The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 6

Scientific Articles | June 01, 2004

Biomechanical Evaluation of Arthroscopic Rotator Cuff Stitches

C. Benjamin Ma, MD¹; John D. MacGillivray, MD²; Jonathan Clabeaux, MD²; Samuel Lee, MSc²; James C. Otis, PhD²

¹ Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU320W, San Francisco, CA 94143. E-mail address: maben@orthosurg.ucsf.edu
² The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at The Hospital for Special Surgery, New York, NY

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 Jun 01;86(6):1211-1216

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Abstract

Background: The suture configurations in arthroscopic rotator cuff repairs have been limited to simple and horizontal stitches. Recent objective evaluations have demonstrated high failure rates of arthroscopic repairs of rotator cuff tears. A novel stitch for arthroscopic repair of the rotator cuff, the massive cuff stitch, was developed to increase the strength of the suture-tendon interface. The goal of this study was to determine the biomechanical properties of the massive cuff stitch and to compare it with other stitches commonly used for rotator cuff repair.

Methods: Eight pairs of sheep infraspinatus tendons were harvested and split in half to yield a set of four tendon specimens from each animal. Four stitch configurations (simple, horizontal, massive cuff, and modified Mason-Allen) were randomized and biomechanically tested in each set of tendon specimens. Each specimen was first cyclically loaded on an MTS uniaxial load frame under force control from 5 to 30 N at 0.25 Hz for twenty cycles. Each specimen was then loaded to failure under displacement control at a rate of 1 mm/sec. Cyclic elongation, peak-to-peak displacement, ultimate tensile load, and stiffness were measured with use of an optical motion analysis system and load-cell output. The type of failure (suture breakage or pull-out) was also recorded. A repeated-measures analysis of variance was performed on the results, with the alpha level of significance set at p < 0.05.

Results: There was no difference in cyclic elongation or peak-to-peak displacement among the four stitches. Ultimate tensile load was significantly higher (p < 0.05) for the massive cuff stitch (233 ± 40 N) and the modified Mason-Allen stitch (246 ± 40 N) than it was for either the simple stitch (72 ± 18 N) or the horizontal stitch (77 ± 15 N). There was no significant difference in the ultimate load between the massive cuff and modified Mason-Allen stitches. There was also no difference in stiffness among the four stitches. The simple and horizontal stitches failed by tissue pull-out, whereas the massive cuff and Mason-Allen stitches failed by a mixture of suture breakage and pull-out.

Conclusions: The massive cuff stitch provides strength comparable with that of the modified Mason-Allen stitch commonly used in open rotator cuff repair. The ultimate tensile load before failure of the massive cuff stitch was significantly higher (p < 0.05) than that of the simple and horizontal stitches.

Clinical Relevance: The massive cuff stitch may be a promising alternative for arthroscopic repairs of rotator cuff tendons.

Figures in this Article

Arthroscopic rotator cuff repairs have become increasingly popular following advances in technique and instrumentation^1-5. The suture configuration in these repairs has been limited to simple or horizontal mattress-type stitches^6,7. Recent objective evaluations have indicated high failure rates of up to 80% for arthroscopic repairs of massive rotator cuff tears^8-10. Early failure can be caused by failure of either the knot or the suture anchor; however, the majority of the failures occur when the suture pulls out through the tendon^10-13. In addition, weak initial fixation with stretching of the repair can lead to gap formation between the repaired tendon and the osseous insertion and subsequently to poor tendon-to-bone healing^10-12,14.

The modified Mason-Allen stitch has been shown to have superior strength when compared with simple and horizontal mattress stitches for open rotator cuff repair^11,12. Previous studies have demonstrated that, among the various stitches used for rotator cuff repair, the modified Mason-Allen stitch leads to the least gap formation and slippage and has the highest ultimate tensile load¹². Also, studies of animals have shown that the modified Mason-Allen stitch does not cause tendon necrosis¹¹. The modified Mason-Allen stitch has been commonly used in open rotator cuff repairs, but the easier-to-perform simple and horizontal stitches have been commonly used in arthroscopic rotator cuff repairs because of the technical difficulty of placing the modified Mason-Allen stitch arthroscopically.

