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Suture Anchors and How Repairs Are Held to Bone

70 citationsUpdated Sep 2026

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Overview

Suture anchors and tacks serve as the primary interface for securing soft tissue to bone in shoulder reconstruction, with recent reviews emphasizing the biological and biomechanical factors that dictate successful fixation [2]. The field has undergone a major shift from metallic to bioabsorbable anchors, driven by higher complication rates associated with metallic devices and lower rates with bioabsorbable alternatives [27]. All-suture anchors offer similar or better mechanical properties than regular anchors while preserving bone tissue through low-profile designs [5]. These implants mitigate risks and difficulties associated with other fixation devices, providing ease and efficiency for the surgeon [3]. Although various bone changes are observed after implantation of an all-suture anchor, these changes are not clinically relevant [1]. Bioabsorbable anchors remain a safe, reproducible, and consistent implant for securing soft tissue to bone in and about the shoulder, with reported complications amounting to a fraction of the total anchors implanted [24].

Complications related to suture anchors and tacks are categorized as technique-related or device-related issues [11]. Prevention depends on the surgeon's familiarity with the devices and knowledge of their indications and limitations [11]. Careful attention to proper anchor insertion techniques can limit the potential for complications with bioabsorbable anchors, while newer materials may address concerns of biocompatibility and material strength [7]. Routine radiographic follow-up is recommended after use of metallic anchors to ensure identification of early failure by anchor pullout [13]. Knotless technology has been found to be a more reproducible method than knotted anchors, with comparable outcomes [16]. However, overtightening sutures during a knotless single-row suture bridge technique may cause anchor pull-out [4]. A disadvantage of the 4.0-mm-size knotless all-suture anchor is a possible large defect if the anchor pulls out, and the knotless all-suture anchor with suture tape lacks a clear differentiator between the looped and non-looped end of the passing suture in the joint [18].

Headline outcomes indicate that good long-term results were observed after arthroscopic Bankart repair in patients older than 20 years with 3 or more suture anchors used [14]. The repair technique, whether knotted suture-bridging or knotless tape-bridging, did not have a significant effect on the final outcome at a mean of 2.9 years in arthroscopic transosseous equivalent rotator cuff repair [9]. Arthroscopic transosseous superior capsular reconstruction outcomes are not inferior to those of anchor-based techniques, involving less suture tangling, more precise suture pass points, and lower costs [10]. Cement augmentation of suture anchors is a quick and reproducible technique for cases with bone defect in the proximal humerus, backed by previous biomechanical studies to provide adequate fixation [33]. Long head of biceps tendon (LHBT) augmentation and knotless sutures provide biological and biomechanical additional advantages to side-to-side and subsequent tendon-to-bone repair [121].

Anatomy & Pathophysiology

Osseous Anatomy

The proximal humerus comprises four main parts: the humeral head, greater tuberosity (GT), lesser tuberosity (LT), and humeral shaft [63]. The articular head is spherical with a diameter of 37 to 57 mm [63] and an arc of approximately 160 degrees covered by articular cartilage [75]. The radius of curvature of the humeral head is approximately 25 mm, slightly larger in men than in women [75]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [63], with the superior margin normally positioned 8 to 10 mm superior to the top of the GT [75]. Humeral version averages 29.8 degrees, ranging from 10 to 55 degrees [63], though proximal retroversion is highly variable, ranging from 0 to 55 degrees depending on measurement method [75]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [63], with an average inclination of 41 degrees [66] and a range of 30 to 55 degrees [75]. The neck-shaft angle measures an average of 135 degrees [64], while the average neck-shaft angle is also cited as 45 degrees with a range of 30 to 50 degrees [75]. Arthritic shoulders exhibit a flatter neck-shaft angle close to 50 degrees [75]. The humeral head is retroverted an average of 30 degrees relative to the transepicondylar axis [77] and averages 19 degrees of retroversion [66].

The bicipital groove lies between the GT and LT, serving as a pathway for the long head of the biceps [63]. The anatomic neck is located at the junction of the articular surface and the tuberosities [63, 64], directly below the humeral head, and serves as an attachment for the shoulder capsule [77]. The surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [63, 64] and is more distal than the anatomic neck, making it more often involved in fractures [77]. The GT is located in a posterior-superior position relative to the humeral shaft and serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [63, 64]. The LT is located on the anterior aspect of the proximal humerus and serves as the attachment site for the subscapularis tendon [63, 64]. The head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [77]. The distance from the lateral base of the coracoid process to the lateral margin of the GT is called the lateral humeral offset [75]. A significant decrease in this offset reduces lever arms for the deltoid and supraspinatus, weakening abduction and impairing function [75]. Conversely, a significant increase causes excessive soft tissue tension, resulting in loss of motion and likely accelerating polyethylene wear [75]. Humeral articular malposition of more than 4 mm led to increased subacromial contact in a biomechanical cadaver study [75], and an offset of 8 mm in any direction significantly decreased passive range of motion [75].

