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. 2019;39(1):131–140.

A Biomechanical Comparison of Varying Base Knot Configurations with Different Overhand/Underhand Combinations of Reversing Half-Hitches on Alternating Posts After Basic Instructional Training

Heather A Evin 1,2, Tyler T Bilden 1,2, Benjamin C Noonan 1,2,3,4, Alexander CM Chong 1,2,5,✉
PMCID: PMC6604527  PMID: 31413686

Abstract

Background:

Constructing a durable arthroscopic knot is critical for secure tissue fixation. The effect of various arthroscopic base knot configurations paired with various overhand/underhand stacking combinations of three reversing half-hitches on alternating posts (RHAPs) on knot strength and integrity remains unanswered.

Methods:

Three common base knots (Surgeon’s, Weston and, Tennessee Slider) followed by different overhand/underhand stacking combinations of three RHAPs were evaluated. Ten knots of each combination were tied by four subjects with varying levels of experience, resulting in the analysis of 480 total knots. A single load-to-failure test was performed to evaluate knot strength and integrity. The ultimate clinical failure load and mode of failure were recorded.

Results:

All knots created surpassed the estimated minimum required load per suture. There was, however, statistically large inter-subject variability for each base knot configuration. The Surgeon’s base knot was found to vary the least in knot strength, while the Tennessee base knot was found to vary the most. Knot security was mostly influenced by the base knot configuration than the different overhand/underhand RHAP stacking combinations. Knot slippage failure mode was higher with knots tied with the Weston base knot compared to the other two configurations.

Conclusions:

Arthroscopic base knot configurations paired with different overhand/underhand stacking combinations of RHAPs yielded knot capable of secure tissue fixation. A short instructional training period appears to be sufficient for inexperienced individuals to learn easier base knot configurations, more challenging and complicated knots, however, may require training in a more gradual fashion.

Clinical Relevance:

The findings of this study provide information that the importance of hands-on experience for inexperienced individuals, such as residents, in performing arthroscopic knot tying, and that can lead to improving the securely constructed arthroscopic knots, which increase positive outcomes related to strengthened soft tissue to bone fixation of post-operative patients.

Level of Evidence: V

Keywords: arthroscopic knots, experience, reversing half-hitches on alternating posts, overhand and underhand half-hitches, loop and knot security

Introduction

With the rise in popularity of arthroscopic surgery, arthroscopic knot tying has become a critically important skill for orthopedic surgeons to master.1-6 Surgeons should understand the unique challenges of tying a knot capable of yielding secure soft tissue fixation through a cannula with a knot pusher. While reviewing the literature, one will be exposed to an array of knot configurations, techniques, sequences, and circumstantial methodologies used across many practice settings and academic institutions. Tying secure arthroscopic knots, defined by their ability to resist slippage or breakage as a load is applied, can be time consuming and tedious. Arthroscopic knots are classified as either sliding or non-sliding, and either locking or non-locking. Complex sliding locking knots, which are commonly used in surgery, have been developed to maximize knot security by their internal resistance and friction.7 Surgeons and residents must be skilled in tying a variety of knots because different knots are indicated for certain situations.

Previous studies have indicated that three reversing half-hitches on alternating posts (RHAPs) are necessary to secure sliding locking knots.8-14 Half-hitches can be created in either an “underhand” or “overhand” throw. An underhand half-hitch is completed by sliding the loop suture limb under and then over the post suture limb, whereas an overhand half-hitch is done by sliding the loop suture limb over and then under the post suture limb.15 To accomplish flipping half-hitches to switch posts, Chan et al.16 described a technique for switching posts by alternating tension on suture limbs, whereby the knot “flips” and the loop limb becomes the post limb. Half-hitches created by an overhand throw when “flipped” form a “reversed underhand” half-hitch (Figure 1a). Similarly, the underhand half-hitch when “flipped” forms a “reversed overhand” half-hitch (Figure 1b). Many orthopedic surgeons have been taught to construct the three RHAPs sequence in an ‘underhand, overhand, underhand’ configuration. However, because of this “flipping” phenomenon,16 they may proceed without realizing that the final RHAPs sequence is converted to a ‘reversed overhand, overhand, reversed overhand’ configuration. The question remains whether this final RHAPs combination will affect arthroscopic knot holding strength.

Figure 1.

Figure 1

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Chan et al.16 switching post technique that the post suture limb “flips” to become loop suture limb. (a) Overhand configuration “flipped” to “reversed underhand” configuration; (b) Underhand configuration “flipped” to “reversed overhand” configuration.

