Comparison of 45° and 90° Medial Row Anchor Insertion Angles in Double-Row Suture Bridge Rotator Cuff Repair: A Biomechanical and Finite Element Analysis

Rotator cuff suture anchors have traditionally been inserted at the 45° “deadman” angle, but this recommendation was largely derived from single-row constructs and may not reflect the biomechanics of contemporary double-row suture bridge repairs. This study compared the biomechanical performance and stress distribution of medial row anchors inserted at 45° versus 90° in a double-row suture bridge construct. Sixteen ovine humeri with intact infraspinatus tendons were randomized to 45° or 90° medial anchor insertion (n = 8 each), and double-row suture bridge repair was performed using 3.5 mm metallic and PEEK anchors. Specimens underwent uniaxial tensile testing (10-N preload, 5 mm/min) to failure, measuring yield load, failure load, displacement, stiffness, and energy absorption; additionally, a CT-based finite element model of the human humerus assessed von Mises stress, strain, and deformation under 200 N loading. Mean failure load was 161.96 ± 50.99 N for 45° and 185.61 ± 60.97 N for 90° (p = 0.447), and stiffness was 31.63 ± 8.18 N/mm versus 36.79 ± 9.26 N/mm (p = 0.291). Displacement at failure was greater with 90° insertion (8.11 ± 0.51 mm vs. 6.65 ± 0.83 mm; p = 0.002), while energy absorption was higher but not significantly different (p = 0.255). Finite element analysis demonstrated lower bone von Mises stress with 90° insertion (14.03 MPa) compared with 45° (24.77 MPa), with similar deformation. In double-row suture bridge repair, 90° medial anchor insertion provides comparable fixation strength to that at 45° while reducing bone stress, suggesting a biomechanical advantage.