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Journal of Orthopaedic Surgery and Research logoLink to Journal of Orthopaedic Surgery and Research
. 2025 Nov 25;20:1100. doi: 10.1186/s13018-025-06513-5

All-suture anchor arthroscopic repair of the distal biceps tendon: impact of suture cross-section on fixation strength and gap formation resistance

Massimiliano Baleani 1,✉, Marco Cavallo 2, Roberta Fognani 1, Paolo Erani 1, Audrey Tonnin 1, Fabio Tortorella 2, Enrico Guerra 2
PMCID: PMC12751613  PMID: 41291826

Abstract

Background

A minimally invasive arthroscopic technique may reduce complications such as heterotopic ossification, synostosis and arthrofibrosis after distal biceps brachii tendon repair. Ensuring adequate postoperative mechanical performance is crucial to minimize complications during healing. This study evaluated the mechanical performance—with a special focus on gap resistance—of a minimally invasive arthroscopic technique performed using two all-suture anchors, with different suture cross-sectional shapes.

Methods

Single-incision repair was performed on twelve arms using two all-suture anchors loaded with either two round (wire) or two flat (tape) sutures. One wire/tape from each anchor was used to grasp the tendon with four Krackow locking loops, while the other was used to stitch a transversal Mattress. Each repair underwent loading cycles, followed by a load-to-failure test. Subsequently, the anchor fixation and the suture-tendon construct underwent the same loading cycles separately to determine their individual gap resistance.

Results

All 12 repairs successfully completed the cyclic test. No significant differences were found in ultimate load values (wire group: median 350 N, range 236–623 N; tape group: median 349N, range 271–483 N; p = 0.63). The most common failure mode (N = 6) was by loosening of both Krackow stitches while the paired Mattress cut through the tendon. A large unrecoverable elongation was measured at the 500th cycle, regardless of the suture cross-sectional shape (wire group: median 5.2 mm, range: 4.0–8.1 mm; tape group: median 5.1 mm, range: 4.2–7.0 mm; p = 0.87). Of this, only 0.7–1.3 mm was due to all-suture anchor seating and suture elongation, the remaining elongation being a combination of tendon strangulation/tearing and stretching. Increasing tendon thickness from 1.7–1.8 to 3.0 mm reduced unrecoverable repair elongation by approximately 50%, from 7–8 to about 4 mm.

Conclusions

Suture cross-section does not seem to affect the mechanical performance of the repair. The minimally invasive arthroscopic technique provides fixation strength that can safely withstand early mobilisation exercises. However, progressive loading, i.e. flexion against resistance, must be allowed with caution to minimise the risk of soft tissue damage, especially in thin tendons, and the associated risk of gap formation and delayed healing.

Level of evidence

Basic science study; Biomechanics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-025-06513-5.

Keywords: Elbow, Distal biceps brachii tendon, Surgical repair, All-suture anchor, Biomechanical evaluation, Ultimate load to failure, Repair elongation

Background

Complete rupture of the distal biceps tendon at the elbow level results in a limited function of the upper arm. Patients with a ruptured distal biceps tendon have been found to have a significant decrease in flexion and supination strength of up to 60% [1, 2]. Surgical repair is often required to restore forearm supination and elbow flexion, particularly in physically active adults [3–5]. However, this procedure carries a risk of complications associated with the surgery [6, 7].

Different distal biceps repair techniques have been proposed for surgical treatment to restore forearm function and minimise the risk of complications. Surgical repair may include different fixation methods (cortical buttons, transosseous sutures, interference screws, metal or all-suture anchors or a combination thereof) and approaches (single- versus double-incision) [8–16]. While there is no clear consensus on the best repair technique, complications associated with distal biceps repair are well known. Nerve palsy or injury is the most common complication, which can lead to temporary or permanent disability for the patient [17–21]. In addition to infection or wound healing delay, other major complications are mechanical failure of the repair, heterotopic ossification, synostosis, arthrofibrosis and pain. The likelihood of these complications occurring, and which nerves are at risk of injury, depends on the fixation technique and approach. Indeed, the lateral antebrachial cutaneous nerve has been reported to be at higher risk with the single-incision approach, whereas the posterior interosseous nerve may be at risk with both single- and double-incision approaches [17–24].