The senior author (J.D.MacG.) has used a novel suture configuration, the massive cuff stitch, when repairing massive rotator cuff tears. This stitch has been used in conjunction with the side-to-side repair stitch used for margin convergence of massive rotator cuff tears. Like the modified Mason-Allen stitch, the massive cuff stitch limits pull-out, but, like the simple stitch, it is easy to perform arthroscopically. The goal of this study was to compare the biomechanical properties of the massive cuff stitch with those of three commonly used stitches (simple, horizontal, and modified Mason-Allen) for rotator cuff tendon repairs. The hypothesis of the study was that the massive cuff stitch would have strength comparable with that of the modified Mason-Allen stitch and superior to that of the simple and horizontal stitches commonly used in arthroscopy.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

Technique

The massive cuff stitch consists of a horizontal loop and a vertical loop that are tied separately (Fig. 1). While it is difficult to place a modified Mason-Allen stitch arthroscopically, it is possible to place a horizontal loop and a vertical loop arthroscopically. The horizontal loop is placed first and tied. Suture anchors are then placed over the decorticated greater tuberosity of the humerus. The suture from the suture anchor is placed medial to the horizontal loop and is tied over the tendon as a simple vertical loop (Fig. 1). The horizontal loop acts as a "checkrein" for the simple loop to prevent pullout from the tendon.

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Fig. 1: Illustration of the simple, horizontal, massive cuff, and modified Mason-Allen stitches evaluated in this study.

Biomechanical Testing

Eight pairs of sheep shoulders were harvested and were kept frozen until the day prior to testing. Each pair of shoulders was thawed at room temperature overnight, and the infraspinatus tendons were dissected free from all surrounding muscles and osseous attachments. Each tendon was cut to approximately 4 cm in length and was split in half longitudinally to yield four tendon specimens from each pair of shoulders. All thirty-two infraspinatus tendon specimens were visually inspected for gross abnormalities, and none were excluded from testing. The specimens were kept moist throughout testing with intermittent sprays of saline solution.

The four suture configurations were randomly selected, placed, and tested in each set of tendon specimens. Eight tendon specimens were tested for each suture configuration. The stitch to be tested was placed 1 cm from the distal tendon end and tied around a fixed metal bar (Fig. 2). We utilized this setup to exclude the tendon-bone interface and thus evaluate the strength of the suture-tendon interface only. Clinically, failures occur primarily at the suture-tendon interface¹³. The suture material used was number-2 FiberWire (Arthrex, Naples, Florida), a polyester braid and long-chain polyethylene suture. One surgeon placed and tied all stitches manually to minimize variability. Each stitch was tied with use of a sliding double half-hitch knot first, followed by alternating half hitches to a total of six throws, as is performed arthroscopically. The proximal tendon end was fixed in a custom tendon clamp attached to a 500-N load cell on an MTS uniaxial load frame (MTS Systems, Eden Prairie, Minnesota). The bar was rigidly clamped to the baseplate of the MTS machine.

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Fig. 2: Schematic diagram of the experimental setup. A custommade clamp (A) was used to secure the tendon (B), on which a marker (C) was placed adjacent to the suturetendon interface. The suture (D) was tied around a metal bar that was rigidly fixed to the MTS machine. A second marker (E) was placed on the metal bar.

Two self-adhesive, 2-mm-diameter, retroreflective markers were placed: one on the tendon at the suture-tendon interface, and the other on the bar adjacent to the suture loop (Fig. 2). An infrared camera (MacReflex; Qualisys Medical, Gothenburg, Sweden) with a resolution of 160 pixels/mm and an accuracy of 0.09 mm was connected to a data-acquisition computer running PCReflex (version 2.0; Qualisys). Calibration was performed before each testing session by collecting video data from three markers at a known distance. The use of the video displacement measurement method prevented possible slippage of the clamp-tendon system from being included in the determination of displacement. Video data were acquired at a sampling frequency of 90 Hz to measure the relative displacement of the tendon and the suture on the basis of the marker displacements. The position data were recorded and were digitized to yield x and y coordinates for each marker.

Cyclic Loading Test

A cyclic loading test was performed to evaluate the performance of the rotator cuff repair under repeated loading conditions^7,15. A 5-N preload was applied to pretension the specimen. The tendon was then cyclically loaded under force control from 5 to 30 N at 0.25 Hz for twenty cycles with use of a half-sinusoidal waveform. The 30-N upper limit was chosen to approximate one-half of the ultimate load of the weakest stitch, as determined in preliminary experiments. We chose twenty cycles because preliminary studies had shown that the cyclic behavior stabilizes after sixteen, seventeen, or eighteen cycles.

Elongation and peak-to-peak displacement were determined in the cyclic loading test. Elongation was defined as the difference in y-displacement between the first cyclic peak and the twentieth cyclic peak (Fig. 3). Peak-to-peak displacement was defined as the average of the local minimum to maximum of the eighteenth, nineteenth, and twentieth cycles.

