title: Bone suture anchor fixation in the lower extremity: a review of insertion principles and a comparative biomechanical evaluation.
abstract: BACKGROUND
  Suture anchors have been developed for the fixation of ligaments, capsules, or tendons to bone. These devices have led to improved fixation, smaller incisions, earlier limb mobility, and improved outcomes. They were originally developed for use in shoulder reconstructions but are now used in almost all extremities. In the lower leg they are used in the tibia, the talus, the calcaneus, tarsal bones, and phalanges. Nevertheless, techniques for insertion and mechanisms of failure are not well described.
  
  
  METHODS
  Five suture anchors were studied to determine the pullout strength in four distal cadaver femurs and four proximal cadaver tibias from 55- and 62-year-old males. Eight hundred ninety Newton line was used, testing the anchors to failure with an Instron testing device (Instron, Norwood, MA). The anchor devices were inserted randomly and tested blindly (12 tests per anchor device, 60 tests in all).
  
  
  RESULTS
  Two anchors in each group tested failed at low loads. Both types of plastic anchors had failures at the eyelet. Average pullout strength varied from 85.4 to 185.6 N.
  
  
  CONCLUSIONS
  Insertion techniques are specific for each device, and they must be followed for optimal fixation. In this study, in all five groups of anchors tested two of the 12 anchors in each group failed with minimal force. On the basis of this finding we recommend that, if suture anchor fixation is necessary, at least two anchors should be used. Since there appears to be a percentage of failure in all devices, the second anchor can serve as a backup. It is imperative that surgeons be familiar with the insertion techniques of each device before use.
authors.affiliation: pescranton@earthlink.net
authors.forename: Pierce E
authors.initials: PE
authors.lastname: Scranton
authors.forename: S Michael
authors.initials: SM
authors.lastname: Lawhon
authors.forename: John E
authors.initials: JE
authors.lastname: McDermott
mesh_terms: D001696:Biomechanical Phenomena; D002102:Cadaver; D019544:Equipment Failure Analysis; D006801:Humans; D007866:Leg / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009984:Orthopedic Fixation Devices / Q000592:standards*; D013536:Suture Techniques