As mentioned above, the fixation technique is a debated topic in distal biceps reinsertion. Developments in fixation techniques have made available all-suture anchors, also known as soft anchors. This fixation technique avoids the use of metal hardware in the patient’s bone, thereby preventing metal-induced artifacts in clinical imaging [25, 26]. All-suture anchors have also recently been proposed for mini-open distal biceps repair [27, 28]. To minimize bone damage, the use of unicortical holes for anchor insertion has been proposed. A previous experimental study compared all-suture and titanium anchors [29]. No significant differences were observed in repair stiffness, ultimate load to failure, or failure mode. Findings regarding fixation strength may support the feasibility of early active mobilisation, as proposed for other reconstruction techniques [30]. Achieving an adequate fixation strength is a requisite to reduce the risk of mechanical failure of the repair in the initial postoperative course. However, gap resistance is also important, as a gap at the tendon-bone interface may have detrimental effect on healing outcomes [31]. Otto et al. reported that all-suture anchor reconstructions have reduced gap resistance compared to titanium anchor reconstructions, although the final gap was always smaller than 3 mm [29]. In that study, gap resistance was assessed by applying a cyclic force to simulate the passive contraction force (50 N) of the biceps tendon [32, 33]. Allowing early active mobilisation subjects the reconstruction to higher cyclic loads [34]. These higher loads may promote the formation of a gap larger than 3 mm. A large gap can delay or even prevent tendon healing [35].

Gap resistance of the repair has improved through changes in tendon reattachment techniques, enhancements in the mechanical performance of sutures, and appropriate suture tensioning [36–38]. A recent study has shown that reconstructions using flat sutures exhibit higher gap resistance than those using wire sutures [39]. Therefore, it could be hypothesised that the cross-section of the sutures affects the mechanical performance of the repair, particularly its gap resistance.

The aims of this experimental study were: (i) to compare the performance of two distal biceps repairs under cyclic loading conditions, intended to simulate early active mobilisation, followed by a load-to-failure test, and (ii) to investigate the source of permanent elongation of the repair that may determine gap formation at the tendon-bone interface. Two different all-suture anchors were used to provide fixation in the two repairs: one with two flat sutures, hereinafter referred to as tapes, and the other with two round-shaped sutures, hereinafter referred to as wires.

Materials and methods

Experimental design

The study consisted of two subsequent experimental sessions. In the first session, the entire repair underwent cyclic loading to assess the gap resistance in terms of repair permanent elongation. This was followed by a load-to-failure test to determine the fixation strength. In the second session, permanent elongation was measured in all-suture anchor fixation as well as in suture-tendon construct under the same cyclic loading conditions as the first session. The aim was to quantify the proportion of repair permanent elongation due to anchor seating and suture elongation rather than tendon strangulation/stretching and stretching.

Specimen collection and management

Six pairs of fresh-frozen human arms were obtained through an international donation program (Science Care, Phoenix, AZ). The average age of the six donors, two females and four males, was 41 years (range 19–54 years). Inclusion criteria required that donors had no history of upper limb surgery, no evidence of soft tissue pathology, and no evidence of osteoporosis.

The twelve arms were divided into two groups of six, with left and right arms alternated between groups. Each group included three left and three right arms from six donors, with the contralateral arms assigned to the opposite group. One of two distal biceps repair techniques was randomly assigned to each group. The order of repairs was alternated between donor pairs, with each technique performed in reverse sequence compared to the previous pair.

