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3 DEADMAN THEORY 897 Fig 5. (A) If the suture anchor is placed directly under the cuff with a vertical suture, there is no x component of tension (T x ) in the suture to balance the pull of the rotator cuff (W x ). The system will attempt to reach equilibrium by having the rotator cuff pull away from the anchor to develop at x to balance W x. This can cause failure of the repair as well as very high tension in the suture at high angles of q. (B) Optimal suture orientation at 45 or less. This configuration builds in at x to balance W x. (Courtesy of the University of Texas Health Science Center at SF x ¼ W x þ A x T x ¼ 0 SF y ¼ A y W y T y ¼ 0 SM ¼ W x a T x a þ M 0 ¼ 0 By substituting the additional relationships a ¼ c sin q b ¼ c cos q T x ¼ T cos q T y ¼ T sin q one establishes the important relationship T cos q ¼ constant. Because q is inversely proportional to cos q, T decreases as q decreases, and T x increases as q decreases. because T cos q ¼ constant, tension in the suture is less at lower angles of q. Ideally, to minimize tension in the suture, thereby minimizing the chance of suture breakage, we should not place the anchor directly The Suture Anchor Construct This model shows two important mechanical relationships in the suture anchor construct. First of all, Fig 6. Pullout strength of a suture anchor increases as q decreases. That is, a suture anchor is more difficult to pull out at a low angle of q (6A) than at a high angle of q (6B). (Courtesy of the University of Texas Health Science Center at San Antonio.) Fig 7. Representation of q 1 and q 2. q 1, the pullout angle for the anchor (angle the suture makes with the perpendicular to the anchor); q 2, the tension-reduction angle (angle the suture makes with the direction of pull of the rotator cuff). Ideally, q 1 and q 2 should both be less than or equal to 45. (Courtesy of the University of Texas Health Science Center at San Antonio.)

4 898 S. S. BURKHART Fig 8. (A) If a vertically placed suture is used to repair the rotator cuff, there is no T x to balance W x. (B) The vertical suture configuration can only reach equilibrium if the repaired rotator cuff pulls away from its bed, decreasing q until T x is adequate to balance W x. (Courtesy of the University of Texas Health Science Center at under the cuff but at the lateral edge of it, and we should place the suture obliquely into the rotator cuff tendon to minimize q (Fig 5). Secondly, pullout strength of a suture anchor increases as q decreases (Fig 6). One can calculate that there is 41% more resistance to pullout at q ¼ 45 than at q ¼ This is one other reason to try to minimize q. Fig 9. Rotator cuff repair through bone tunnels. The obliquity of the tunnels ensures a significant T x to balance W x. (Courtesy of the University of Texas Health Science Center at The Obliquely Placed Suture Anchor One can infer from the above discussion that it is mechanically advantageous to place the suture anchor oblique into bone. However, if this is done, then there are two ideal angles of interest (Fig 7): q 1 ¼ the pull-out angle for the anchor, which is the angle the suture makes with the perpendicular to the anchor; and q 2 ¼ the tension-reduction angle, which is the angle that the suture makes with the direction of pull of the rotator cuff. Ideally, both q 1 and q 2 should be less than or equal to 45, the ideal angle that the ranchers strive for on their deadman wires. Avoiding Predestined Failure An ideally placed suture anchor will have an obliquely-placed suture that develops a tension (T x )to balance the pull of the rotator cuff (W x ) (Fig 5B). However, rotator cuff tears are frequently repaired directly over the top of a bone trough with a vertical suture (Fig 8A). This is a dysequilibrium situation because there is no T x to balance W x (Fig 8B). The only way that this system can reach equilibrium is for the cuff to pull away from its bed, thereby decreasing q until there is a T x adequate to counteract W x. This is exactly analogous to the fence post leaning until it reaches its ideal angle. It is interesting and instructive to look at the balance of forces in a standard rotator cuff repair through bone tunnels. Because the tunnels are always positioned obliquely across the greater tuberosity, there is always a significant T x in this configuration to balance W x, thus

5 DEADMAN THEORY 899 making it less likely that the repair will pull away from the bone (Fig 9). For a given value of pull by the rotator cuff, there is a specific value of T x required to counteract it. Because T x ¼ T cos q, the total tension T in the suture increases as q increases. As q approaches 90 (the verticallyplaced suture), one must bear in mind that cos 90 ¼ 0, so that T in this case would be infinite. It is important to appreciate that as q approaches 90, the tension in the suture rises dramatically, and the chance of suture breakage is much greater than at low angles of q. Conclusions Attention to minimizing the angle of insertion of the suture anchor (q 1 ), as well as the angle that the suture makes with the rotator cuff (q 2 ) can increase the pullout strength of the anchor and reduce the tension in the suture, thereby minimizing the chance of suture breakage. The deadman theory of suture anchors explains how to maximize the mechanical stability of the suture anchorerotator cuff construct by minimizing q 1 and q 2. References 1. Bartlett EC. Arthroscopic rotator cuff repair. Presented at the Arthroscopy Association of North America, Fall Course, Albuquerque, NM, October 7, Bachner EJ, Snyder SJ. Arthroscopic fixation of the torn rotator cuff tendon using suture anchors and permanent mattress sutures: A preliminary report. Presented at the Arthroscopy Association of North America, 1994 Speciality Day Meeting, New Orleans, LA, February 27, Tippett JW. Arthroscopic repair of the rotator cuff using plastic suture anchors. Presented at the Arthroscopy Association of North America, 1994 Specialty Day Meeting, New Orleans, LA, February 27, Faris ME. Personal communication, January Burkhart SS. The deadman theory of suture anchors. Presented at Update 1994: New Perspectives in Arthroscopy and Sports Medicine, Palm Springs, CA, March 16-19, 1994.

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