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Locking, Jamming, and Ratchet Mechanisms of Sliding Surgical Knots Topologically Revisited

Abstract

Background

The geometry of lockable, ratchet, or jamming sliding surgical knots was assessed to enhance practical and topological understanding of knots among surgeons.

Methods

Using a database of more than 100 surgical knots, 29 knots that reportedly feature locking, ratchet, or jamming mechanisms were topologically assessed for their ability to lock antegradely or retrogradely, to lock by assuming their flat geometry, or to jam.

Results

Eighteen of the 29 investigated surgical knots have previously been mistakenly categorized. Topologically, the concept of a true ratchet knot is a fallacy.

Conclusions

Surgical knots may be consistently classified on the basis of precise and detailed definition of various anti-backsliding geometrical characteristics of knots.

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References

  1. Wiley WB, Goradia VK (2004) The Tuckahoe knot: a secure locking slip knot. Arthroscopy 20:556–559

    PubMed  Google Scholar 

  2. Kim SH, Yoo JC, Wang JH et al (2005) Arthroscopic sliding knot: how many additional half-hitches are really needed? Arthroscopy 21:405–411

    PubMed  Google Scholar 

  3. Abbi G, Espinoza L, Odell T et al (2006) Evaluation of 5 knots and 2 suture materials for arthroscopic rotator cuff repair: very strong sutures can still slip. Arthroscopy 22:38–43

    PubMed  Google Scholar 

  4. Hassinger SM, Wongworawat MD, Hechanova JW (2006) Biomechanical characteristics of 10 arthroscopic knots. Arthroscopy 22:827–832

    PubMed  Article  Google Scholar 

  5. Kim SH, Ha KI, Kim SH, Kim JS (2001) Significance of the internal locking mechanism for loop security enhancement in the arthroscopic knot. Arthroscopy 17:850–855

    PubMed  CAS  Google Scholar 

  6. Dinsmore RC (1995) Understanding surgical knot security: a proposal to standardize the literature. J Am Coll Surg 180:689–696

    PubMed  CAS  Google Scholar 

  7. Walker JC, Baumgarten KM, Wright RW (2004) Arthroscopic knot tying principles and instruments. Oper Tech Sports Med 12:240–244

    Article  Google Scholar 

  8. De Beer JF, van Rooyen K, Boezaart AP (1998) Nicky’s knot: a new slip knot for arthroscopic surgery. Arthroscopy 14:109–110

    PubMed  Google Scholar 

  9. Hughes PJ, Hagan RP, Fisher AC et al (2001) The kinematics and kinetics of slipknots for arthroscopic Bankart Repair. Am J Sports Med 29:738–745

    PubMed  CAS  Google Scholar 

  10. Elkousy HA, Sekiya JK, Stabile KJ, McMahon PJ (2005) A biomechanical comparison of arthroscopic sliding and sliding-locking knots. Arthroscopy 21:204–210

    PubMed  Article  Google Scholar 

  11. Fischer SP (2006) How to make sense out of arthroscopic knot-tying. Rosemont, IL: Arthroscopy Association of North America, 2006. http://www.aana.org/pdf/FallCourse/2006knot tying handout.pdf. Accessed 26 Jan 2008

  12. Lo IKY, Burkhart SS, Chan KC, Athanasiou K (2004) Arthroscopic knots: determining the optimal balance of loop security and knot security. Arthroscopy 20:489–502

    PubMed  Google Scholar 

  13. Fleega BA, Sokkar SH (1999) The giant knot: a new one-way self-locking secured arthroscopic slip knot. Arthroscopy 15:451–452

    PubMed  CAS  Article  Google Scholar 

  14. Mochiziku Y, Hachisuka H, Natsu K et al (2005) The HU knot: a new sliding knot for arthroscopic surgery. Arthroscopy 21:1014.e1–1014.e3

    Article  Google Scholar 

  15. Campbell DF, Nassar AHM, Tamijmarane A (2000) The Vale knot: an intracorporeal slipknot. Surg Endosc 14:90–91

    PubMed  Article  CAS  Google Scholar 

  16. Yiannakopoulos CK, Hiotus I, Antonogiannakis E (2005) The triad knot: a new sliding self-locking knot. Arthroscopy 21:899.e1–899.e3

    Google Scholar 

  17. Cuschieri A (1991) Tissue approximation. Probl Gen Surg 8:366–377

    Google Scholar 

  18. Lirici MM, Melzer A, Taddeo FS, Buess G, Angelini L (1994) Tissue approximation in minimal invasive surgery. Endosc Surg Allied Technol 2:47–54

    PubMed  CAS  Google Scholar 

  19. Jo CH, Yoon KS, Lee JH et al (2007) The slippage-proof knot: a new, nonstacking, arthroscopic, sliding locking knot with a lag bight. Orthopedics 30:349–350

    PubMed  Google Scholar 

  20. Budworth G (2003) The book of practical fishing knots. Stackpole Books, Mechanicsburg, PA

    Google Scholar 

  21. Hage JJ (2007) How capsizing, flipping, and flyping of traditional knots can result in new endoscopic knots: a geometrical review. J Am Coll Surg 205:717–723

    PubMed  Article  Google Scholar 

  22. Brooks M (1990) A slip knot for tying nylon sutures. Surg Gynecol Obstet 170:67

    PubMed  CAS  Google Scholar 

  23. Field MH, Edwards TB, Savoie FHIII (2001) Technical note: a “new” arthroscopic sliding knot. Orthop Clin N Am 32:525–526