Preliminarily, bone mineral density (BMD) of the proximal radius was assessed. Dual-energy X-ray absorptiometry (bone densitometer: Discovery Wi, Hologic, Marlborough, MA) was performed with the elbow fully extended and the forearm fully pronated. BMD was measured at the radial tuberosity, to exclude differences in bone tissue quality between the two groups, and at the radial neck, for comparative purposes with a previous report (see the discussion section). No significant differences were found in radial tuberosity BMD values measured for the two groups (wire group: median 0.62 g/cm3, range 0.44–0.65 g/cm3; tape group: median 0.60 g/cm3, range 0.44–0.71 g/cm3; Mann–Whitney test: p = 0.69).

Forty-eight hours prior to the first experimental session, the arm was transferred from the freezer to a 4 °C refrigerator. Distal biceps lesion, lesion repair, preparation for mechanical testing and mechanical testing were completed within 7 h after removal from the refrigerator, including 4 h of room-temperature warming. At the end of the experimental session the arm and the tendon-biceps brachii specimen were refrozen separately at − 20 °C. The same thawing protocol was used for the arm before the second experimental session, while the smaller tendon-biceps specimen was thawed on the day of testing.

First experimental session

Distal biceps lesion

A 30 mm skin incision at the level of the supinatory crest of the ulna was performed with the forearm in full pronation. The anconeus muscle was split along its fibres and the distal biceps insertion was reached. No distal biceps lesion or tear was observed. The distal biceps was completely sectioned with a scalpel blade at its insertion point on the radial tuberosity.

All-suture anchor arthroscopic repair

The distal biceps lesion was repaired with a single anterior approach. With the forearm in full supination the cubital fossa was identified. A 20 mm longitudinal skin incision was performed, starting 30 mm distally to the cubital fossa and medially to the brachio-radialis muscle. The previously sectioned biceps tendon was identified, and the procedure continued under endoscopic guidance with a 4 mm–30° arthroscope (HD4300 Arthroscope Set/IM3300 EDTV camera console/C3140 Xenon Light Source, Linvatec, FL).

The bicipital tuberosity was identified, and the insertional area was cleaned of any residual fibrous tissue. Two 2.7 mm holes were performed for the anchor insertion, centered between the medial and lateral radial edges. Each pilot hole was drilled in proximal-to-distal direction at a 55-degree angle relative to the table, with the forearm in full supination. This angle was chosen to allow arthroscopic access and minimize the incision and dissection required with an insertion angle of 90 degree. Only the anterior cortex was drilled to avoid breaching the posterior cortex. The pilot hole was then enlarged with a 2.8 mm drill bit to facilitate the anchor insertion. Two different all-suture anchors were used in the two groups: all-suture anchors loaded with two wires (Y-Knot® with two #2 Hi-Fi® Sutures YRC02, ConMed, NY) and all-suture anchors loaded with two tapes (Y-Knot® with two 1.3 mm Hi-Fi® Ribbons YRC02R, ConMed, NY). Each all-suture tissue anchor was inserted into the bone at the same 55-degree angle. The gross stability of each of the 24 anchors was assessed by manually pulling on all the wires/tapes.

Tendon reattachment preparation began by measuring its thickness and width 10 mm from the distal end using a digital caliper. The long head of the biceps tendon was sutured with the proximal anchor and the short head with the distal anchor to recreate the tendon anatomical insertion [36, 40]. A free needle was used to pass one end of the first wire/tape of the first anchor through the tendon four times on one side, going proximally and then distally and achieving four Krackow locking loops. The second wire/tape of the anchor was used to create a transversal Mattress stitch, sewn more than 5 mm from tendon’s end. This ensured a bone-tendon contact area similar to the native one and a free-end extension beyond the stitch of over 5 mm. The same procedure was carried out on the other side of the biceps tendon using the wire/tape of the second anchor. The sliding ends of the wires/tapes were pulled, docking the end of the tendon onto the bicipital tuberosity. The wires/tapes were secured with Samsung Medical Centre (SMC) sliding knots and finished with four simple knots starting from the Mattress stitch, while pulling the sliding end of the Krackow wire/tape to keep the tendon close to the tuberosity (Supplementary file Video 1).