The glenoid is a convex structure of shallow depth shaped like an inverted pear [63] and is a shallow socket approximately one-third the size of the humeral head [64]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [75]. The glenoid diameter ranges from 18 to 30 mm superiorly and 21 to 35 mm inferiorly in the anteroposterior direction [75], with a superoinferior height ranging from 30 to 48 mm [75]. The average inclination of the glenoid is 4.2 degrees, with a range of -7 to 20 degrees [75]. The average version of the glenoid is 1.5 degrees retroversion, with a range of 10.5 degrees anteversion to 9.5 degrees retroversion [75]. The normal position of the glenoid surface in relation to the axis of the scapular body ranges from 2 degrees of anteversion to 7 degrees of retroversion [75], averaging 5 degrees of retroversion [66, 77]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [66]. The surface area of the glenoid ranges from 4 to 6 mm [75], while the surface area of the humeral head ranges from 11 to 19 mm [75]. The cartilage thickness of the glenoid is 2.16 mm [75], and the cartilage thickness of the humeral head is 1.44 mm [75].

The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [77]. It is anteverted on the chest wall approximately 30 degrees relative to the body [77]. The glenoid is connected with the flat body of the scapula by the scapular neck [65]. The coracoid process curves forwards from the superior surface of the scapular neck [65]. The scapular spine ends in a flattened bony process, the acromion, which curves forwards [65]. The highest concentration of bony mass in the scapula is found in the glenoid, the scapular neck, and the lateral border of the scapular body [65]. Two bony pillars extend between the glenoid and the scapular body to transmit compressive forces from the glenoid fossa [65]. The lateral pillar connects the inferior border of the glenoid with the inferior angle of the scapula [65]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [65]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [65]. The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [65].

The clavicle is the first bone to ossify at the fifth week of gestation and is the only long bone to ossify by intramembranous ossification [66]. The medial epiphysis of the clavicle is the last ossification center to fuse, occurring at age 20 to 25 years [66]. Ossification of the scapular body begins at the eighth week of gestation [66]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [66]. Failure of fusion of the acromial ossification centers results in os acromiale [66], which is incomplete fusion of secondary ossification centers, most commonly between the mesoacromion and meta-acromion [77]. The proximal humerus has three centers of ossification: the humeral head (4 to 6 months), greater tuberosity (1 to 3 years), and lesser tuberosity (3 to 5 years) [66]. The proximal humeral ossification centers fuse to the shaft at age 17 to 20 years [66].

The humeral shaft extends from the level of the insertion of the pectoralis major muscle proximally to the supracondylar ridge distally [64]. The upper portion of the humeral shaft is cylindrical and becomes more flattened in an anteroposterior direction as it proceeds distally [64]. Medial and lateral intermuscular septae divide the arm into anterior and posterior compartments [64]. The anterior compartment contains the biceps brachii, coracobrachialis, and brachialis muscles, along with the neurovascular bundle [64]. The posterior compartment contains the triceps brachii muscle and the radial nerve [64].

Ligamentous & Soft Tissue Anatomy

The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure that imparts stability to the shoulder girdle [63]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency and should be preserved with irreparable cuff tears to prevent anterosuperior escape [77]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [77]. The coracoacromial ligament is the arthroscopic landmark for a complete release of the rotator interval for adhesive capsulitis [77]. The transverse humeral ligament is an important stabilizer of the biceps tendon [77], which lies within the bicipital groove and is covered by this ligament [64].

The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [66]. It is composed of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion [66]. The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [66] and is a double gliding joint with an articular disc [77]. It rotates 30 degrees with shoulder motion [77]. The posterior sternoclavicular joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [66], with the posterior sternoclavicular ligament being the strongest and primary restraint to anteroposterior instability [77].

The acromioclavicular joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [66] and is a plane/gliding joint [77]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [66] and are considered the strongest [77]. The acromioclavicular ligaments prevent anteroposterior displacement of the clavicle [77]. The coracoclavicular ligaments are the primary stabilizers to superior translation of the distal clavicle [66] and prevent superior displacement of the distal clavicle [77]. The trapezoid ligament is anterolateral and located approximately 25 mm from the acromioclavicular joint [77]. The conoid ligament is posteromedial, stronger than the trapezoid, and located approximately 45 mm from the acromioclavicular joint [77].

The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [64]. The teres major is not a rotator cuff muscle [64]. The rotator cuff stabilizes the glenohumeral joint via joint compression [66] and serves as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [64]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [64]. The deltoid and pectoralis major muscles, along with the rotator cuff, cause predictable displacement of fractures around the proximal humerus [64].

Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [66]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [66]. Stability of the glenohumeral joint depends on the capsule, ligament, and muscle [64]. The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [66]. It contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [66]. Laxity of the rotator interval results in inferior laxity, known as the sulcus sign [66]. Contracture of the rotator interval is seen with adhesive capsulitis [66].

The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [66]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [66]. It forms a pulley with the coracohumeral ligament that provides restraint against medial subluxation of the long head of the biceps tendon [66]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45 degrees of abduction [66]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90 degrees of abduction and external rotation [66]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [66].

Vascular & Neural Anatomy

The primary blood supply to the clavicle is periosteal, with no nutrient artery present [66]. The major blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery [64]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [66]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [66]. The brachial plexus and axillary artery lie anterior to the coracoid process of the scapula and humeral head [64].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [66]. The suprascapular artery runs superior to the superior transverse scapular ligament, while the nerve runs deep to it [66]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [66]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [66]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [66].

Kinematics

Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [66]. The scapula is attached to the axial skeleton by the acromioclavicular and sternoclavicular joints [65]. The scapula has only one true diarthrodial articulation, the acromioclavicular joint [66]. The coracobrachialis muscle and the short head of the biceps tendon originate from the coracoid process [66]. The pectoralis minor muscle inserts onto the medial coracoid process [66].

Classification

Complication Categorization: Complications associated with suture anchors and tacks are categorized as either technique-related or device-related issues [11].

Postage Stamp Fracture Phenotype: Postage stamp fractures are frequently reported in patients who are male, age 25 years or younger, and participants in sporting activities [12]. These fractures are also frequently reported in fractures initially stabilized with 3 or more anchors [12], fractures initially stabilized with conventional knot-tying anchors [12], and fractures that experienced osteolysis around anchor sites [12].

Mayo Classification: The Mayo classification uses fracture displacement and elbow stability to classify olecranon fractures in three main types: type 1 (undisplaced), type 2 (displaced), and type 3 (displaced with associated ulnohumeral instability) [109]. This classification is further divided into subtypes A and B according to the presence of comminution [109].

Yoo et al. Classification: The Yoo et al. classification categorizes rotator cuff repair tendon mobilization as type I (to the distal lateral end) or type II (within half of the distance to the proximal medial end) of the greater tuberosity [114]. It categorizes incomplete rotator cuff repair as type III (small <10 mm portion exposed) or type IV (moderate >10 mm portion exposed) [114].

Moroder Classification: The Moroder classification is used to classify posterior labral lesions, with type B2 lesions being an indication for specific posterior Bankart repair techniques [115].

Ogden Classification: The Ogden classification is the most commonly used system for tibial tubercle fractures, modified from the original Watson-Jones description [53].

Clinical Presentation

Radiographic Findings: Various bone changes are observed following the implantation of an all-suture anchor; however, these changes are not clinically relevant [1]. In patients undergoing rotator cuff repair with bioabsorbable anchors, radiolucent rings frequently appear around the implants, most commonly at anteromedial anchors [51]. These radiolucencies are not associated with clinical outcomes [51], and mechanical factors may play a role in their development [51].

Complications and Fracture Patterns: Suture anchor complications, such as prolapse, remain a concern in medical practice [50]. Overtightening sutures may cause anchor pull-out [4]. Postage stamp fractures are reported frequently in specific patient populations and clinical scenarios. These fractures occur frequently in patients who are male, age 25 years or younger, and participants in sporting activities [12]. They are also reported frequently in fractures initially stabilized with 3 or more anchors or conventional knot-tying anchors [12], as well as in fractures that experienced osteolysis around anchor sites [12].

Biological Safety and Outcomes: Bioabsorbable anchors are a safe, reproducible, and consistent implant to secure soft tissue to bone in and about the shoulder [24]. No inflammatory reactions were documented in studied biodegradable lactide-containing suture anchors [49]. Regarding postoperative outcomes, patients treated using knotted anchors were significantly more likely to experience a postoperative complication compared with patients treated using knotless anchors after arthroscopic repair of isolated type II SLAP lesions [37].

Investigations

Plain radiography: Standardized plain films are almost always sufficient to garner the information needed for shoulder evaluation [43]. The purpose of imaging is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient [43]. Unless a specific research protocol is in place, the temptation to “overimage” should be resisted, obtaining only the scans or reconstructions that are necessary for the care of the patient [43]. The standard shoulder series should include orthogonal views of the shoulder, including a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [87]. At least two X-ray views should be obtained for shoulder imaging: an anteroposterior in the plane of the glenoid and an axillary projection with the arm in abduction to show the relationship of the humeral head to the glenoid [80].