Notably, many orthopedic residency-training programs across the United States have not developed a standardized training protocol for arthroscopic knot tying.2,17-22 Resident education has traditionally been based on apprenticeship, didactic learning, literature review, skills lab, and surgical experience. Arthroscopic knot tying is difficult to teach and to assess objectively. Comparing experienced and inexperienced residents’ skills could identify potential shortcomings in the educational process. Hanypsiak et al.23 performed a study demonstrating that even experienced practicing surgeons are relatively inconsistent when it comes to arthroscopic knot tying. Cronin et al.24 and Chong et al.25, however, suggests that after an adequate educational period is attained, any resident, at any level, can tie arthroscopic knots with acceptable knot security. Because of the complexity and large variety of knots to master, residents often feel confused and frustrated.2,17,19 It is still undetermined how arthroscopic knot-tying skills can be best taught to reduce frustration, streamline education, and enhance outcomes. The specific aims of this study were to 1) evaluate the effect of various arthroscopic base knot configurations paired with different overhand/underhand stacking combinations of three RHAPs on knot strength and integrity, and 2) analyze after a short instructional training period on variations of knot integrity and security seen between test subjects.

Methods

Three commonly used base knot configurations for arthroscopic knots were evaluated in this study (Figure 2): the Surgeon’s, the Weston,26 and the Tennessee Slider.11 The Surgeon’s knot, a non-sliding “static” knot with a simple stack design of three half-hitches, is most frequently used in arthroscopic surgery because this knot configuration is the easiest to learn.24,25 The Weston knot is a complex sliding and locking knot, and is among the more difficult knot configurations to master.2 This configuration can easily be prematurely locked while advancing the knot if improper tension is applied to the wrong suture limb.27 The Tennessee Slider is a much simpler sliding configuration and one of the easier arthroscopic knots to learn. Its figure-of-eight design makes its construction easy for surgeons to recall.28

Figure 2.

Figure 2

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Three base knot configurations evaluated (black: post suture limb). (a) Surgeon’s Knot; (b) Weston Knot; (c) Tennessee Slider Knot

Once the base knot was tied, one of the four overhand/ underhand stacked RHAPs configurations was added to secure the base knot. The four RHAPs configurations tested were (Figure 3):

Figure 3.

Figure 3

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Four reversing half-hitches on alternating posts (RHAPs) stack combinations evaluated. (a) Configuration 1: reversed underhand (RU)–overhand (O)–reversed underhand (RU); (b) Configuration 2: reversed overhand (RO)–underhand (U)–reversed overhand (RO); (c) Configuration 3: reversed overhand (RO)–overhand (O)–reversed overhand (RO); (d) Configuration 4: reversed underhand (RU)–underhand (U)–reversed underhand (RU).

  1. Configuration 1: reversed underhand – overhand – reversed underhand

  2. Configuration 2: reversed overhand – underhand – reversed overhand

  3. Configuration 3: reversed overhand – overhand – reversed overhand

  4. Configuration 4: reversed underhand – underhand – reversed underhand

The suture material used for all knots in this study was a 356 N (80 lbs) tested braided fishing line (Power Pro Microfilament Braided Line, Irvine, CA). This material was chosen based on its similarity to commercially available arthroscopy suture material in terms of line diameter (0.46 mm vs. arthroscopy suture: 0.50 mm), manufacturer’s tested strength (356 N vs. arthroscopy suture: 228 N), and the braided design. A length of 45 cm (18 inches) of the suture was used for tying all knots. A custom-designed arthroscopic knot-tying apparatus was used for tying knots with a standard knot pusher using standard arthroscopic technique in a dry laboratory environment, similar to other published studies (Figure 4).29-35

Figure 4.

Figure 4

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Arthroscopic knot tying setup.

Four subjects, who were verbally informed about the purpose of the study, voluntarily participated in this study. Three of the subjects had no prior knot arthroscopic knot tying experience, while one subject had over 10 years of arthroscopic knot tying experience in a dry lab setting. Each subject received proper knot-tying technique instructional training with short training videos describing step-by-step instruction on how to appropriately tie each knot configuration. Each knot was also demonstrated by an instructor, while verbally explaining how the knot is tied. The instructor was available during the practice period to answer questions and assist the subjects with knot tying. Once the subjects felt sufficiently prepared and demonstrated competence, the base knot was constructed and fastened to a standardized 30 mm circumference post to provide a consistent starting circumference for each knot. The base knot was then followed by three RHAPs from one of the aforementioned configurations. The knotted suture loop was then removed from the post and was trimmed, leaving approximately 6 mm length tags from the most distal end of the knot. Ten knots were tied for each base knot configuration and for every RHAPs configuration. Therefore, each subject tied 120 knots, resulting in the analysis of 480 total knots.

