Biomechanical Evaluation of Knotless and Knotted All‐Suture Anchor Repair Constructs in 4 Bankart Repair Configurations

Purpose To evaluate the biomechanical performance of Bankart repair using 1.8‐mm knotless all‐suture anchors in comparison to 1.8‐mm knotted all‐suture anchors with both simple and horizontal mattress stitch configurations. Methods Thirty fresh‐frozen human cadaveric shoulders were dissected to the capsule, leaving the glenoid and humeral capsular insertions intact. A standardized anteroinferior labral tear was created and repaired using 3 anchors. A 2 × 2 factorial design was implemented, with 6 matched pairs randomized between knotless and knotted anchor repairs and 6 matched pairs randomized into simple and horizontal mattress stitch configurations. In addition, 6 unpaired shoulders were used to evaluate the native capsulolabral state. First failure load, ultimate load, and stiffness were assessed. Linear mixed‐effects modeling was used to compare endpoints. Digital image correlation was used to evaluate capsular strain throughout testing. Failure modes were reported qualitatively. Results The knotless all‐suture anchor repair showed similar biomechanical strength to the knotted all‐suture anchors for first failure load (coefficient, 142 N; 95% confidence interval CI, –30 to 314 N; P = .12), ultimate load (coefficient, 11.1 N; 95% CI, –104.9 to 127.2 N; P = .847), and stiffness (coefficient, 3.4 N/mm 2 ; 95% CI, –14.1 to 20.9 N/mm 2 ; P = .697) when stitch configuration was held constant. No statistically significant differences were found on comparison of simple and mattress stitch configurations for first failure load (coefficient, –31 N; 95% CI, –205 to 143 N; P = .720), ultimate load (coefficient, 112 N; 95% CI, –321 to 97 N; P = .291), and stiffness (coefficient, –9.6 N/mm 2 ; 95% CI, –27.3 to 8.1 N/mm 2 ; P = .284) when anchor type was held constant. Specimens with knotless anchors and simple stitch techniques resulted in lower stiffness compared with the native state ( P = .030). The knotless‐mattress configuration resulted in significantly lower strain than the knotted‐mattress ( P = .037) and knotless‐simple ( P = .019) configurations and was the only configuration that did not result in a significant increase in strain compared with the intact specimens ( P = .216). Fewer instances of suture slippage (loss of loop security) were observed with knotless anchors versus knotted anchors (11% vs 30%), and less soft‐tissue failure was observed with the mattress stitch configuration versus the simple stitch configuration (36% vs 47%). Conclusions Knotless and knotted all‐suture anchor repairs with simple and mattress stitch configurations showed similar values of ultimate load, first failure load, and stiffness. However, the horizontal mattress stitch configuration proved to decrease capsular strain more similarly to the native state compared with the simple stitch configuration. Ultimate load and first failure load for all repairs were similar to those of the native state. Clinical Relevance Knotless all‐suture anchors have a smaller diameter than solid anchors, can be inserted through curved guides, and preserve glenoid bone stock. This study presents knotless, tensionable all‐suture anchor repair for labral tears that displays high biomechanical fixation strength, similar to the native capsulolabral state.