Concise Review

The Use of Anchors in Shoulder Surgery: A Shift From Metallic

to Bioabsorbable Anchors

Mehmet Ozbaydar, M.D., Bassem Elhassan, M.D., and Jon J. P. Warner, M.D.

Abstract: With major advances in arthroscopy, suture anchors became the primary devices used to
assist in fixing soft tissues to bone. Metallic anchors were first produced and used in soft tissue
fixation around the shoulder. However, their use resulted in some reported complications, including
articular surface damage from migrating implants and distortion and artifact production in postop-
erative magnetic resonance imaging. Bioabsorbable anchors were developed to avoid these problems.
Their newer versions were proven to have pulling-out strength equal to that of metallic anchors, with
a reported lower complication rate. This had led to a major shift away from metallic anchors toward
bioabsorbable anchors. Key Words: Anchor—Arthroscopy—Bioabsorbable.

T he techniques and methods used to repair tendons

and ligaments to bone have evolved and signifi-
cantly improved over the past several years, which par-
alleled the general increase in expertise in arthroscopic
surgical techniques.1 Suture anchors were probably one
of the most commonly used tools to assist in different
types of labral, tendon, and ligament repairs around the
wrist and elbow in general, and the shoulder in particu-
lar.2 Thus, there was a major shift in the surgical tech-
niques from open repairs of the rotator cuff and labrum
using transosseous sutures, screws and washers, and sta-
ples, to arthroscopic repair using anchors.
A variety of different types of anchors were pro-
duced, and their designs have evolved over the past
decade in order to maximize their effectiveness in
From the Division of Shoulder Surgery, Department of Ortho-
pedic Surgery, Harvard Medical School, Massachusetts General
Hospital, Boston, MA, U.S.A.
The authors report no conflicts of interest.
Address correspondence and reprint requests to Bassem Elhas-
san, M.D., Shoulder Fellow, Harvard Medical School, Massachu-
setts General Hospital, Department of Orthopedic Surgery, Divi-
sion of Shoulder Surgery, 55 Fruit St., Boston, MA 02114. E-mail:
belhassan@partners.org
© 2007 by the Arthroscopy Association of North America
0749-8063/07/2310-7227$32.00/0
doi:10.1016/j.arthro.2007.05.011
creating a secure tendon-to-bone repair.3 This im-
provement has been proven in cadaveric studies,
which demonstrated that the initial pullout strength of
certain types of suture anchors were similar to those of
transosseous tunnel fixation.4
The first suture anchor designs were metallic, non-
absorbable sutures. Despite the good initial reports
using these kinds of anchors, later investigations re-
ported multiple complications, especially around the
shoulder.5 These complications include loosening, mi-
gration, incarceration of the metal implant within the
joint, difficulty with revision surgery, chondral dam-
age, and interference with imaging studies, such as
magnetic resonance imaging (MRI).6,7
Because of the reported complications of the metal
anchors, bioabsorbable tissue fixation devices have
been produced as an alternative, and lately have been
used much more frequently than metal anchors.8 One
of the main advantages of absorbable suture anchors is
their absorption over time, theoretically minimizing or
avoiding the problems of migration or interference
with revision surgery.9 They are also generally radi-
olucent, minimizing the interference with imaging
studies.7 In addition, their effectiveness in creating a
secure tendon-to-bone repair has been comparable to
metallic suture anchors.10