The first key view is the anteroposterior (AP) view in the plane of the scapula taken so that the x-ray beam passes through the glenohumeral joint [43]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration [87]. The AP view in the plane of the scapula shows the superoinferior position of the humeral head relative to the glenoid, the presence of osteophytes on the humeral head and glenoid, narrowing of the joint space, and the degree of medial displacement of the humerus in relation to the lateral acromial line [43]. The AP view with the arm held in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [87].

The second key view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula and oriented so that both the spinoglenoid notch and the scapular neck are visible [43]. The axillary view is referred to as the “truth view” because it demonstrates the glenohumeral relationships in the functional position of elevation [43]. It shows a different perspective of the humeral anatomy, the amount of glenoid bone, the shape of the glenoid, its version in relation to the plane of the scapula, and the relationship of the humeral head to the glenoid fossa [43]. The axillary view is a necessary view in evaluation of glenohumeral joint instability and enables determination of the humeral head position in the glenoid fossa [87]. It may detect occult, locked posterior shoulder dislocation in a patient who exhibits a lack of passive external rotation [87]. The axillary truth view can show posterior subluxation or “functional decentering” that is not evident in images taken with the arm at the side [43].

The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs, which have been closely associated with the presence of rotator cuff pathology [87]. When taken properly, standardized anteroposterior and axillary views indicate the thickness of the cartilage space between the humerus and the glenoid, relative positions of the humeral head and the glenoid, presence of osteophytes, degree of osteopenia, and extent of bony deformity and erosion [43]. The acromiohumeral distance is normally 7 to 14 mm [87]. The width of the glenohumeral joint space should be symmetric superiorly and inferiorly [87]. The coracoclavicular distance is normally 1.1 to 1.3 cm [87].

Patients presenting with shoulder instability and dislocations are initially imaged with standard radiographs to provide an overview of bony anatomy, orientation of the humeral head in relation to the glenoid, and initial assessment for both bony Bankart and Hill–Sachs lesions [89]. In a systematic review of posterior shoulder dislocations, a missed initial diagnosis was reported in 73% of patients due to the lack of an axillary view, Y view, or computed tomography (CT) imaging [89]. Of the patients with missed initial diagnoses of posterior dislocation, almost all (147/150 or 98%) had only AP or lateral views of the shoulder [89]. When axillary or Y-view radiographs were made subsequently, the diagnosis of posterior dislocation was confirmed in 100% of patients [89].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [86]. Traditional magnetic resonance imaging (MRI) is utilized for evaluation of soft tissues, which can be performed with high contrast and spatial resolution [84]. MRI is useful to identify osteonecrosis of the humeral head, or a bone tumour [80]. MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [80]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of the joint surfaces [86]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [86]. MR accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [84].

Magnetic resonance (MR) arthrography (MRA) refers to MRI of a joint that has been injected with an intra-articular contrast agent such as diluted gadolinium or saline solution [84]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [86]. MRA has proven utility by increasing both sensitivity and specificity in detecting injuries to the capsulolabral–ligamentous complex as compared to traditional MRI [84]. In a meta-analysis of the diagnostic test accuracy of MRA compared to MRI for the detection of glenoid labral injuries, MRA sensitivity was 88% and specificity was 93%, compared to MRI sensitivity of 76% and specificity of 87% [84]. Abduction and external rotation (ABER) of the arm is an alternative position utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [84]. The sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of the MRA in neutral position [84]. MRAs can demonstrate a patulous capsule on the coronal, sagittal, and axial imaging in patients with multidirectional instability (MDI) [84]. The diagnosis of multidirectional instability (MDI) is a clinical one, and the need for expensive and/or invasive imaging should be weighed against the information that will be gained from these studies [84]. When MRI or MR arthrography is contraindicated, CT arthrography is indicated [86]. All-suture anchor fixation facilitates postoperative imaging on magnetic resonance imaging [26].

CT: CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary truth view [43].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [80]. It is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [86]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [86]. As a result of providing images in real-time, ultrasonography can evaluate impingement in various positions and motions [86]. It can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [86]. Ultrasonography can be useful in guiding injections or barbotage (aspirating calcific deposits in the rotator cuff) [80]. The most commonly performed joint examination using ultrasonography is the shoulder examination [78]. Accuracy of rotator cuff ultrasonography depends on the skill of the scanner operator and an awareness of pitfalls that are encountered [78]. Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [86].

Other Considerations: Routine radiographic follow-up is recommended after the use of metallic suture anchors to ensure the identification of early failure by anchor pullout [13]. Various bone changes are seen after implantation of an all-suture anchor, but these changes are not clinically relevant [1]. Most radiolucent rings around bioabsorbable anchors appeared at anteromedial anchors, indicating that mechanical factors may play a role for the radiolucencies [51]. Use of bioabsorbable anchors should be reconsidered because of possible interference with revision surgery [137].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, or pharmacological interventions. Surgical indications are framed by the need for secure fixation and the limitations of non-operative care in restoring anatomical reduction and biomechanical stability.

