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Editorial Commentary: Innovations in Anchor Design—Are Patients Really Benefiting?

      Abstract

      Vented open-architecture suture anchors provide theoretical benefits over traditional screw-in solid anchors to include improved osseous ingrowth, elution of marrow elements to enhance biology at the repair site, and easier revision because of reduced anchor material. However, there is no evidence that open-architecture anchors result in improvements in patient-reported outcomes or early cytokine and marrow element release into the subacromial space compared with traditional screw-in solid anchors. Although innovation and evaluation of new technologies are paramount to surgical progress, decisions on implant use should be based on factors including cost, impact on revision, and surgeon familiarity because frequently, clinical differences based on patient-reported outcomes are not appreciated between anchor types or designs.
      Suture anchor design, technology, and materials are constantly being innovated in a quest for improved soft tissue–to–bone repair, biological integration, and ultimately, patient-reported outcomes.
      • Barber F.A.
      • Herbert M.A.
      Cyclic loading biomechanical analysis of the pullout strengths of rotator cuff and glenoid anchors: 2013 Update.
      • Barber F.A.
      • Herbert M.A.
      All-suture anchors: Biomechanical analysis of pullout strength, displacement, and failure mode.
      • Barber F.A.
      Biodegradable materials: Anchors and interference screws.
      Rotator cuff repairs fail for a variety of reasons, including biology, infection, mechanical strength, and rehabilitation challenges.
      • Ma B.C.
      Editorial Commentary: Success of rotator cuff healing—Do we need to improve on the strength anymore?.
      • Benson E.C.
      • MacDermid J.C.
      • Drosdowech D.S.
      • Athwal G.S.
      The incidence of early metallic suture anchor pullout after arthroscopic rotator cuff repair.
      • Lubowitz J.L.
      • Poehling G.
      Rotator cuff repair: Obviously.
      • Dhawan A.
      Editorial Commentary: Will new technology improve outcomes or are all-suture rotator cuff surgery anchors like a new set of golf clubs? Not a question for the biomechanics lab.
      These factors are often interrelated because mechanical failure can occur over time with fatigue and attrition of the implant owing to failure of biological healing, overaggressive rehabilitation may lead to mechanical failure and/or biological failure, and so on. The implants and suture materials used in arthroscopic rotator cuff repair are selected by surgeons in an attempt to try to shift the equation in favor of biological healing success and better patient outcomes. A number of different anchor designs and materials can be used in arthroscopic rotator cuff repair, including traditional screw-in suture anchors, knotless anchors, and vented anchors, all made from different materials, including metal alloy as well as bioabsorbable and nonabsorbable polymers and composites.
      • Barber F.A.
      • Herbert M.A.
      Cyclic loading biomechanical analysis of the pullout strengths of rotator cuff and glenoid anchors: 2013 Update.
      • Barber F.A.
      • Herbert M.A.
      All-suture anchors: Biomechanical analysis of pullout strength, displacement, and failure mode.
      • Barber F.A.
      Biodegradable materials: Anchors and interference screws.
      ,
      • Dhawan A.
      Editorial Commentary: Will new technology improve outcomes or are all-suture rotator cuff surgery anchors like a new set of golf clubs? Not a question for the biomechanics lab.
      Vented “open-architecture” suture anchors are now offered by a variety of different manufacturers and theoretically allow for improved osseous ingrowth into the anchor itself, as well as the elution of marrow elements from within the anchor directly to the soft tissue–to–bone repair site. Because the biological enhancement of rotator cuff repairs is an area of significant interest and a variety of techniques have been used to achieve this, the use of the implants for repair themselves as biological agents is a novel concept and would be potentially of great benefit to the repair and patient.
      • Jeong J.Y.
      • Chung P.K.
      • Yoo J.C.
      Effect of sodium hyaluronate/carboxymethyl cellulose (Guardix-sol) on retear rate and postoperative stiffness in arthroscopic rotator cuff repair patients: A prospective cohort study.
      • Rodeo S.A.
      • Delos D.
      • Williams R.J.
      • Adler R.S.
      • Pearle A.
      • Warren R.F.
      The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: A prospective, randomized clinical study.
      • Hernigou P.
      • Flouzat Lachaniette C.H.
      • Delambre J.
      • et al.
      Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: A case-controlled study.
      • Ebert J.R.
      • Wang A.
      • Smith A.
      • et al.
      A midterm evaluation of postoperative platelet-rich plasma injections on arthroscopic supraspinatus repair: A randomized controlled trial.
      • Charles M.D.
      • Christian D.R.
      • Cole B.J.