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Fig. 3: Graph of displacement (in millimeters) versus time (in seconds) illustrating how elongation and peak-to-peak displacements were determined. The difference in displacement between the first and twentieth peaks was defined as elongation. An average of the displacement of the eighteenth, nineteenth, and twentieth cycles equals peak-to-peak displacement.

Load-to-Failure Tensile Test

Following cyclic loading, each tendon specimen was loaded to failure under displacement control at a rate of 1 mm/sec. Load (in newtons) versus displacement (in millimeters) was recorded until failure. Ultimate tensile load was considered to be the peak force. Stiffness was calculated by determining the slope of the load-elongation curve with use of a best-fit line on the load versus displacement curve following the initial toe region. The failure mechanism (suture breakage or pull-out) for each specimen was also recorded.

Statistical Methods

All four suture configurations were tested in each set of tendon specimens. A repeated-measures analysis of variance was used to analyze the effect of the stitches on the biomechanical properties of the suture-tendon interface as a within-subjects factor. A Newman-Keuls multiple comparisons test was used for pairwise differences if a significant difference was determined. Statistical analysis of elongation, peak-to-peak displacement, ultimate tensile load, and stiffness was performed. Significance was set at p < 0.05.

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

The cyclic loading test revealed no significant difference among the four stitches with regard to peak-to-peak displacement measurements. Peak-to-peak displacements ranged from 0.5 to 0.7 mm with cyclic loads 5 to 30 N. Also, no significant difference was found among the four stitches with regard to elongation (Table I).

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TABLE I Results of Cyclic and Load-to-Failure Tests

	Stitch*
	Simple (N = 8)	Horizontal (N = 8)	Massive Cuff (N = 8)	Modified Mason-Allen (N = 8)
Cyclic loading test
Peak-to-peak displacement (mm)	0.7 ± 0.2	0.6 ± 0.1	0.6 ± 0.2	0.5 ± 0.2
Elongation (mm)	0.9 ± 0.2	0.9 ± 0.3	0.7 ± 0.3	0.9 ± 0.2
Load-to-failure-test
Ultimate tensile load (N)	72 ± 18	77 ± 15	233 ± 40†	246 ± 40†
Stiffness (N/mm)	27.3 ± 11.8	25.8 ± 8.2	24.0 ± 10.0	29.0 ± 11.8

The results are given as the mean and standard deviation. †p < 0.05 when compared with the simple and horizontal stitches.

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TABLE I Results of Cyclic and Load-to-Failure Tests

	Stitch*
	Simple (N = 8)	Horizontal (N = 8)	Massive Cuff (N = 8)	Modified Mason-Allen (N = 8)
Cyclic loading test
Peak-to-peak displacement (mm)	0.7 ± 0.2	0.6 ± 0.1	0.6 ± 0.2	0.5 ± 0.2
Elongation (mm)	0.9 ± 0.2	0.9 ± 0.3	0.7 ± 0.3	0.9 ± 0.2
Load-to-failure-test
Ultimate tensile load (N)	72 ± 18	77 ± 15	233 ± 40†	246 ± 40†
Stiffness (N/mm)	27.3 ± 11.8	25.8 ± 8.2	24.0 ± 10.0	29.0 ± 11.8

The results are given as the mean and standard deviation. †p < 0.05 when compared with the simple and horizontal stitches.

In the load-to-failure test, the massive cuff stitch and the modified Mason-Allen stitch both demonstrated significantly higher ultimate load (p < 0.05) than did either the simple or the horizontal stitch (Fig. 4, Table I). No significant difference in ultimate load was found between the massive cuff stitch (233 ± 40 N) and the modified Mason-Allen stitch (246 ± 40 N) or between the simple and horizontal stitches. Also, there was no significant difference in stiffness among the four stitches.

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Fig. 4: Mean ultimate failure loads (and standard deviations) for the four stitches.

All of the simple and horizontal stitches failed as a result of suture pull-out. The massive cuff and modified Mason-Allen stitches failed through a combination of pull-out and suture breakage at the knot.

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

The results of this study support the hypothesis that the massive cuff stitch has strength comparable with that of the modified Mason-Allen stitch and superior to that of the simple and horizontal stitches. In this in vitro sheep infraspinatus tendon model, the massive cuff stitch demonstrated three times the ultimate strength of the simple and horizontal stitches, two stitches commonly used in arthroscopy, and no significant difference in ultimate load when compared with the modified Mason-Allen stitch. The failure loads of the Mason-Allen stitch (246 N) and massive cuff stitch (233 N) are comparable with the reported mechanical strength of FiberWire suture (270 N)¹⁶. These results indicated that the tissue-holding strength of these stitches in the sheep tendon nearly reached the mechanical strength of the suture material itself. The cyclic loading test did not demonstrate any significant difference among stitches with regard to peak-to-peak displacement or elongation. A power analysis of the results of the cyclic loading test showed a power of 0.99 to detect a difference of 0.5 mm, which we thought was clinically relevant. The power to detect a difference of 0.2 mm was 0.8.