Mechanical testing of arthroscopic repair

The mechanical test requires a force to be applied to the biceps brachii along the direction of anchor insertion, simulating the worst-case scenario (Fig. 1). Therefore, the proximal end of the biceps brachii was freed of any overlying soft tissue to allow grasping of the muscle, and the lacertus fibrosus was cut. Additionally, the lateral soft tissues were removed distally to the radial tuberosity to expose the proximal lateral side of the radius. The annular ligament integrity was preserved.

Fig. 1.

Fig. 1

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a The simulated activity involves supporting a 1 kg weight placed on the hand with the elbow flexed at 90 degrees. b To minimize bias, the load was applied along the axis of the holes. This approach required extending the humerus to avoid impingement with the cryo-clamp. c Due to practical constraints, the arm was mounted upside down on the material testing machine. d A rigid rotation of the entire arm was required to align the biceps brachii muscle with the actuator axis of the testing machine

The arm was placed in a custom-made chassis consisting of two frames inclined towards each other by an angle of 30 degrees (Fig. 2). An M10 threaded rod was screwed into the medullary canal of the humerus and locked with a locknut. The humerus was pushed against the support plane, on which the forearm rested in full supination, by means of a sliding guide acting on the threaded rod. The distal frame maintained the longitudinal alignment of the forearm. A silicone pad (Fig. 2) forced the wrist against the support plane. This custom-made chassis maintained the spatial orientation and restricted the radius movement, while allowing a slight adjustment in radius orientation to align the repair with the applied load.

Fig. 2.

Fig. 2

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Schematic representation of the experimental model. The custom-made chassis is mounted in an upside-down position The supporting plane, on which the forearm is rested in full supination, is inclined by 30 degrees from the crosshead. Since the posterior forearm muscle prevented the olecranon from contacting the support plane, a concave wedge was inserted between the elbow and the support plane and pushed longitudinally in distal direction to provide support. The concave wedge is inserted, while adjusting the tightening of the locknut, until the exposed radius is inclined by about 5 degrees versus the support plane. The elbow is flexed at 30 degrees to avoid the interference of the proximal frame supporting the humerus with the cryo-clamp. The custom-made cryo-clamp grasps the proximal end of the biceps brachii to apply a tensile load to the muscle. The two-arm extensometer is attached to the lateral side of the repair. The extensometer measures the elongation between the radius and the distal biceps tendon (circular inset). A small hinge on the bracket attached to the radio allows the extensometer to swivel and track any off-axis tendon elongation

The custom-made chassis was mounted on a material testing machine in an upside-down position at an angle of 30 degrees from the crosshead (Fig. 2). Therefore, the biceps brachii was suspended vertically, aligned with the direction of anchor insertion. The biceps brachii was clamped in a custom-made cryo-clamp. A preload of 10 N was applied. A two-arm extensometer (2620-601 modified to increase the travel length to 20 mm, accuracy of 0.01 mm, Instron, Norwood, MA) measured the elongation of the repair. One arm of the extensometer was attached to the lateral side of the radius by means of two metal pins inserted into the cortical wall; the other arm was directly fixed to the tendon by means of a needle (Fig. 2, circular inset). To ensure comparability between replicates, the initial distance between the radius surface and the needle inserted into the tendon was kept constant at 12 mm (Fig. 2, arrow in circular inset).

Cyclic loading (10–100 N) was applied in load control mode for 500 cycles at 0.25 Hz. The repair was then loaded to failure at a deformation rate of 0.1 s−1 to determine the fixation strength.

The gap resistance was assessed by measuring the repair unrecoverable elongation. Unrecoverable elongation is defined as the difference in repair length at the start of the test and after cyclic loading, that is the lengthening of the entire repair when the tensile load is released (Fig. 3). This was measured at the end of the 20th and 500th cycle.

Fig. 3.