Operative

Indications: Surgical intervention is indicated to achieve anatomic reduction and secure fixation of avulsed fragments, particularly when preserving surrounding soft tissue and bone stock is critical [20]. The goals of surgical evaluation focus on examining the biological and biomechanical factors that influence the successful use of suture anchors and tacks [2]. For rotator cuff pathology, indications include partial articular supraspinatus tendon avulsion-type tears [4], delaminated rotator cuff tears [102], musculotendinous junction rotator cuff tears [134], and massive rotator cuff tendon tears where a single anchor medial-row construct offers technical efficiency and biomechanical strength [46]. Arthroscopic repair is also indicated for posterior labral tears [15], bony Bankart lesions [8], and acromioclavicular joint instability requiring ligament augmentation [57].

Surgical Approach / Technique: Technique selection depends on the specific pathology and desired biomechanical outcome. For rotator cuff repairs, both knotted suture-bridging and knotless tape-bridging techniques yield comparable final outcomes at a mean of 2.9 years [9]. A knotless single-row suture bridge technique is utilized for partial articular supraspinatus avulsions, though overtightening sutures may cause anchor pull-out [4]. The arthroscopic retro all-suture anchor technique for subscapularis repair avoids difficult trajectories and large-diameter bone punches, providing reproducible and secure fixation [6]. For bony Bankart lesions, fixation using knotless double-loaded suture anchors and buttress sutures requires only two anchors, allowing slow, controlled compression of the fracture during reduction [8]. The suture bridge technique enables even distribution of sutures above the fracture fragment, reduces suture displacement, and allows excellent arthroscopic reduction while fully preserving the posterior septum [48]. This technique is also applied to posterior cruciate ligament tibial avulsions [48] and the arthroscopic 'double-pulley' suture anchor technique achieves anatomic reduction of avulsed fragments while preserving soft tissue [20]. For delaminated tears, the modified arthroscopic en masse suture bridge technique yields favorable clinical outcomes comparable to nondelaminated tears [102]. The dynamic convergence suture bridge technique is used for musculotendinous junction rotator cuff tears [134]. In cases of intraoperative anchor pullout, bar anchoring with a threaded Steinmann pin is a viable solution that utilizes primary anchor sites with acceptable results [17].

Implant Selection: All-suture anchors offer similar or better mechanical properties than regular anchors, with a low-profile design that preserves bone tissue [5]. This low-profile design eliminates a prominent knot stack superiorly and decreases the risk of stress riser in the acromion and distal clavicle compared to larger, solid body anchors [57]. All-suture anchor fixation preserves glenoid bone stock, facilitates postoperative magnetic resonance imaging, and offers biomechanically stable fixation [26]. An all-suture anchor provides equivalent clinical performance to an established solid suture anchor at 12-month follow-up in arthroscopic rotator cuff repair [56]. Patients using all-suture medial row anchors in transosseous equivalent repairs demonstrate increased abduction and strength, as well as lower pain scores, compared to traditional suture anchors [31]. Double-row repair increases the surface area of contact between the osteochondral fragment and fracture site in the glenoid, distributing load more evenly and reducing stress on individual suture anchors [22]. This configuration provides higher pull-out strength and reduces the risk of failure or recurrence [22]. Several biomechanical studies show that double-row repair provides a statistically significant biomechanical advantage compared to single-row repair for shoulder instability [22]. However, published literature does not support the use of double-row suture anchor fixation to improve clinical outcome, although some studies report it may improve tendon healing [34]. Tape-like double-row suture bridge repair is clinically non-superior to conventional double-row suture bridge repair despite theoretical biomechanical advantages [55]. The double-loaded biodegradable suture anchor eliminates the need for implant removal and reduces the potential risk of abrasion to the glenohumeral joint cartilage from knots [22]. For flexor digitorum profundus reinsertion, meta-analysis indicates that suture anchor repair offers increased initial construct stiffness and less gap formation compared to suture button pullout, with no significant differences in ultimate failure load [107].

Alignment / Balancing Strategy: The single-row technique is preferred due to its simplicity and effectiveness in achieving good tendon-to-bone healing [91]. This technique has shown positive outcomes in terms of pain relief, improved range of motion, and functional recovery [91]. The success of the single-row technique depends on various factors such as the size and location of the tear, patient characteristics, and surgeon expertise [91].