In this study, our main focus was on the strength of the suture-tendon interface—i.e., the tissue-holding strength of the stitch—where clinical failures are frequently reported¹³. In the experimental setup, the sutures were tied around a metal bar to exclude the suture-bone or bone-anchor interfaces. Schneeberger et al. showed that arthroscopically placed modified Mason-Allen stitches did not improve the strength of the rotator cuff tendon repair when used in conjunction with a suture anchor¹⁷. It should be noted that most of the failures in that study occurred at the suture anchor eyelet or with anchor pull-out. Additional studies with protocols similar to that used in the study by Schneeberger et al. are needed to evaluate the performance of the massive cuff stitch with inclusion of the tendon-bone and bone-anchor interfaces.

One of the limitations of the present study was the use of sheep tendons. Some studies have shown that sheep rotator cuff tendons resemble human rotator cuff tendons in size, shape, and microstructure; however, they are different from the degenerated and thinner tendons seen in human shoulders with chronic rotator cuff tears^12,18. Nevertheless, the sheep infraspinatus tendon has been shown to be a good model and has been used extensively for the evaluation of rotator cuff tendon repairs^11,12,19,20. Another limitation of the study was that all stitches were placed in an open environment, as opposed to arthroscopically. However, we utilized arthroscopic sequences such as sliding knots as well as alternating half hitches when tying the stitches. All knots were tied by the same surgeon, with a technique similar to that used arthroscopically except for the use of a knot pusher.

A strength of the current study was our ability to evaluate all four stitches in a randomized manner within each pair of shoulders. This allowed us to eliminate interspecimen variability and enabled intraspecimen comparison for our statistical analysis. We were also able to isolate the suture-tendon interface with our experimental setup, which removed potentially confounding variables related to the tendon-bone and bone-anchor interfaces, such as bone density and anchor strength.

The results of this study suggest that a method of combining a horizontal loop and a vertical loop at the site of a rotator cuff repair can provide strength and stiffness comparable with those provided by the modified Mason-Allen stitch. Our biomechanical tests showed the massive cuff stitch to be three times stronger than simple and horizontal stitches. The massive cuff stitch enabled us to protect the simple vertical loops from the highest strain at the leading edge of the tendon. When a surgeon is repairing a massive rotator cuff tear with margin convergence, the side-to-side margin convergence stitch can also be utilized as the horizontal loop of the massive cuff stitch (Fig. 5). Clinically, the massive cuff stitch may be a promising alternative to the simple and horizontal stitches for arthroscopic rotator cuff repairs.

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Fig. 5: Illustration of the massive cuff stitch used to repair a large tear of the rotator cuff. The margin convergence stitch can be used as the horizontal loop of the massive cuff stitch.

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: The authors thank Bryan Kelly, MD, for his support and help in obtaining the sheep shoulder specimens as well as Arthrex for donating the FiberWire used in this study.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

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Burkhart SS, Fischer SP, Nottage WM, Esch JC, Barber FA, Doctor D, Ferrier J. Tissue fixation security in transosseous rotator cuff repairs: a mechanical comparison of simple versus mattress sutures. Arthroscopy.1996;12: 704-8.12704 1996 [PubMed][CrossRef]

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Gerber C, Schneeberger AG, Perren SM, Nyffeler RW. Experimental rotator cuff repair. A preliminary study. J Bone Joint Surg Am.1999;81: 1281-90.811281 1999 [PubMed]

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Burkhart SS, Diaz Pagan JL, Wirth MA, Athanasiou KA. Cyclic loading of anchor-based rotator cuff repairs: confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation. Arthroscopy.1997;13: 720-4.13720 1997 [PubMed][CrossRef]

Arthrex.FiberWire: collective summary of strength and biocompatibility testing data comparisons of polyester and polyblend sutures.2002; Naples, Florida. 2002

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Topics

rotator cuff ; sheep ; sutures ; tendon ; rotator cuff repair

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C. Benjamin Ma, John D. MacGillivray, Jonathan Clabeaux, Samuel Lee, James C. Otis; Biomechanical Evaluation of Arthroscopic Rotator Cuff Stitches. The Journal of Bone & Joint Surgery. 2004 Jun;86(6):1211-1216.

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