Fig. 3

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Schematic representation of the unrecoverable elongation of the entire repair. The green double arrow represents the initial length of the repair as monitored by the extensometer. The nominal initial distance between the radius surface and the needle inserted into the tendon was kept constant and equal to 12 mm. The yellow and red double arrows indicate the unrecoverable elongation at the end of the 20th and 500th cycle, respectively. The unrecoverable elongation is the sum of four components: tendon stretching, tendon tissue strangulation and/or tearing due to load transfer at the level of the stitches, wires/tapes elongation and seating of the all-suture anchor against cortical wall

Fixation strength was evaluated in terms of repair stiffness and ultimate load to failure. Repair stiffness was calculated as the slope of the load–displacement curve measured during the load to failure test. Ultimate load to failure was the maximum force value measured by the load cell during the test. Two operators determined the failure mode by visually inspecting the failed repair and reviewing the video footage recorded during the test.

Second experimental session

Mechanical testing of all-suture anchor fixation

The proximal radius was excised from the arm starting at the mid-diaphysis and cleared of soft tissue. A bone cement cylinder was moulded around the diaphysis, leaving the radial tuberosity exposed. The previously drilled distal pilot hole was identified. If an all-suture anchor remained from the earlier testing, it was pushed into the tuberosity using a blunt tip 1.4 K-wire. A new all-suture anchor, identical to the one already inserted in the first experimental session, in order to maintain the previous grouping scheme, was inserted at a 55-degree angle. Gross stability was assessed by manually pulling on all the wires/tapes.

The radius was clamped via the bone cement cylinder to align the pilot hole axis vertically and with the testing machine actuator axis (Fig. 4). The wires/tapes of the all-suture anchor were passed around a 6 mm metal rod, maintaining a constant initial distance of 12 mm between the radius surface and the rod tip (Fig. 4), and knotted. Cyclic loading (5–50 N; halved from the previous test due to the use of a single anchor) was applied in load control mode for 500 cycles at 0.25 Hz. The unrecoverable elongation was measured at the end of the 20th and 500th cycles.

Fig. 4.

Fig. 4

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Schematic representation of the experimental model. The radius is inclined at 35 degrees to the crosshead. The wires/tapes of the all-suture anchor are passed around a metal rod, maintaining an initial distance of 12 mm between the radius surface and the rod tip

Mechanical testing of suture-tendon construct

The first 20 mm distal tendon was cut to remove the tissue damaged during the first experimental session. Tendon suturing followed the method described in the Sect. “All-suture anchor arthroscopic repair” paragraph. The biceps brachii was vertically aligned and clamped in a custom-made cryo-clamp. Each wire/tape was passed around a vertically adjustable pulley and knotted, forming two parallel loops. The pulley height was adjusted to apply a preload of 5 N per loop, ensuring a balanced total preload of 10 N. Two two-arm extensometers (2620-601, Instron, Norwood, MA) were used to measure the tendon elongation on both sides. One arm was attached to the suture near the tendon’s distal end while the other to the tendon itself, via a needle inserted 12 mm away from the distal end (Fig. 5). The unrecoverable elongation was measured at the end of the 20th and 500th cycles.

Fig. 5.

Fig. 5

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Schematic representation of the experimental model. The muscle, along with its tendon, is clamped vertically. Each wire/tape is passed around a vertically adjustable pulley and knotted, forming two parallel loops. Two two-arm extensometers measure the tendon elongation on both sides

Statistical analysis

A sample size of N = 6 was calculated to detect a 50% difference in gap resistance using the threshold of 3 mm as the reference level [35], with a type I error probability of 5% and a statistical power of 80%. Based on data scattering reported in a similar study [29], a standard deviation of 0.8 mm was assumed.

The Mann–Whitney test was used to assess differences in radial tuberosity BMD, gap resistance and fixation strength between the two groups. This non-parametric test was selected due to the small sample size.

Results

Gap resistance of arthroscopic repair

All 12 repairs successfully completed 500 cycles at 100 N. All repairs showed unrecoverable elongation at both the 20th and 500th cycle. No significant differences were found in repair elongation at either the 20th cycle (wire group: median 3.5 mm, range 2.9–5.1 mm; tape group: median 3.4 mm, range 2.9–4.2 mm; Mann–Whitney test: p = 0.69) or at the 500th cycle (wire group: median 5.2 mm, range 4.0–8.1 mm; tape group: median 5.1 mm, range 4.2–7.0 mm; Mann–Whitney test: p = 0.87).