A single load-to-failure test was performed to evaluate knot tensile strength and integrity by using a servohy-draulic material testing system (model 8874; Instron, Norwood, MA). The experimental setup and test protocol used were similar to those described in the literature.11,12,25,29,30-36 The knots were mounted around two 3.9 mm diameter hooks that attached to the actuator and the load cell (Figure 5). Each suture loop was initiated with five preconditioned loading cycles from 6 N to 30 N at 1 Hz to avoid potential errors produced from slack in the loops and stretching of the suture materials. The loops were then preloaded to 6 N to provide a well-defined starting point for data collection. Next, the loops were continuously loaded at an across-head speed of 1.0 mm/ sec until either complete structure failure occurred or a 10 mm relative crosshead displacement was reached. Load and displacement data were collected at 100 Hz, and the mode of knot failure was recorded. This study defined three modes of knot failure: 1) failure by the suture material, 2) knot loop elongated but the loop and knot remained intact, and 3) knot slippage.

Figure 5.

Figure 5

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Load-to-failure experimental setup.

Clinical failure was defined as the knot slippage of 3 mm (crosshead displacement), which has been supported by previous evaluations of different suture/ knot configurations.5,11,13,14,21,25,32,36,37,38 The “fail” criteria for this study were defined as 1) the ultimate tensile knot strength at crosshead displacement less than 3 mm with less than 100 N load, as previous studies have determined that 100 N is the estimated minimum required ultimate load per suture during maximum muscle contraction.37,38 And 2) the initial loop circumference at 6 N preload with more than 33 mm (circumference of the standardized post from the knot-tying apparatus: 30 mm). The initial loop circumference of the loop was calculated according to the formula as:

CL = (2*L) + (4*r) + Cr Eqn 1

Where CL represents loop circumference, L represents crosshead displacement, r represents rod radius, and Cr represents rod circumference.

Statistical Analysis:

Data retrieved from the load-to-failure tests were analyzed for any differences among test subjects using one-way analysis of variance (ANOVA) with the least significant difference (LSD) multiple comparisons post hoc test method in SPSS software (Version 19.0; SPSS Inc, Chicago, IL) with p<0.05 denoted significant. The percentage of each failure mode group was calculated for each RHAP and base knot configuration. These values were used to determine the statistical relevance of the difference in arthroscopic loop and knot security for each configuration.

Results

Figure 6 shows the mean ultimate clinical failure load (3 mm crosshead displacement) results of the three base knot configurations paired with four overhand/underhand stacking combinations of three RHAPs tied by each of the four subjects. Assessing knot tensile strength, all knots surpassed the estimated minimum required ultimate load per suture during a maximum muscle contraction (100 N).10,37,38 There was, however, statistically large inter-subject variability for each base knot configuration. With the Surgeon’s knot as the base knot, knot strength was found to vary the least between subjects with only thirteen (54%) significant differences noted out of twenty-four comparisons (Table 1). With the Weston knot as the base knot, knot strength was found to vary in a larger portion of samples with sixteen significant different between subjects noted out of twenty-four comparisons (67%), while with Tennessee base knot it was found to vary the most between subjects with twenty-one significant different noted out of twenty-four comparisons (Table 1). Assessing experience level, statistically significant differences were detected amongst base knot combinations with different overhand/underhand stacking combinations of three RHAPs (Table 1). When comparing different overhand/ underhand stacking combinations of three RHAPs for each subject, some statistically significant differences were detected, except for two inexperienced subjects tying with the Tennessee Slider base knot (Table 2).

Figure 6.

Figure 6

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Mean ultimate clinical failure load (3 mm crosshead displacement) results of the four overhand/underhand stacked reversing half-hitches on alternating posts configurations with different base knot configurations. (a) Surgeon’s Knot; (b) Weston Knot; (c) Tennessee Slider Knot

Table 1.

Statistical Analysis Results of Knot Tensile Strength Performance Comparing Different Overhand/Underhand Stacking RHAP Configurations on Each Base Knot Configuration and Between Test Subjects

graphic file with name IOJ-2019-131-f7.jpg
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* Subject 1 had over 10 years of arthroscopic knot tying experience in a dry lab setting

Table 2.

Statistical Analysis Results Comparing Knot Tensile Strength Performance for Each of the 4 Overhand/Underhand Stacking RHAP Configurations with Each Base Knot Created by Each Subject

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* Subject 1 had over 10 years of arthroscopic knot tying experience in a dry lab setting

Mode of knot failure results indicated that the knot security was mostly influenced by the base knot configuration, and was not affected by the different overhand/ underhand RHAP stacking combinations (Table 3). Knots tied with the Surgeon’s base knot configuration had a higher incidence of suture material failure than the Tennessee Slider or Weston base knot configuration, across all the overhand/underhand stacking RHAP configurations. Knots tied with the Weston base knot had a higher incidence of failure in knot elongated but the loop and knot remained intact. Knot slippage failure mode, however, was higher compared to the other two configurations. Similar to the knots tied with Weston base knot, knots tied with Tennessee slider base knot experienced higher rates of elongated but intact failure modes (Table 3).

