- Email: [email protected]
Suture Anchor Pullout
Letters to the Editor Suture Anchor Pullout
To the Editor: I congratulate Benson et al.1 on their documentation of the early rates of metallic anchor pullout after arthroscopic cuff repair. They recommend “routine radiographic follow-up after use of metallic anchors to ensure identification of early failure by anchor pullout.” Anchor pullout is not limited to metal anchors. The difference between plastic, resorbable, or nonresorbable anchors and metallic anchors is simply that we can see the metallic anchors on radiographs. The risk of complications with hard plastic anchors, even if they are resorbable, should be just as much of a concern to us. Before significant resorption has occurred, even resorbable anchors are hard enough to cause significant complications around the shoulder. Orthopaedists should muster support for the incorporation of radiographic markers within plastic suture anchors so that routine assessment of these anchors can be performed in a traditional, simple, and inexpensive way. The incorporation of radiographic markers in polyethylene glenoid components, cement restrictors, and so on has proven to be valuable and clinically
worthwhile. I have no doubt that numerous patients who otherwise might have gone undiagnosed would be able to be readily diagnosed as having suture anchor dislodgement or malpositioning if such radiographic markers were incorporated into plastic anchors. I think it is time that we take this initiative and require this of the companies that are developing and producing these devices. It may be inconvenient and it may add some cost, but in the long run, it will contribute to patient safety and improved diagnosis and detection of complications. Shawn O’Driscoll, M.D., Ph.D. Rochester, Minnesota
Reference 1. Benson EC, MacDermid JC, Drosdowech DS, Athwal GS. The incidence of early metallic suture anchor pullout after arthroscopic rotator cuff repair. Arthroscopy 2010;26:310-315.
© 2010 by the Arthroscopy Association of North America
doi:10.1016/j.arthro.2010.05.002
Author’s Reply We appreciate Dr. O’Driscoll’s letter and comments regarding our article.1 He highlights a valid point that with the use of nonmetallic anchors that cannot be visualized on plain radiographs, the problem of suture anchor pullout may go unrecognized. This may affect our ability to accurately diagnose and treat patients with persistent pain after rotator cuff repair. As a result, we may miss opportunities to identify ways to improve patient outcomes. The suggestion to work with industry and encourage them to place radiopaque markers in nonmetallic anchors is an excellent one that we would strongly support. Until that becomes standard, however, we believe there are several advantages to using metallic anchors. Being able to recognize anchor failure by pullout or migration using plain radiographs is only one advantage. Another advantage is visual confirmation of accurate anchor placement and insertion angle that can be used for surgeon education and technical improvement. Metallic anchors also allow quantification of the number of anchors used previously in the setting of revision surgery. Dr. O’Driscoll appropriately points out the clinical benefit of radiographic markers in other nonmetallic implants, and we believe suture anchors are no different.
872
In addition, we know the value of other types of implants and radiographic parameters that help predict outcomes, such as the tip-apex distance with sliding hip screws. This is well documented as a technical parameter measured radiographically to decrease cutout rates with these devices.2,3 Surgeon education about these parameters has also shown to be effective in the adoption of these principles and, hopefully, decreasing failure rates.4 If all anchors, metallic and nonmetallic alike, are visible on radiographs, it may give us the opportunity to study anchor failure further, possibly developing radiographic criteria correlated to failure, thereby helping us to improve patient outcomes. We thank Dr. O’Driscoll for his comments and believe that he has identified an important discussion relevant to our study. Eric C. Benson, M.D. Joy C. MacDermid, B.Sc.P.T., M.Sc., Ph.D. Darren S. Drosdowech, M.D., F.R.C.S.C. George S. Athwal, M.D., F.R.C.S.C. London, Ontario, Canada
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 7 (July), 2010: pp 872-876
To the Editor: I congratulate Benson et al.1 on their documentation of the early rates of metallic anchor pullout after arthroscopic cuff repair. They recommend “routine radiographic follow-up after use of metallic anchors to ensure identification of early failure by anchor pullout.” Anchor pullout is not limited to metal anchors. The difference between plastic, resorbable, or nonresorbable anchors and metallic anchors is simply that we can see the metallic anchors on radiographs. The risk of complications with hard plastic anchors, even if they are resorbable, should be just as much of a concern to us. Before significant resorption has occurred, even resorbable anchors are hard enough to cause significant complications around the shoulder. Orthopaedists should muster support for the incorporation of radiographic markers within plastic suture anchors so that routine assessment of these anchors can be performed in a traditional, simple, and inexpensive way. The incorporation of radiographic markers in polyethylene glenoid components, cement restrictors, and so on has proven to be valuable and clinically
worthwhile. I have no doubt that numerous patients who otherwise might have gone undiagnosed would be able to be readily diagnosed as having suture anchor dislodgement or malpositioning if such radiographic markers were incorporated into plastic anchors. I think it is time that we take this initiative and require this of the companies that are developing and producing these devices. It may be inconvenient and it may add some cost, but in the long run, it will contribute to patient safety and improved diagnosis and detection of complications. Shawn O’Driscoll, M.D., Ph.D. Rochester, Minnesota
Reference 1. Benson EC, MacDermid JC, Drosdowech DS, Athwal GS. The incidence of early metallic suture anchor pullout after arthroscopic rotator cuff repair. Arthroscopy 2010;26:310-315.
© 2010 by the Arthroscopy Association of North America
doi:10.1016/j.arthro.2010.05.002
Author’s Reply We appreciate Dr. O’Driscoll’s letter and comments regarding our article.1 He highlights a valid point that with the use of nonmetallic anchors that cannot be visualized on plain radiographs, the problem of suture anchor pullout may go unrecognized. This may affect our ability to accurately diagnose and treat patients with persistent pain after rotator cuff repair. As a result, we may miss opportunities to identify ways to improve patient outcomes. The suggestion to work with industry and encourage them to place radiopaque markers in nonmetallic anchors is an excellent one that we would strongly support. Until that becomes standard, however, we believe there are several advantages to using metallic anchors. Being able to recognize anchor failure by pullout or migration using plain radiographs is only one advantage. Another advantage is visual confirmation of accurate anchor placement and insertion angle that can be used for surgeon education and technical improvement. Metallic anchors also allow quantification of the number of anchors used previously in the setting of revision surgery. Dr. O’Driscoll appropriately points out the clinical benefit of radiographic markers in other nonmetallic implants, and we believe suture anchors are no different.
872
In addition, we know the value of other types of implants and radiographic parameters that help predict outcomes, such as the tip-apex distance with sliding hip screws. This is well documented as a technical parameter measured radiographically to decrease cutout rates with these devices.2,3 Surgeon education about these parameters has also shown to be effective in the adoption of these principles and, hopefully, decreasing failure rates.4 If all anchors, metallic and nonmetallic alike, are visible on radiographs, it may give us the opportunity to study anchor failure further, possibly developing radiographic criteria correlated to failure, thereby helping us to improve patient outcomes. We thank Dr. O’Driscoll for his comments and believe that he has identified an important discussion relevant to our study. Eric C. Benson, M.D. Joy C. MacDermid, B.Sc.P.T., M.Sc., Ph.D. Darren S. Drosdowech, M.D., F.R.C.S.C. George S. Athwal, M.D., F.R.C.S.C. London, Ontario, Canada
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 7 (July), 2010: pp 872-876