      The role of biologic therapy in rotator cuff tears and repairs.
      • Morikawa D.
      • Johnson J.D.
      • Kia C.
      • et al.
      Examining the potency of subacromial bursal cells as a potential augmentation for rotator cuff healing: An in vitro study.
      • Mazzocca A.D.
      • McCarthy M.B.
      • Chowaniec D.
      • et al.
      Bone marrow-derived mesenchymal stem cells obtained during arthroscopic rotator cuff repair surgery show potential for tendon cell differentiation after treatment with insulin.
      In this issue, Chahla, Liu, Manderle, Beletsky, Cabarcas, Gowd, Inoue, Chubinskaya, Treinhaile, Forsythe, Cole, and Verma
      • Chahla J.
      • Liu J.N.
      • Manderle B.
      • et al.
      Bony ingrowth of coil-type open architecture anchors compared with screw-type PEEK anchors for the medial row in rotator cuff repair: A randomized control trial.
      explore the biological and clinical benefits of using vented open-architecture suture anchors in rotator cuff repair in their study “Bony Ingrowth of Coil-Type Open Architecture Anchors Compared With Screw-Type PEEK Anchors for the Medial Row in Rotator Cuff Repair: A Randomized Control Trial.” They found that despite the theoretical benefits of the open-architecture suture anchor design, validated clinical outcomes up to 1 year after surgery were no different between patients randomized to the open-architecture anchor and those randomized to a traditional screw-in solid anchor. It is interesting to note that at the time of surgery, marrow elements and cytokine markers aspirated from the subacromial space were also no different between patients randomized to the open-architecture anchor and those randomized to the traditional screw-type solid anchor. Chahla et al. did find that the open-architecture anchors resulted in better bony ingrowth surrounding the anchor and a larger total bone mineral mass. Similar findings of equivalent patient-reported outcomes between patients undergoing rotator cuff repair with solid screw-type anchors and those receiving open-architecture anchors were recently reported by Kim et al.
      • Kim J.H.
      • Kim Y.S.
      • Park I.
      • et al.
      A comparison of open-construct PEEK suture anchor and non-vented biocomposite suture anchor in arthroscopic rotator cuff repair: A prospective randomized clinical trial.
      They also found no difference in rotator cuff retear rates at 12 months between groups when rotator cuff repairs were evaluated postoperatively with magnetic resonance imaging or ultrasound.
      These results are not all that surprising, and similarly, no significant clinical differences have been seen when comparing other differences in anchor design and material including comparisons of knotless versus standard anchors and bioabsorbable versus nonabsorbable anchors,
      • Cho N.S.
      • Lubis A.M.T.
      • Ha J.H.
      • Rhee Y.G.
      Clinical results of arthroscopic Bankart repair with knot-tying and knotless suture anchors.
      • Tan C.K.
      • Guisasola I.
      • Machani B.
      • et al.
      Arthroscopic stabilization of the shoulder: A prospective randomized study of absorbable versus nonabsorbable suture anchors.
      • Brown L.
      • Rothermel S.
      • Joshi R.
      • Dhawan A.
      Recurrent instability after arthroscopic Bankart reconstruction: A systematic review of surgical technical factors.
      despite studies showing differences in time-zero biomechanical properties.
      • Nho S.J.
      • Frank R.M.
      • Van Thiel G.S.
      • et al.
      A biomechanical analysis of anterior Bankart repair using suture anchors.
      This mismatch between the biomechanical and clinical data reminds us of the many factors at play when soft tissue is repaired to bone and the complex integrative process that occurs that dominates small changes in time-zero biomechanics or theoretical biological changes seen in vitro or in animal models. In the end and as I have commented before, perhaps the most valuable information that we often glean from studies such as that by Chahla et al.
      • Chahla J.
      • Liu J.N.
      • Manderle B.
      • et al.
      Bony ingrowth of coil-type open architecture anchors compared with screw-type PEEK anchors for the medial row in rotator cuff repair: A randomized control trial.
      is that if the outcomes are similar between implant types, decisions on implant use can and should be based on factors including cost, impact on revision, and surgeon familiarity.
      • Dhawan A.
      Editorial Commentary: Will new technology improve outcomes or are all-suture rotator cuff surgery anchors like a new set of golf clubs? Not a question for the biomechanics lab.
      Although innovation and evaluation of new technologies are paramount to progress, our time as surgeons is often better spent on improving technique and rotator cuff repair fundamentals including mobilization and tension-free repair versus just looking for a new technology or implant design, which—at least to date—has rarely made much difference in patient-reported outcomes.

      Supplementary Data

      References

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