Clinical Orthopaedics and Related Research®

, Volume 472, Issue 6, pp 1930–1935 | Cite as

Optimization of the Racking Hitch Knot: How Many Half Hitches and Which Suture Material Provide the Greatest Security?

  • James D. KellyII
  • Suketu Vaishnav
  • Bradley M. Saunders
  • Mark A. SchrumpfEmail author
Multimedia Article



Reliable methods of fixation of soft tissue and bone are of utmost importance in reconstructive shoulder surgery and in many orthopaedic applications. Current methods of securing lesser tuberosity osteotomies performed during shoulder arthroplasty and tuberosity fixation performed during repair of proximal humeral fractures often rely on alternating half hitches or surgeon’s knots regardless of the suture configuration used passing through the tissue (eg, Mason-Allen, Krackow). The racking hitch knot in contrast to half hitches allows sequential tightening, even under tension, with minimal risk of knot slippage or premature locking. These knot characteristics allow the surgeon to stepwise improve their reduction before committing and locking a construct, preventing hanging knots or under-tensioned repairs. However, little data exist to support the use the racking hitch knot to guide decision making regarding how to back up the knot or to explain the effect of suture material on security and strength.


The objectives of our study were (1) to identify the optimal number of half hitches necessary to maintain knot security for a single knot; (2) to evaluate if a difference exists in the relative behavior of racking hitch knots when tied using different suture materials; and (3) to define the biomechanical differences between the racking hitch and two other knot configurations commonly used in shoulder surgery (Weston and square knots).


Using an Instron device we tested the effect of adding supplemental half hitches (from one to four) to the racking hitch. Additionally, a selection of commercially available braided nonabsorbable polyethylene sutures and different knot configurations (racking hitch, Weston knot, and square knot) also were tested. Data were compared using ANOVA.


Increasing the number of half hitches improved knot performance in peak load testing and cyclic testing, revealing a significant difference between the racking hitch supplemented with one and four half hitches (199.2 N versus 428.8 N, p < 0.05). Force Fiber™ #2 (359.6 N) and FiberWire® #2 (302 N) showed increased loads to failure compared with Ethibond Excel™ #2 or Force Fiber™ #3/4, whereas Ethibond Excel™ had the least amount of slippage during cyclic testing (0.09 mm). The racking hitch knot had considerably higher loads to failure (359.6 N) than the Weston (145.2 N) or square (77 N) knots.


The racking hitch knot exhibited significantly higher loads to failure and comparable knot slippage (elongation during cyclic testing) when compared with other commonly used knots. According to the biomechanical data, the addition of four half hitches to supplement the racking hitch and the choice of FiberWire® #2 or Force Fiber™ #2 suture resulted in increased knot security.

Clinical Relevance

This knot adds a tool to the arsenal for surgeons best suited for repairs requiring a high degree of knot security and reliable tissue tensioning.


Peak Load Ultimate Load Cyclic Testing Suture Material Shoulder Arthroplasty 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Ryan Schlotterback, Austin Allen, and Huong Do for assistance with the statistical analysis on this project.

Supplementary material

Supplementary material 1 (MP4 81920 kb)

Supplementary material 2 (M4 V 14802 kb)


  1. 1.
    Abbi G, Espinoza L, Odell T, Mahar A, Pedowitz R. Evaluation of 5 knots and 2 suture materials for arthroscopic rotator cuff repair: very strong sutures can still slip. Arthroscopy. 2006;22:38–43.PubMedCrossRefGoogle Scholar
  2. 2.
    Barber FA, Herbert MA, Beavis RC. Cyclic load and failure behavior of arthroscopic knots and high strength sutures. Arthroscopy. 2009;25:192–199.PubMedCrossRefGoogle Scholar
  3. 3.
    Baumgarten KM, Brodt MD, Silva MJ, Wright RW. An in vitro analysis of the mechanical properties of 16 arthroscopic knots. Knee Surg Sports Traumatol Arthrosc. 2008;16:957–966.PubMedCrossRefGoogle Scholar
  4. 4.
    Burkhart SS, Wirth MA, Simonich M, Salem D, Lanctot D, Athanasiou K. Knot security in simple sliding knots and its relationship to rotator cuff repair: how secure must the knot be? Arthroscopy. 2000;16:202–207.PubMedCrossRefGoogle Scholar
  5. 5.
    Chokshi BV, Ishak C, Iesaka K, Jazrawi LM, Kummer FJ, Rosen JE. The modified racking hitch (MRH) knot: a new sliding knot for arthroscopic surgery. Bull NYU Hosp Jt Dis. 2007;65:306–307.PubMedGoogle Scholar
  6. 6.
    Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br. 2011;93:811–816.PubMedCrossRefGoogle Scholar
  7. 7.
    Elkousy HA, Sekiya JK, Stabile KJ, McMahon PJ. A biomechanical comparison of arthroscopic sliding and sliding-locking knots. Arthroscopy. 2005;21:204–210.PubMedCrossRefGoogle Scholar
  8. 8.
    Ilahi OA, Younas SA, Alexander J, Noble PC. Cyclic testing of arthroscopic knot security. Arthroscopy. 2004;20:62–68.PubMedCrossRefGoogle Scholar
  9. 9.
    Ilahi OA, Younas SA, Ho DM, Noble PC. Security of knots tied with ethibond, fiberwire, orthocord, or ultrabraid. Am J Sports Med. 2008;36:2407–2414.PubMedCrossRefGoogle Scholar
  10. 10.
    Lo IK, Ochoa E Jr, Burkhart SS. A comparison of knot security and loop security in arthroscopic knots tied with newer high-strength suture materials. Arthroscopy. 2010;26(9 suppl):S120–126.PubMedCrossRefGoogle Scholar
  11. 11.
    Swan KG Jr, Baldini T, McCarty EC. Arthroscopic suture material and knot type: an updated biomechanical analysis. Am J Sports Med. 2009;37:1578–1585.PubMedCrossRefGoogle Scholar
  12. 12.
    Wieser K, Zingg P, Dora C. Trochanteric osteotomy in primary and revision total hip arthroplasty: risk factors for non-union. Arch Orthop Trauma Surg. 2012;132:711–717.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • James D. KellyII
    • 1
  • Suketu Vaishnav
    • 2
  • Bradley M. Saunders
    • 1
  • Mark A. Schrumpf
    • 1
    Email author
  1. 1.San Francisco Shoulder, Elbow, and Hand ClinicSan FranciscoUSA
  2. 2.Cedars-Sinai Medical CenterBeverly HillsUSA

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