor 2.9 AB anchor at 500 cycles was signifi-
cantly greater than that of the PEEK PushLock and
Bio-SutureTak (P ⬍ .05). No other statistical differ-
ences exist for cyclic displacements at 500 cycles.
There were no statistical differences in ultimate
load-to-failure strength with destructive testing after
500 cycles among any of the anchors (P ⫽ .139).
The stiffness of the Lupine Loop BR anchor was
significantly lower than that of all other anchors (P ⬍
TABLE 2. Mode of Failure
No. of Anchor Eyelet Suture
Specimens Anchor Pullout Failure Failure
significantly lower than that of the PEEK PushLock,
Bio-SutureTak, PEEK SutureTak, and BioRaptor 2.9
AB (P ⬍ .05). No other statistical differences between
stiffness values were found.
The modes of failure for the various anchors are
listed in Table 2. One Lupine Loop BR and one
Bio-Mini Revo anchor failed during cycling and did
not reach the ultimate load-to-failure stage. Others
were damaged during insertion, reducing the initial
number below 10 for some anchors.
The correlation analysis showed no significant
mode of association between the suture anchor’s stiff-
ness and its cyclic load displacement. The results are
shown in Table 3.
DISCUSSION
This comparison of acetabular labral anchors using
cyclic loading and load-to-failure testing supports our
hypothesis that different suture anchors indicated for
hip arthroscopy would show different biomechanical
characteristics. It should be noted that the Lupine
Loop BR (a common shoulder labral anchor) is the
only one in this group of anchors not approved for hip
labral fixation. It was chosen for testing as an anchor
commonly used for shoulder labral repair. This fact is
TABLE 3. Correlation Coefficient Between Stiffness and
Cyclic Displacement
Pearson Coefficient
(r) for Stiffness/ Pearson Coefficient
Cyclic Load (r) for Stiffness/
Displacement Load to Failure

8 BioRaptor 2.9 AB 6 2 0 Lupine Loop BR ⫺0.12 0.008

8 Bio-SutureTak 4 4 0 PEEK PushLock 0.14 0.23
8 Lupine Loop BR 5 3 0 Bio-SutureTak 0.23 0.15
7 Bio-Mini Revo* 2 5 0 PEEK SutureTak 0.33 ⫺0.69
8 PEEK SutureTak 5 3 0 BioRaptor 2.9 AB ⫺0.46 0.05
8 PEEK PushLock 0 8 0 Bio-Mini Revo ⫺0.21 0.07