1124 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 10 (October), 2007: pp 1124-1126
 USE OF ANCHORS IN SHOULDER SURGERY
Designs and Biology of Suture Anchors
Healing of tendon to bone requires a device (like an
anchor) that allows the tendon to stay strongly fixed to
the bone during the time of the healing process (usu-
ally 12 weeks).11,12 If this fixation device is not secure
or does not maintain its strength until the tendon is
completely healed to the bone, then healing may not
occur, and the repair will ultimately fail. Therefore, an
ideal suture anchor is one that has the above men-
tioned characteristics and, in addition, its design,
whether absorbable or not, should be compatible with
soft tissues and bone, so that its use will result in the
fewest amount of both short- and long-term compli-
cations.
Different types of bioabsorbable suture anchors
have been manufactured.13,14 The earlier absorbable
implants were made of large amounts of pure polyg-
lycolic acid (PGA) polymers, and were used in frac-
ture fixation.15 These implants were shown to have the
potential to degrade rapidly, leading to hydrolysis of
the polymer, which resulted in lytic bone changes and
draining skin sinuses. The Bio-Suture Tak anchor
(Sure Tak; Smith & Nephew Endoscopy, Andover,
MA) came later; it was one of the first bioabsorbable
anchors. It was composed of PGA and trimethylene
carbonate copolymer, which led to rapid loss of
strength in the first 3 to 4 weeks after implantation and
resulted in loose bodies and synovitis.16,17 Later still,
anchors were manufactured using poly-L-Lactic acid
(PLLA), which has been shown to dissolve very
slowly and may remain in place for up to 5 years.18
The slow degradation of PLLA could cause failure to
absorb after arthroscopic surgery.19
In order to increase the amorphous nature of the
PLLA, copolymers of lactide and PGA were added to
copolymers of the levo- and dextro-stereoisomers of
lactic acid, thus reducing their degradation time.19-21
The TissueTak implant (Arthrex; Naples, FL) is an
example of a combination of the two forms of PLLA
(the crystalline I-PLA and the amorphous d-PLA),
called PLDLA. Athanasiou et al.21 highlighted the fact
that differences in the molecular arrangement between
PLLA and PLDLA affect the biomechanical response
of the body and the degradation characteristics of the
implant.
Mode of Failure of Suture Anchors
Most anchors, both metallic and bioabsorbable, are
preloaded with 1 or 2 high-strength nonabsorbable
sutures.22 These sutures pass through eyelets in the
anchors that could be metallic as part of a metallic
1125
anchor, made of nonabsorbable suture, contained
within a bioabsorbable anchor, or absorbable as an
integral part of a bioabsorbable anchor.23 As a result,
the failure of a suture anchor can occur at the bone
anchor level, the eyelet level, the suture level, or the
anchor itself if it were deficient or rapidly degradable
(in absorbable anchors). In addition, even if all mea-
sures were taken to perfect the manufacturing of an
anchor, failure may still occur if the execution of the
surgical technique was inadequate or deficient.
The weakest link in tendon repair using suture an-
chors was found to be the pullout of the suture from
the tissue.24-27 It is a challenge to find the most ap-
propriate suture that will be strong enough to be able
to withstand the pulling forces of the muscles of the torn
tendons, but compatible and gentle enough on tissues so
that it will not cut through them. In addition, the older
sutures in metallic anchors used to be weaker and break
more easily.13 Passage of these sutures through sharp
metallic eyelets makes them more prone to abrasion
and rupture, especially if the angle of the suture within
the anchor is not directly in line with the eyelet.25
Newer sutures are much stronger and more compatible
with soft tissue.
Anchor eyelet breaking or anchor pullout are more
common mechanisms of failure with bioabsorbable
anchors.28,29 Barber30 reported on 2 cases of failed
suture anchors. In 1 case, the suture forming the eyelet
of the anchor became loose in the joint. This method
of failure was attributed to the rapidly degrading anchor
copolymer. In the second case, a portion of the eyelet and
upper screw thread, composed of a biodegradable copol-
ymer, became a loose body in the shoulder joint. He
related the second case to the eyelet becoming proud
with regard to the host bone during cyclic loading, which
led to anchor failure during its absorption.
Failure at the bone–anchor interface is mostly
related to the design of the anchor and the density of
the bone.16,31 Tingart et al.32 found that the anterior
and proximal tuberosity of the humerus had denser
bone than did the posterior and distal tuberosity.
The design of the anchor includes the screw-in
anchors and biodegradable hook-type anchors. If
the method of insertion is correct and the bone is
strong with normal bone density, then there is no
statistical difference in the pullout strength between
these 2 types of anchors.32 However, if the bone is
weak with lower density, then the screw-in anchors
produce a strong construct with statistically higher
pullout strength than the hook-type anchors.
1126 M. OZBAYDAR ET AL.
CONCLUSIONS
Over the past several years, there has been a major
shift in the types of anchors used (from metallic to
bioabsorbable). This has been attributed to the higher
number of complications reported earlier with the use
