Pull-out Strength of Three Anchors for Rotator Cuff Repair in Standardized Physiological and Osteoporotic Bone
ESSKA Academy. Rosso C. 05/09/18; 209931; P22-1664
Assoc. Prof. Claudio Rosso
Assoc. Prof. Claudio Rosso
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Objectives: Previous studies only tested the anchor constructs with a single-pull destructive test in line with the anchor. Furthermore, there is a great variability of cadaver bone mineral density. To address and overcome these relevant limitations, we provided a more physiologic setting.
We hypothesized that the TwinFix® (Smith&Nephew) Iconix® (Stryker) and Healix® (DePuySynthes Mitek) anchors would show comparable failure properties in physiologic bone but the Iconix anchor would fail earlier in osteoporotic bone.

Methods: Artificial bone specimen were used for biomechanical testing to overcome bias due to different bone densities (AO, Arbeitsgemeinschaft Osteosynthese- Project MT_2004_EXT-01). A particular advantage of these specimen is the homogenous bone density, which reduces the inter-donor variability.
Using custom-built steel clamps, the anchors were placed in 45° slope as used in clinical practice when inserted into the humeral head. Testing was performed using a servohydraulic universal testing machine (type LFV-5-PA ECD 120 hydropulser testing device; 65 kN static and 64 kN dynamic test load cell) and DionPro software version 4.43 (both from walter1bai ag Testing Machines) at a sample rate of 50 Hz. Load-to-failure (LTF) testing was performed at 12.5 mm/s until the construct failed. The load at failure and the mode of failure was noted.

Sixty specimen were tested, 30 for the "physiological" and 30 for the "osteoporotic" group with 10 bone-anchor constructs in each group. We chose three different anchor techniques: Titantium (TwinFix Ti 4.5mm), bioresorbable (Healix BR 4.5mm) and an all-suture anchor (Iconix 2,3mm) in order to account for different fixation methods.

Results: In the physiological group, the highest LTF was found for the Iconix (632.9±96.8N, range 449.4-750.6N] and it was significantly higher than for the other two anchors (TwinFix 497.1±50.5N, 430.0-575.0N and Healix 322.4±31.4N, 316.7-328.0N, p<0.0001). The TwinFix anchor showed a higher LTF than the Healix anchor (p<0.0001).
The most common mode of failure was suture failure at the eyelet for the TwinFix and suture rip-out of the anchor for the Healix anchor while suture breakage was found to be the most common mode of failure for the Iconix anchor.

In the osteoporotic group, the Iconix again showed a higher LTF compared to the Healix anchor (500.9±50.6N, 420.9-562.9N vs. 315.1±11.3N, 290.4-333.9N, p<0.0001] but was not significantly higher compared to the TwinFix anchor [467.4±39.4N, 433.7-561.5N, p=0.17].
The mode of failure was identical in this group compared to the physiological group for the Healix and TwinFix anchor. The Iconix anchor most commonly anchor pulled out of the bone.

Conclusions: Interestingly, the Iconix anchor, although being an all-suture anchor, outperformed the other two anchors in the physiological group. It was also the strongest anchor in osteoporotic bone but only compared to the Healix significance was reached. Currently, all-suture anchors are not yet indicated in osteoporotic bone.

rotator cuff; biomechanical testing; LTF; load to failure; all-suture anchor; healix; iconix; TwinFix; bioresorbable; titanium; bone mineral density; standardtized
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