The unrecoverable elongation seems to be inversely correlated with tendon thickness (Fig. 6). Indeed, the thinnest tendon represented the worst case, where a repair involving two all-suture anchors with two wires showed an unrecoverable elongation of 5.1 and 8.1 mm at the 20th and 500th cycle, respectively.

Fig. 6.

Fig. 6

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Scatterplot showing the possible inverse relation between the thickness of the biceps tendon and the unrecoverable elongation at the end of the 500th cycle

Fixation strength of arthroscopic repair

No significant differences were found in repair stiffness values (wire group: median 146 N/mm, range 126–164 N/mm; tape group: median 152 N/mm, range 123–186 N/mm; Mann–Whitney test: p = 0.52).

No significant differences were found in ultimate load to failure values (wire group: median 350 N, range 236–623 N; tape group: median 349 N, range 271–483 N; Mann–Whitney test: p = 0.63).

Three different modes of failure were observed (Fig. 7, Supplementary file Video 2): (i) wires/tapes of both the Krackow stitches became loose and the two Mattress stitches cut through tendon tissue (N = 6). In these cases, the two ends of the wires/tapes used for the Krackow stitches were loose with no visible knots. In contrast, the two loops of the mattress stitches were closed, and four parallel longitudinal cuts were visible at the end of the tendon; (ii) wire/tape of one Krackow stitch became loose and the paired Mattress cut through tendon tissue while one anchor pulled out of the radius (N = 5). While the loosening of one Krackow stitch was verified as described in the previous point, the grip of the second wire/tape on the tendon, i.e. the integrity of the Krackow and Mattress stitches, was assessed by pulling on the anchor that had been pulled out; (iii) both anchors pulled out of the radius (N = 1). The integrity of the Krackow and Mattress stitches were verified as previously described. The mode of failure impacts the ultimate load to failure of the repair (Fig. 8).

Fig. 7.

Fig. 7

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The three modes of failure observed in this study: a wires/tapes of both the Krackow stitches became loose and the two Mattress stitches cut through tendon tissue; b wire/tape of one Krackow stitch became loose and the paired Mattress cut through tendon tissue while the other anchor pulled out of the radius; c both anchors pulled out of the radius

Fig. 8.

Fig. 8

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Plot showing the ultimate load to failure values categorised according to the three different modes of failure

Gap resistance of all-suture anchor fixation

All 12 all-suture anchor fixations successfully completed 500 cycles at 50 N. All fixations showed small unrecoverable elongation at both the 20th and 500th cycle. No significant differences were found in fixation elongation at either the 20th cycle (wire group: median 0.8 mm, range 0.6–1.0 mm; tape group: median 0.8 mm, range 0.6–1.1 mm; Mann–Whitney test: p = 0.69) or at the 500th cycle (wire group: median 1.1 mm, range 0.8–1.3 mm; tape group: median 1.0 mm, range 0.7–1.3 mm; Mann–Whitney test: p = 0.58).

Gap resistance of suture-tendon construct

Ten out of 12 specimens successfully completed 500 cycles at 100N. Of the remaining two specimens, one tendon-biceps brachii specimen was damaged at the end of the first session and had to be discarded as unsuitable for the test, while one specimen did not complete the test due to an experimental error that occurred during the test. Therefore, in the latter case, only the elongation at the 20th cycle was measured.

No significant differences were found in fixation elongation at either the 20th cycle (wire group: median 2.2 mm, range 1.7–3.0 mm; tape group: median 2.5 mm, range 1.6–2.6 mm; Mann–Whitney test: p = 0.65) or at the 500th cycle (wire group: median 3.6 mm, range 2.9–4.6 mm; tape group: median 3.7 mm, range 2.7–4.3 mm; Mann–Whitney test: p = 0.75).