*One anchor broke during insertion. NOTE. None of the coefficients showed statistical significance.
 SUTURE ANCHORS IN ACETABULAR RIM
relevant because it shows that common glenoid an-
chors cannot be assumed to be appropriate for hip
labral repairs. The Lupine Loop BR was the only
anchor that reached the 5-mm displacement level con-
sidered equivalent to clinical failure during cycling.
Although the suture-tissue interface is the greatest
area of concern for most soft-tissue repairs, its robust
nature makes it unlikely that sutures will pull through
the acetabular labrum. Consequently, achieving secure
knots and anchors that do not pull out may be more
important. Clinical failure may result if a significant
gap develops between the bone and capsulolabral tis-
sue as a result of cyclic loads.
In the cuff model, Burkhart et al.11 have shown that
as few as 25 cycles can cause a 5-mm gap between a
rotator cuff tendon edge and the bone and that a
10-mm gap can occur after only 188 cycles. In our
study almost all of the displacement encountered for
these anchors occurred during the initial 100 cycles
(Table 1). This is consistent with prior cyclic loading
anchor studies.7,10 The anchor with the largest 100-
cycle and 500-cycle displacement (Lupine Loop BR)
also had 1 failure during cyclic loading, showed the
lowest stiffness, and was 1 of the smallest anchors. It
was the only anchor in this group not specifically
indicated for use in the acetabulum, and its perfor-
mance in the acetabular environment was clearly dif-
ferent from the rest. The BioRaptor 2.9 AB is a
designated acetabular suture anchor, and it alone
showed an increase in cyclic displacement between
the 100-cycle mark and 500-cycle mark, more than
doubling its displacement during that interval. The
BioRaptor 2.9 AB and Lupine Loop BR displace-
ments were significantly greater than those shown by
the PEEK PushLock and Bio-SutureTak (P ⬍ .001).
Variations in stiffness were also observed (Table 1).
The Lupine Loop BR anchor showed significantly less
stiffness than all other anchors (P ⬍ .001). The Bio-
Mini Revo anchor stiffness was significantly less than
that of the PEEK PushLock, Bio-SutureTak, PEEK
SutureTak, and BioRaptor 2.9 AB (P ⬍ .001). Nev-
ertheless, it is important to mention that we found no
significant correlation between the suture anchors’
stiffness and their cyclic load displacement or load-
to-failure strength. These data suggest that the design
of the suture anchor may be more important than its
stiffness.
The ultimate loads to failure of many suture anchors
have been reported. The mean ultimate load to failure
for the anchors tested in this study ranged from 154 N
(PEEK SutureTak) to 255 N (Bio-Mini Revo). How-
767
ever, these failure loads were not statistically differ-
ent.
All anchors tested were threaded with high-strength
sutures composed either in part or entirely of UHM-
WPE. The cyclic loads were applied directly to these
sutures, and no case of suture breakage was observed.
The mode of failure for these anchors was close to
evenly divided between anchor pullout from the bone
and anchor eyelet failure. An exception to this was the
PEEK PushLock, which failed exclusively by the su-
ture slipping past the anchor and leaving the anchor
body behind in the bone. Sutures containing UHM-
WPE have been shown to slip more readily than
conventional braided polyester.12,13 Although the ul-
timate suture strength is significantly greater than that
of braided polyester, how the UHMWPE-containing
suture is secured (knot type or anchor type) may
influence the most appropriate method of use.
Hip arthroscopy is a surgical procedure that is increas-
ingly performed worldwide.9,14-20 Labral injuries are one
of the most prevalent lesions found during this proce-
dure.21 Although there is no definite consensus on
whether to repair this type of injury or not, it is
imperative that the surgeon have a firm understanding
of the characteristics of the implants used for acetab-
ular labral fixation and recognize that the differences
between acetabular and glenoid bone make anchor
performance different. Biomechanical testing of su-
ture anchors designated for hip arthroscopy should be
performed in the acetabular rim before their use. Su-
ture anchors used for shoulder arthroscopy may not
perform as well in the hip.
Strengths of this study include the use of paired
human acetabular specimens, the number of tests per-
formed, the distribution of the anchors among differ-
ent testing sites in each of 2 acetabula from the same
individual, and the cyclic loading protocol. These
specimens were fresh-frozen acetabula with intact la-
brums. There is little published information about the
biomechanical properties of suture anchors indicated
for use in the hip. This study provides information that
should be considered when designing rehabilitation
protocols used after an acetabular labrum hip repair.
The limitations of this study include the fact that it
is an in vitro study and was performed at room tem-
perature in a dry (non-arthroscopic) environment.
Variations in acetabular bone density within a single
specimen do exist, as do variations between speci-
mens. In addition, a load to failure in line with the
angle of anchor insertion may not replicate in vivo
anchor loading. This test does not have direct appli-
cation to the clinical setting for several reasons. The
768 M. RUIZ-SUAREZ ET AL.
cadaveric specimens had ages between 53 and 65
years, which are greater than what would be expected
clinically for labral repairs. On the other hand, bone
density may not be significantly different from a
younger population because the acetabular rim is pre-
dominantly cortical bone. An appropriate postopera-
tive rehabilitation program might not stress a capsu-
lolabral repair consistent with the methods of this
study.
CONCLUSIONS
Anchors with specific indications for hip arthroscopy
(PEEK PushLock, PEEK SutureTak, Bio-SutureTak,
Bio-Mini Revo, and BioRaptor 2.9 AB) showed very
little displacement and had consistent failure loads
under cyclic conditions in the acetabular rim. All hip
anchors except the BioRaptor 2.9 AB showed less
than 2.0 mm of displacement after 500 cycles.
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