    Article  CAS  Google Scholar 

  24. Wattchow DA, Watts JM (1984) The half blood knot tor tying nylon in surgery. Br J Surg 71:333

    PubMed  Article  CAS  Google Scholar 

  25. Conca M, Taschieri S, Del Fabbro M, Conca R (2007) Inverse knot: a personal sliding knot for arthroscopic surgery. Knee Surg Sports Traumatol Arthrosc 15:620–623

    PubMed  Article  Google Scholar 

  26. Delimar D, Cicak N, Bojanic I (1996) A new instrumentally tied approximation knot. Plast Reconstr Surg 97:488–490

    PubMed  Article  CAS  Google Scholar 

  27. Israelsson LA, Jonsson T (1994) Physical properties of self locking and conventional surgical knots. Eur J Surg 160:323–327

    PubMed  CAS  Google Scholar 

  28. Nottage WM, Lieurance RK (1999) Arthroscopic knot tying techniques. Arthroscopy 15:515–521

    PubMed  CAS  Article  Google Scholar 

  29. Delimar D, Korzinek K (1996) A secure knot for suturing structures under tension. Eur J Surg 162:505–506

    PubMed  CAS  Google Scholar 

  30. Kim SH, Ha KI (2000) The SMC knot: a new slipknot with locking mechanism. Arthroscopy 16:563–565

    PubMed  CAS  Article  Google Scholar 

  31. Weston PV (1991) A new clinch knot. Obstet Gynecol 78:144–147

    PubMed  CAS  Google Scholar 

  32. Balg F, Boileau P (2007) The Mid-Ship knot: a new simple and secure sliding knot. Knee Surg Sports Traumatol Arthrosc 15:217–218

    PubMed  Article  Google Scholar 

  33. Ng JWT, Yeung BBY (2005) An optimal instrument-tied extyracorporeal slip knot: a further note of caution. ANZ J Surg 75:922–923

    PubMed  Article  Google Scholar 

  34. Nathanson LK (1993) The sutured laparoscopic gastrointestinal anastomosis. In: Hunter JG, Sackier JM (eds) Minimally invasive surgery. McGraw Hill, New York, pp 157–170

    Google Scholar 

  35. Ashley CW (1944) The Ashley book of knots. Doubleday, New York

    Google Scholar 

  36. Brouwers JE, Oosting H, de Haas D, Klopper PJ (1991) Dynamic loading of surgical knots. Surg Gynecol Obstet 173:443–448

    PubMed  CAS  Google Scholar 

  37. Khatri VP, Balshi JD (1995) Slip knot for tying monofilament nylon sutures. Am Surg 61:735–737

    PubMed  CAS  Google Scholar 

  38. Mahar AT, Moezzi DM, Serra-Hsu F, Pedowitz RA (2006) Comparison and performance characteristics of 3 different knots when tied with 2 suture materials used for shoulder arthroscopy. Arthroscopy 22:610–614

    Article  Google Scholar 

  39. Al Fallouji M (1993) Making loops in laparoscopic surgery: state of the art. Surg Laparosc Endosc 3:477–481

    PubMed  CAS  Google Scholar 

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Acknowledgement

The authors thank Mr. Adri Jans, medical illustrator and knot-tier, for his artwork, encouraging comments, and constructive criticism.

Financial Disclosure and Products

The authors hereby certify, that to the best of their knowledge:

1. This work has been executed as part of our regular appointment at the Netherlands Cancer Institute and VU Medical Center, and that there have been no external or commercial sources or funds supporting this work.

2. No financial support or benefits have been received by us, by any member of our immediate family or any individual or entity with whom or with which we have a significant relationship from any commercial source which is related directly or indirectly to the scientific work or any product that is reported on in the article.

3. We understand an example of such a financial interest would be a stock interest in any business entity which is included in the subject mater of the manuscript or which sells a product relating to the subject matter of the manuscript.

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Correspondence to J. Joris Hage.

Glossary Box

Sliding knot:

allows both forward and backward sliding, even after tightening the knot.

Ratchet knot:

allows only forward sliding toward the suture loop after tightening the working end.

Jamming knot:

prevents both forward and backward sliding, as a result of anything less than a bight in the standing part that was caused by traction on the working end.

Locking knot:

prevents both forward and backward sliding by change to a flat knot or by distortion of the straight standing part into a bight upon traction on the working end.

Retrograde locking knot:

locked by distortion upon traction on the loop part of the working end.

Antegrade locking knot:

locked by distortion upon traction on the tag end of the working end.

Proximal antegrade locking knot:

locked by a bight that is formed in the standing part by the most proximal turn of the working end, nearest to the knot-tier.

Middle antegrade locking knot:

locked by a bight that is formed in the standing part by an intermediate turn of the working end.

Distal antegrade locking knot:

locked by a bight being formed in the standing part by the most distal turn of the working, nearest to the suture loop.

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Hage, J.J., van der Steen, L.P.E. Locking, Jamming, and Ratchet Mechanisms of Sliding Surgical Knots Topologically Revisited. World J Surg 33, 751–757 (2009). https://doi.org/10.1007/s00268-008-9904-2

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  • DOI: https://doi.org/10.1007/s00268-008-9904-2

Keywords

  • Suture Loop
  • Consistent Classification
  • Ratchet Effect
  • Ratchet Mechanism
  • Loop Security