of metallic anchors, and the lower complication rate
using the newer bioabsorbable anchors. To avoid their
failure, the bioabsorbable anchors should be sunk be-
low the level of the cortex of the bone to cover the
eyelet of the anchor completely. In addition, excessive
recycling, by allowing early active range of motion,
should be avoided in order to allow bone to grow over
the anchor and cover the suture. This helps avoid
repetitive loading of the eyelet, which may lead to
eyelet failure.
REFERENCES
1. Abrams JS. Arthroscopic approach to massive rotator cuff
tears. Instr Course Lect 2006;55:59-66.
2. McFarland EG, Park HB, Keyurapan E, Gill HS, Selhi HS.
Suture anchors and tacks for shoulder surgery, part 1: biology
and biomechanics. Am J Sports Med 2005;33:1918-1923.
3. Mueller MB, Fredrich HH, Steinhauser E, Schreiber U, Arians
A, Imhoff AB. Biomechanical evaluation of different suture
anchors for the stabilization of anterior labrum lesions. Arthro-
scopy 2005;21:611-619.
4. Hecker AT, Shea M, Hayhurst JO, Myers ER, Meeks LW,
Hayes WC. Pull-out strength of suture anchors for rotator cuff
and Bankart lesion repairs. Am J Sports Med 1993;21:874-879.
5. Kaar TK, Schenck RC, Wirth MA, Rockwood CA. Compli-
cations of metallic suture anchors in shoulder surgery: A report
of 8 cases. Arthroscopy 2001;17:31-37.
6. Silver MD, Daigneault JP. Symptomatic interarticular migra-
tion of glenoid suture anchors. Arthroscopy 2000;16:102-105.
7. Gaenslen ES, Satterlee CC, Hinson GW. Magnetic resonance
imaging for evaluation of failed repairs of the rotator cuff.
J Bone Joint Surg Am 1996;78:1391-1396.
8. Marquardt B, Witt KA, Gotze C, Liem D, Steinbeck J, Potzl
W. Long-term results of arthroscopic Bankart repair with a
bioabsorbable tack. Am J Sports Med 2006;34:1906-1910.
9. Barber FA, Snyder SJ, Abrams JS, Fanelli GC, Savoie 3rd FH.
Arthroscopic Bankart reconstruction with a bioabsorbable an-
chor. J Shoulder Elbow Surg 2003;12:535-538.
10. Tan CK, Guisasola I, Machani B, Kemp G, Sinopidis C,
Brownson P, et al. Arthroscopic stabilization of the shoulder:
A prospective randomized study of absorbable versus nonab-
sorbable suture anchors. Arthroscopy 2006;22:716-720.
11. Tuoheti Y, Itoi E, Yamamoto N, Seki N, Abe H, Minagawa H,
et al. Contact area, contact pressure, and pressure patterns of
the tendon-bone interface after rotator cuff repair. Am J Sports
Med 2005;33:1869-1874.
12. Burkhart SS, Lo IK. Arthroscopic rotator cuff repair. J Am
Acad Orthop Surg 2006;14:333-346.
13. van Oostveen DP, Schild FJ, van Haeff MJ, Saris DB. Suture
anchors are superior to transglenoid sutures in arthroscopic
shoulder stabilization. Arthroscopy 2006;22:1290-1297.
14. Burkhart SS, Brady PC. Arthroscopic subscapularis repair:
Surgical tips and pearls A to Z. Arthroscopy 2006;22:1014-
1027.
15. Bostman OM. Osteolytic changes accompanying degradation
of absorbable fracture fixation implants. J Bone Joint Surg Br
1991;73:679-682.
16. Speer KP, Warren RF, Pagnani M, Warner JJ. An arthroscopic
technique for anterior stabilization of the shoulder with a
bioabsorbable tack. J Bone Joint Surg Am 1996;78:1801-1807.
17. Edwards DJ, Hoy G, Saies AD, Hayes MG. Adverse reactions
to an absorbable shoulder fixation device. J Shoulder Elbow
Surg 1994;3:230-233.
18. Barber FA. Biology and clinical experience of absorbable
materials in ACL fixation. Tech Orthop 1999;14:34-42.
19. Ticker JB, Lippe RJ, Barkin DE, Carroll MP. Infected suture
anchors in the shoulder. Arthroscopy 1996;12:613-615.
20. Middleton JC, Tipton AJ. Synthetic biodegradable polymers as
orthopedic devices. Biomaterials 2000;21:2335-2346.
21. Athanasiou KA, Agrawal CM, Barber FA, Burkhart SS. Or-
thopaedic applications for PLA-PGA biodegradable polymers.
Arthroscopy 1998;14:726-737.
22. Barber FA, Herbert MA, Coons DA, Boothby MH. Sutures
and suture anchors—Update 2006. Arthroscopy 2006;22:1063-
1069.
23. Wust DM, Meyer DC, Favre P, Gerber C. Mechanical and
handling properties of braided polyblend polyethylene sutures
in comparison to braided polyester and monofilament poly-
dioxanone sutures. Arthroscopy 2006;22:1146-1153.
24. Antonogiannakis E, Yiannakopoulos CK, Karabalis C, Hiotis
I. Intraoperative arthroscopic suture anchor reloading. Arthro-
scopy 2005;21:898.
25. Tao SS, Kaltenbach J. Arthroscopic placement of a modified
Mason-Allen stitch. Arthroscopy 2006;22:1248.
26. Coons DA, Barber FA, Herbert MA. Triple-loaded single-anchor
stitch configurations: An analysis of cyclically loaded suture-
tendon interface security. Arthroscopy 2006;22:1154-1158.
27. Cummins CA, Appleyard RC, Strickland S, Haen PS, Chen S,
Murrell GA. Rotator cuff repair: An ex vivo analysis of suture
anchor repair techniques on initial load to failure. Arthroscopy
2005;21:1236-1241.
28. Nawab A, Kocabey Y, Caborn D, Nyland J. Salvage rotator
cuff repair using a biotenodesis screw. Arthroscopy 2005;21:
122-124.
29. Sassmannshausen G, Sukay M, Mair SD. Broken or dislodged
poly-L-lactic acid bioabsorbable tacks in patients after SLAP
lesion surgery. Arthroscopy 2006;22:615-619.
30. Barber FA. Biodegradable shoulder anchors have unique
modes of failure. Arthroscopy 2007;23:316-320.
31. Meyer DC, Nyffeler RW, Fucentese SF, Gerber C. Failure of
suture material at suture anchor eyelets. Arthroscopy 2002;18:
1013-1019.
32. Tingart MJ, Apreleva M, Zurakowski D, Warner JJ. Pullout
strength of suture anchors used in rotator cuff repair. J Bone
Joint Surg Am 2003;85-A:2190-2198.