Adjuncts: Arthroscopic transosseous superior capsular reconstruction outcomes are not inferior to anchor-based techniques and involve less suture tangling, more precise suture pass points, and lower costs [10]. Arthroscopic transosseous rotator cuff repair using a bone tunneling device facilitates robust and reproducible repairs while substantially reducing procedural costs compared to suture anchor techniques [21]. The dermal tuberoplasty technique for irreparable supraspinatus tears simplifies graft delivery and suture management by using a graft inserter and a self-punching, knotless technique of graft fixation [39]. The modified procedure maintains the advantages of the original all-suture tape cerclage technique, including negligible risk of hardware irritation, limited material requirements, and reliable maintenance of reduction, while reducing the risk of postoperative fracture [117].

Other Considerations: Complications related to suture anchors and tacks are categorized as technique-related or device-related issues, and prevention depends on the surgeon's familiarity with the devices and knowledge of their indications and limitations [11]. Careful attention to proper anchor insertion techniques can limit the potential for complications, and newer materials may address concerns of biocompatibility and material strength [7]. Postage stamp fractures were reported frequently in patients who were male, age 25 years or younger, and participants in sporting activities, and in fractures initially stabilized with 3 or more anchors or conventional knot-tying anchors or that experienced osteolysis around anchor sites [12]. Bioabsorbable poly-L/D-lactic acid anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable suture anchors [90]. The arthroscopic shoulder labral repair using a knotless all-suture anchor with suture tape has disadvantages including a possible large defect if the 4.0-mm-size anchor were to pull out and no clear differentiator between the looped and non-looped end of the passing suture in the joint [18]. The shoulder Latarjet procedure using all-suture anchor and button fixation offers a biomechanically stable fixation [26]. The acromioclavicular joint reconstruction with acromioclavicular ligament augmentation uses a knotless, all-suture anchor construct [57]. There is a paucity of literature in the repair techniques and outcomes for musculotendinous junction rotator cuff tears [134].

Complications

General Classification and Prevention

Prevention of suture anchor complications relies on the surgeon’s familiarity with the devices and a thorough knowledge of their indications and limitations [11]. Careful attention to proper anchor insertion techniques can limit the potential for complications [7]. Suture anchor designs and materials have evolved to minimize complications [127].

Device-Related Complications

Bioabsorbable anchors are considered a safe, reproducible, and consistent implant, with reported complications amounting to a fraction of the total anchors implanted [24]. Suture anchor prolapse is a recognized complication in medical practice [50]. A 1.8-mm all-suture anchor for acetabular labral repair demonstrated exceptionally reliable security at the time of implantation with no demonstrable learning curve in experienced hands [62].

Recovery

Other Considerations: Long-term follow-up is necessary to determine if the durability of arthroscopic double-row transosseous-equivalent rotator cuff repairs and the structural integrity of these constructs maintain their performance over time [103]. Following arthroscopic double-row suture-bridge rotator cuff repair, longer follow-up time was associated with better patient-reported outcomes in both anchor type groups [54]. The all-suture anchor offered equivalent clinical performance to an established solid suture anchor at the 12-month follow-up in patients undergoing arthroscopic repair of rotator cuff tears [56]. Excellent short-term clinical outcomes and substantial improvements were demonstrated for patients undergoing double-row suture bridge rotator cuff repair with all-suture anchors for medial row fixation [19]. In a case report of non-simultaneous bilateral distal biceps brachii tendon rupture, no significant differences were evident between one-point and two-point fixation in the short-term follow-up [35]. Bioabsorbable anchors remain a safe, reproducible, and consistent implant to secure soft tissue to bone in and about the shoulder, with reported complications amounting to a fraction of the total anchors implanted [24]. The use of bone anchors results in less risk of migration of the implant into the joint capsule or interference caused by the device during later radiological examinations (MRI/CT) [32].