Table 3.

Knot Failure Mode Results

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Discussion

The most important finding of this study was that when constructing an arthroscopic knot, the base knot configuration has a higher influence on knot strength and security than the different overhand/underhand stacking combinations of three RHAPs. Few studies have been performed to objectively evaluate the ability of a surgeon to tie secure arthroscopic knots capable of resisting slippage when a load is applied.2,7,25,30,32,39-41 Arthroscopic knot tying requires significant practice and attention to detail. Past studies, however, have not clearly described how the RHAPs were created, leaving the reader unsure of how to interpret their findings. This uniquely designed study specified that stacking combinations of the three RHAPs are less likely to affect arthroscopic knot holding strength than selection of the base knot. Because using the overhand RHAPs stacking combination is secure enough to surpass the estimated maximum ultimate load per suture, residency-training programs can use this information to simplify the way they train the residents. This may reduce resident frustration and confusion for tying the three RHAPs. Using a single-handed “overhand” throw technique is less likely to create unintentional tension applied to the suture limb which “flips” the seated half-hitch, and converts a series of RHAPs into a series of identical half-hitches on the same post. Half-hitches tied onto the same post are more likely to create insecure knots or suture loops with slippage as the most likely failure mechanism.

Previous studies had also noted variability among surgeons in knot and loop security.2,7,25,30,32,39-41 These studies suspected this difference in ultimate failure loads and failure mode is caused by the tightness of the three RHAPs. The results of this study also showed vast inter-subject variability probably due to lack of basic competency in arthroscopic knot tying. The test subjects of this study were provided a brief instructional training period using a unique simulator device accompanied by an instructor verbally explaining how the knot is tied, how to eliminate twists and slack between throws, and provide guidance on proper tensioning of the suture limbs. The ability of each individual to appropriately learn and tie each arthroscopic knot greatly varies among each individual based upon learning styles. Basic instructional training appears to be sufficient for inexperienced individuals to learn easier base knot configurations, like the Surgeon’s knot. A more challenging arthroscopic knot such as the Weston knot and the Tennessee Slider, however, requires training that is more intensive in order to obtain greater consistency in knot holding strength. This study discovered distinct learning curve variations for each base knot tied by each individual. This study agrees with previous studies24,25 that a more comprehensive and intensive arthroscopic knot tying training program for orthopedic residents is needed. Gilmer et al.17 and Chong et al.25 suggest that a more structured, formal training program for inexperienced surgeons and residents may lead to higher consistency and improved biomechanical properties of arthroscopic knots. A brief training period does not appear to be adequate for mastery of skill, especially for the more complicated arthroscopic knot configurations. More structured training programs could address the learning curves for each base knot for each individual, as introducing each additional knot configuration adds an extra challenge to inexperienced residents or surgeons.

This study has certain limitations to recognize. First, this biomechanical investigation was performed in a dry laboratory environment at room temperature, whereas a fluid environment with varying temperature could potentially affect the results. Second, knots were tied on a standardized rigid post (30 mm in circumference) which differs from what is performed clinically, and therefore cannot account for the variability seen in clinical practice. The suture loop did not pass through any soft tissue, turn acute angles, risk abrasion on suture anchors, or rub over bony surfaces. Third, the data collected may not be generalizable to the fundamental aspects of training in arthroscopic surgery, such as difficulties with depth of vision on a 2-dimensional screen and hand-eye coordination, or on the long-term aspects of training. Fourth, only a single load-to-failure test was performed, however, a leading source of failure in orthopedic repairs has long been recognized by cyclic loading. Fifth, this study contained only three arthroscopic knot configurations with four overhand/underhand stacking combinations of three RHAPs that could limit the generalizability to other types of base knot configurations. Sixth, all knots were tied in one day and were tested as a batch, as opposed to immediately after knot construction. This short period of storage could have altered the properties of the knots. Despite these limitations, the outcomes of this study are valuable in revealing the possible impact of different overhand/underhand stacking combinations of three RHAPs involving different base knot configurations on arthroscopic knot security.

Conclusions

Arthroscopic base knot configurations paired with different overhand/underhand stacking combinations of RHAPs yielded an arthroscopic knot capable of secure tissue fixation. This study demonstrated that a short instructional training period appears to be sufficient for inexperienced individuals to learn easier base knot configurations, whereas more challenging and complicated base knots may require further training that is more gradual and intensive.

Acknowledgements

The authors wish to thank Tyler M. Fritz for his participation and assistance on data collection.

References

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Articles from The Iowa Orthopaedic Journal are provided here courtesy of The University of Iowa

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