participate in this session, not just to be back in public, but also to be able to share some of these really important and relevant topics that are really helpful for our soldiers' practices. I'll cover some of the solutions that to consider when the anchor doesn't hold. And just like when it comes to any kind of diagnosis, we want to first figure out what the etiology is, prevent it hopefully, and if it does happen what to do about it. So I'll talk about it in those terms. In terms of etiology, the bone quality makes a difference. Anchor design and technique. In terms of bone, the osteoporotic bone always is going to give us a lower pull-out strength, and decortication makes a difference. So you don't want to be too aggressive preparing your footprint. In terms of anchors, we have a lot of options. Big ones, small ones, hard and soft anchors push in and screw in. So you want to pick the correct instrument for the bone that you're dealing with. And in terms of technique, obviously that makes a difference in terms of the angle of insertion. Everybody's familiar with Dr. Burkhardt's dead man post, but in the biomechanics lab, that doesn't always duplicate the clinical scenario. And anatomic limitations also may change the angle of insertion. So the bottom line is, is you want to come in as perpendicular as possible to the cortical surface. And when it comes to the distance between the anchors, six millimeters or greater is the way to go. Otherwise you're going to decrease the pull-out strength. Now what happens if the anchor really doesn't hold? How do we manage that? So some people may use the sailboat to deal with that. In the operating room, we don't have that option. So you want to approach it a couple different ways. If the fixation is suboptimal, and the anchor doesn't come out, and you decide to leave the anchor, you enhance that fixation with a more lateral fixation device. You put an anchor more distal, whether it's a single or double row construct. The other way to go is the buddy anchor, which basically the anchor is supported by adjacent anchor, preferably a bigger one that provides sort of an interference screw construct. Now if that anchor is really pretty wiggly in there, and you decide to change it, you either go with a new anchor that's bigger, wider, or new location, which is more realistic with all soft tissue anchors. And again, if that anchor totally pulls out, again, new anchor in the old place, or in new location, you put a different anchor, and hopefully a bigger one. Now you can also modify the location, and the way to do that using a coring reamer to, if it's really markedly osteoporotic, or if there's a big defect, coring reamer, transfer some cancellous allograft, and impact it in, and put the anchor in. The other option is the tricalcium phosphate cement that's injected, allow it to set, and then the anchor comes in. So in summary, you want to think about the reasons for it, hopefully prevent the problems by identifying osteoporotic bone, choosing the right anchor, and the proper technique. If it does happen, either reinforce the original construct, or replace the anchor, or enhance the environment that you're working with. Thank you.

anchor failure

bone quality

anchor design

reinforcing construct

osteoporotic bone