Key Evidence

• [L3] Various bone changes are seen after implantation of an all-suture anchor, but these are not clinically relevant. [1] (10.1177/17585732221127433)
• [L5] The goals of this article are to review the biological and biomechanical factors that influence the successful evaluation and use of suture anchors and tacks. [2] (10.1177/0363546505282621)
• [L5] The small, 2.6-mm all-suture anchor mitigates risks and difficulties associated with other fixation devices while providing ease and efficiency for the surgeon. [3] (10.1016/j.eats.2023.02.030)
• [L5] The authors summarize the pearls and pitfalls of the new technique, noting that overtightening sutures may cause anchor pull-out. [4] (10.1016/j.eats.2023.11.019)
• [L4] All-suture anchors have similar or better mechanical properties than regular anchors, with low-profile design preserving bone tissue. [5] (10.1016/j.asmr.2020.02.007)
• [L5] This technique avoids a difficult trajectory and large-diameter bone punches during anchor insertion seen with other techniques, providing a reproducible and secure fixation. [6] (10.1016/j.eats.2024.103354)
• [L4] Careful attention to proper anchor insertion techniques can limit the potential for complications, and newer materials may address concerns of biocompatibility and material strength. [7] (10.1016/j.arthro.2008.08.018)
• [L5] It requires only 2 suture anchors, fewer than for double-row repair, and allows slow, controlled compression of the fracture during reduction. [8] (10.1016/j.eats.2024.103297)
• [L3] The repair technique (knotted suture-bridging or knotless tape-bridging) did not have a significant effect on the final outcome at a mean of 2.9 years. [9] (10.1007/s00402-017-2750-7)
• [L5] The outcomes of ATSCR are not inferior to those of anchor-based techniques and involve less suture tangling, more precise suture pass points, and lower costs. [10] (10.1016/j.eats.2023.03.022)
• [L4] Complications related to suture anchors and tacks can be categorized as technique-related or device-related issues, and prevention depends on the surgeon's familiarity with the devices and knowledge of their indications and limitations. [11] (10.1177/0363546505284240)
• [L4] Postage stamp fractures were reported frequently in patients who were male, age 25 years or younger, and participants in sporting activities and in fractures initially stabilized with 3 or more anchors or conventional knot-tying anchors or that experienced osteolysis around anchor sites. [12] (10.1016/j.arthro.2019.02.047)
• [L3] We recommend routine radiographic follow-up after use of metallic anchors to ensure identification of early failure by anchor pullout. [13] (10.1016/j.arthro.2009.08.015)
• [L4] Good longterm results were observed after arthroscopic Bankart repair in patients older than 20 years with 3 or more suture anchors used. [14] (10.1016/j.jse.2018.09.027)
• [L5] This technical description describes knotless 'all-suture' suture anchor fixation for isolated posterior labral tears. [15] (10.1016/j.eats.2023.03.011)
• [L5] Knotless technology has been found to be a more reproducible method and have comparable outcomes with those found using knotted anchors. [16] (10.1016/j.eats.2024.102909)
• [L3] While no single technique is overwhelmingly superior, bar anchoring with a threaded Steinmann pin is a viable solution that utilizes primary anchor sites with acceptable results. [17] (10.1007/s00167-020-05935-4)
• [L5] However, disadvantages include a possible large defect if the 4.0-mm-size anchor were to pull out and no clear differentiator between the looped and non-looped end of the passing suture in the joint. [18] (10.1016/j.eats.2025.103598)
• [L4] Our study demonstrated excellent short-term clinical outcomes and substantial improvements for patients undergoing double-row suture bridge RCR with all-suture anchors for medial row fixation. [19] (10.1177/23259671231192134)
• [L5] The arthroscopic 'double-pulley' suture anchor technique achieved anatomic reduction and secure fixation of the avulsed fragment while preserving surrounding soft tissue. [20] (10.1016/j.eats.2025.103949)
• [L5] This system facilitates robust and reproducible repairs while substantially reducing procedural costs compared to suture anchor techniques. [21] (10.1016/j.eats.2025.103566)
• [L5] [22] (10.1016/j.eats.2023.07.020)
• [L5] Bioabsorbable anchors remain a safe, reproducible, and consistent implant to secure soft tissue to bone in and about the shoulder, with reported complications amounting to a fraction of the total anchors implanted. [24] (10.1177/0363546511417573)
• [L5] All-suture anchor fixation preserves glenoid bone stock, facilitates postoperative imaging on magnetic resonance imaging, and offers a biomechanically stable fixation. [26] (10.1016/j.eats.2025.103636)
• [L5] There has been a major shift from metallic to bioabsorbable anchors due to higher complication rates with metallic anchors and lower rates with bioabsorbable ones. [27] (10.1016/j.arthro.2007.05.011)
• [L3] Patients who undergo aRCR using all-suture medial row anchors have increased abduction and strength postoperatively, as well as lower pain scores compared to traditional suture anchors during a transosseous equivalent repair. [31] (10.1177/2325967126s00050)
• [L3] [32] (10.1016/s0020-1383(02)00130-4)
• [L5] The cement augmentation technique described is quick, reproducible, and backed by previous biomechanical studies to provide adequate fixation of suture anchors in cases with bone defect in proximal humerus. [33] (10.1016/j.eats.2023.02.025)