Discussion

The experimental data did not confirm the hypothesis: switching from an all-suture anchor with wires to one with tapes does not significantly improve the mechanical performance of the distal biceps repair, regardless of the parameter analysed.

The fact that no significant difference was found between the two groups does not contradict the findings of Gnandt et al. [41]. Their data show that switching from sutures (wires) to tape-like sutures improves cut through tendon tissue resistance of Krackow locking loops. This mode of failure did not occur in the present study. In our series, failure was due to loosening of both Krackow stitches in 6 out of 12 cases. Knot tying in the arthroscopic technique used here appears challenging, suggesting that a learning curve exists. Indeed, in the first three arm pairs, knot loosening occurred in four out of six cases. In the next three, pullout of at least one anchor occurred in four out of six cases. This highlights the importance of securely tying the SMC sliding knot and the four additional simple knots. When knots are tied securely, failure typically involves at least one anchor pullout. The ultimate load to failure tends to increase, becoming more comparable with the values reported in two similar studies where failure consistently occurred by all-suture anchor pullout [29, 42] (Table 1).

Table 1.

Ultimate load to failure reported in the literature for all-suture anchor repairs compared with that measured in the present study

Reference Radial tuberosity BMD
mean (SD)		 Radial neck BMD
median (IQR)		 Anchor type Insertion
angle		 Ultimate load to failure, mean (SD)
Otto 2019 [29] 0.58 (0.08) g/cm3 – FiberTak with one #2 FiberWire CL 45 degrees 293 (122) N
Colantonio 2022 [42] – 0.60 (0.08) g/cm3 FiberTak with one 1.3 mm FiberTape 45 degrees 537 (262) N
Present study 0.62 (0.08) g/cm3* 0.48 (0.07) g/cm3* Y-Knot with two 1.3 mm Hi-Fi Ribbons (tapes) 55 degrees 395 (83) N*
Present study 0.60 (0.06) g/cm3* 0.46 (0.08) g/cm3* Y-Knot with two #2 Hi-Fi Sutures (wires) 55 degrees 481 (149) N*
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*calculated by selecting cases where at least one anchor was pulled out of the radius

BMD values are reported in the same way as in the listed studies for comparative purposes. (SD = Standard deviation; IQR = interquartile range)

The BMD of the radial tuberosity, the anchor type, and the insertion angle all affect the ultimate load to failure. A smaller insertion angle (45° versus 90°) reduces the ultimate load to failure [43]. However, since the angles used in the three studies were similar, this effect is negligible. Bone quality also affects anchor performance [43, 44]. Therefore, the higher BMD in the radial neck reported by Colantonio et al. [42] may explain the higher ultimate load to failure reported in their study, despite the use of single-loaded anchors. Conversely, with similar BMD, the variation in ultimate load to failure compared to Otto et al. [29] is likely due to differences in anchor type. Indeed, Barber and Herbert have shown that “the ultimate failure load of an all-suture anchor is correlated directly with its number of sutures” [45].

It must be acknowledged that some repair techniques outperform the ones described in this study (Fig. 9).

Fig. 9.

Fig. 9

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Ultimate load to failure values reported in the literature for different techniques of distal biceps tendon repairs compared with those measured in the present study. The mean value and the standard deviation are given for comparison purposes. (N = sample size; * = calculated from published raw data; ** = approximate value estimated from figures in article)

However, even the lowest ultimate load to failure measured here exceeds the estimated biceps force needed to:

  • flex the elbow without resistance (about 50 N) [46];

  • support the forearm and a 1 kg weight placed on the hand at 90-degree elbow flexion [47].

This suggests that, provided elbow flexion against resistance is avoided, mechanical failure due to repair overload is unlikely during the initial stages of passive or active rehabilitation exercises. Such an approach is recommended to prevent stiffness or arthrofibrosis [48, 49] and to improve long-term QuickDASH scores [50].