• [L2] At present, the data in the published literature do not support the use of DR suture anchor fixation to improve clinical outcome, but there are some studies that report that DR suture anchor fixation may improve tendon healing. [34] (10.1016/j.arthro.2009.02.005)
• [Case_report] In this case, no significant differences were evident between one-point and two-point fixation in the short-term follow-up. [35] (10.1186/s12891-020-03304-3)
• [L5] This all-suture tape cerclage technique for the fixation of high-grade AC joint separations was designed to capitalize on the physical properties of this recently developed suture material while minimizing the risk of complications inherent to currently popular procedures. [36] (10.1016/j.eats.2024.103184)
• [L4] Patients treated using knotted anchors were significantly more likely to experience a postoperative complication compared with patients treated using knotless anchors after arthroscopic repair of isolated type II SLAP lesions. [37] (10.1177/2325967120911361)
• [L5] The technique described simplifies graft delivery and suture management by using a graft inserter and a self-punching, knotless technique of graft fixation. [39] (10.1016/j.eats.2022.08.060)
• [L5] Due to technical efficiency of the proposed procedure, and ability to still maintain a strong biomechanical construct, we believe that a single anchor medial-row construct to be a promising technique in the repair of even massive rotator cuff tendon tears. [46] (10.1016/j.eats.2022.03.035)
• [L4] This technique enables the even distribution of sutures above the fracture fragment, reduces the possibility of suture displacement, and enables excellent reduction under arthroscopy while fully preserving the posterior septum. [48] (10.1016/j.eats.2025.103558)
• [L4] No inflammatory reactions were documented in the studied anchors. [49] (10.1016/j.arthro.2014.02.011)
• [Case_report] Suture anchor complications, such as prolapse, are a concern in medical practice. [50] (10.1186/s12891-024-07476-0)
• [Paper] Most radiolucent rings appeared at anteromedial anchors, indicating that mechanical factors may play a role for the radiolucencies. [51] (10.1007/s00402-017-2772-1)
• [L4] [53] (10.1002/atn2.70169)
• [L2] Following arthroscopic double-row suture-bridge RCR, longer follow-up time was associated with better patient-reported outcomes (PROs) in both anchor type groups. [54] (10.1016/j.xrrt.2025.100639)
• [L3] Tape-like double-row suture bridge repair was clinically non-superior to conventional double-row suture bridge repair despite theoretical biomechanical advantages. [55] (10.1007/s00167-023-07454-4)
• [L1] The all-suture anchor offered equivalent clinical performance to an established solid suture anchor at the 12-month follow-up in patients undergoing arthroscopic repair of rotator cuff tears. [56] (10.1016/j.arthro.2023.06.056)
• [L5] The knotless, low-profile design, using a readily available biomechanically tested anchor, eliminates a prominent knot stack superiorly and decreases the risk of stress riser in the acromion and distal clavicle compared to larger, solid body anchors. [57] (10.1016/j.eats.2024.103226)
• [L4] The data support that the security of this particular 1.8-mm all-suture anchor at the time of implantation is exceptionally reliable, and there is no demonstrable learning curve in employing the product in the hands of an experienced surgeon. [62] (10.1016/j.arthro.2017.09.049)
• [L3] Bioabsorbable PLDLA anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable suture anchors. [90] (10.1016/j.arthro.2011.06.021)
• [L1] [91] (10.1016/j.xrrt.2025.05.017)
• [L4] The modified arthroscopic en masse suture bridge technique was effective for repairing delaminated RCTs, yielding favourable clinical outcomes comparable to those of nondelaminated tears. [102] (10.1002/ksa.12412)
• [L4] Long-term follow-up will be necessary to determine if the durability of these repairs and the structural integrity of these constructs maintain their performance over time. [103] (10.1177/0363546510397725)
• [L1] Via meta-analysis, there was increased initial construct stiffness and less gap formation for suture anchor repair compared to suture button pullout for FDP reinsertion, with no significant differences for ultimate failure load. [107] (10.1177/15589447221126760)
• [L2] [109] (10.1177/17585732221094828)
• [L3] [114] (10.1016/j.jse.2017.10.040)
• [L5] [115] (10.1016/j.eats.2023.03.009)
• [L4] The modified procedure maintains the advantages of the original all-suture tape cerclage technique, including negligible risk of hardware irritation, limited material requirements, and reliable maintenance of reduction, while reducing the risk of postoperative fracture. [117] (10.1016/j.eats.2025.103752)
• [L5] LHBT augmentation and knotless sutures provide both biological and biomechanical additional advantages to the side-to-side and subsequent tendon-to-bone repair. [121] (10.1016/j.eats.2024.102980)
• [L4] Suture anchors have revolutionized upper limb surgery by enabling arthroscopic soft tissue-to-bone repair, with designs and materials evolving to minimize complications. [127] (10.1016/j.hcl.2012.08.002)
• [L5] There is a paucity of literature in its repair techniques and outcomes. [134] (10.1016/j.eats.2023.07.036)
• [L4] Use of these anchors should be reconsidered because of possible interference with revision surgery. [137] (10.1177/0363546513517538)

See Also

• Rotator cuff repair
• Fractures
• Os Acromiale
• Rotator Cuff
• Shoulder Instability
• Calcific Tendinitis
• Latarjet Procedure

References

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