Stability and tendon-footprint contact also play crucial roles, as excessive gap formation or motion at the tendon-bone interface impairs healing [31, 51]. While both investigated repairs exhibited high stiffness, non-negligible unrecoverable elongation was measured at the end of the cyclic loading. These values are:

  • comparable to those reported by Rutka et al. [52], who applied the same cyclic loading conditions;

  • greater than those reported by other groups [32, 53–56], where the applied cyclic loading conditions were half of those used in the present study.

The unrecoverable elongation is the combination of:

  • all-suture anchor seating against cortical wall [45];

  • localized tendon strangulation/tearing [57];

  • tendon stretching [58].

Tests conducted in the second experimental session showed that anchor seating and suture elongation accounted for about 1/4 of the total unrecoverable elongation. The remaining 3/4 likely resulted from localized tendon strangulation/tearing and tendon stretching. It is important to note that tendon stretching does not contribute to gap formation, whereas tendon strangulation/tearing occurs regardless of the type of suture-to-bone fixation. Although tendon-bone overlap on the medial side of the radius –initially extended by more than 5 mm—tends to prevent gap formation [59], the risk of gap formation still exists under loading conditions simulating a 1 kg mass lifting.

It has been suggested that a cheese-wire effect may play a role in determining unrecoverable elongation [57]. Indeed, the present data indicate that tendon thickness strongly influences this phenomenon: doubling the tendon thickness nearly doubles the gap resistance of the repair. Therefore, tendon thickness should be considered one of the key factors when planning a rehabilitation protocol. In cases involving thinner tendons, early elbow flexion against resistance may increase the risk of gap formation at the bone-tendon interface, regardless of the suture-to-bone fixation. This can potentially lead to delayed healing [31, 51] and, if the repair is overloaded, mechanical failure [57].

Some limitations must be considered when interpreting the present findings: (i) the small sample size of each group. A larger sample size would provide more detailed information on the effect of failure mode on ultimate load to failure (Fig. 8). However, the overall results would not change, as differences between the two repairs were small and not clinically relevant; (ii) all specimens had good-quality radial bone, which limits the extendibility of the results to osteoporotic cases; (iii) the experimental model does not account for tendon degeneration, which in clinical practice could reduce stitch grasping power and increase the risk of cut-through failure.

Conclusions

The present findings suggest that suture cross-section has no significant effect on the mechanical performance of the all-suture anchor arthroscopic repair. Both investigated all-suture repairs provide fixation strength in good-quality radial bone, enough to withstand early passive mobilisation. However, when a load simulating active flexion against resistance is applied to the repair, there is a risk of gap formation at the bone-tendon interface. This risk is higher with thinner tendon, as the gap resistance is mainly driven by tendon strangulation/tearing and stretching, together accounting for up to three-quarters of the final bone-tendon gap.

Data availabilty

Supporting data are provided in the supplementary information files.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file 1. (36.3MB, mp4)
Supplementary file 2. (5.2MB, mp4)
Supplementary file 3. (1.8KB, txt)

Acknowledgements

The authors would like to thank Gianpaolo Kauten for providing the medical devices and equipment used in this study, Luigi Lena for the illustrations and videos and Lucia Mancini for her help in revising the manuscript.

Author contributions

M.B., M.C. and E.G. conceived and designed the study; R.F., P.E. and A.T. contributed to implementing the experimental model; M.B., M.C., R.F., P.E., A.T. and F.T. carried out the experimental sessions; R.F. and P.E. processed the collected raw data; M.B, M.C. and E.G. analysed the data; M.B and M.C. wrote the original draft of the manuscript; All authors reviewed and approved the final version of the manuscript; M.B and E.G. acquired the financial support for the project; F.T. and E.G. managed the provision of materials, instrumentation and other tools.

Funding

Italian Program of Donation for Research “5 × 1000” is gratefully acknowledged for financial support. The funding bodies had no role in the design of the study, collection, analysis, and interpretation of data, or in writing the manuscript.

Declarations

Competing interests

The authors declare no competing interests.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

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Supplementary Materials

Supplementary file 1. (36.3MB, mp4)
Supplementary file 2. (5.2MB, mp4)
Supplementary file 3. (1.8KB, txt)

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