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Zhijiexi MD ArthroscopicknottypingainstructionManual TheDepartmentofTraumaandHandSurgeryTheFirstAffiliatedHospitalofuniversityofGuangxiTraditionalChineseMedicine 1 AnincreasingnumberofsurgeonsareperformingarthroscopicsurgeryinthekneetorepairmeniscaltearsandintheshouldertorepairrotatorcufforlabraltearsManyarealsoperformingcapsularshiftstotreatinstability Essentialtotheseproceduresistheabilitytotiearthroscopicknotstoapproximateintraarticular Introduction 2 ThesurgeonmustsequentiallyconstructtheknotoutsidethejointandthenpasstheknotintothejointthroughsmallcannulasTyingarthroscopicknotsistechnicallydemandingandrequiresconsiderablepracticeWiththepopularityofarthroscopicsurgery thenumberofusedarthroscopicknotsandthenumberofsurgeonsusingtheseknotshasincreased 3 KnotTyingPrinciples ThegoalofknottyingistoapproximatetissueundertensionandmaintainthetissueinappositionuntilbiologicrepairandhealingcanoccurItisimperativeforallsurgeonstolearnanduseknot tyingtechniquesthatminimizethechanceofknotfailure 4 Knotsecurityfriction internalinterference andslackbetweenthrowsFrictionisinherenttothesuturematerialInternalinterferencetheconfigurationoftheknotandincreasedbythelengthofthecontactbetweenthelooplimbandthepostlimbslackbetweentheindividualthrowsineachknottomaximizeloopsecurityslippagecanleadtofailureoftissueapposition KnotTyingPrinciples 5 fourdifferentprocessesofknotfailureknotslippageandlooseningsuturebreakagetissuefailuresutureanchorpulloutfrombonethroughsuturebreakage Knotfailure 6 KnotTerminology postlimb alsocommonlyknownastheaxiallimb looplimb alsocommonlyknownasthewrappinglimb workingend runningend orfreeend Knotsareconstructedbytyingthelooplimbaroundthepostlimb Fig 1 7 FIGURE1 Loopandpostconfiguration 8 ArthroscopicKnotPushers Anarthroscopicknotpusherisadeviceusedtoadvancetheloopdownthepostlimbintothejointtocreatetheknot Arthrexknotpushers A Single hole B Double hole C 6thFinger 9 FIGURE3 Mitekknotpushers A Single hole B Double hole C Slotted 10 double holeknotpushersanddoublediameterknot double holeknotpushersanddoublediameterknotpushersliketheArthrex6thFinger Arthrex Naples FL Double diameterknotpushersprovidebetterloopsecuritycomparedtostandardsingle holeknotpushers 11 Double holeknotpusher FIGURE4 Double holeknotpusher 12 HowtoUsetheDouble DiameterKnotPusher FIGURE5 A F TyingknotswiththeArthrex6thfinger 13 SutureProperties Twotypesofsuturesarecommonlyusedintyingarthroscopicknots apermanent braided polyester nonabsorbablesutureandanabsorbable monofilamentsutureExamplesofpermanent braided polyester nonabsorbablesuturesareEthibondandTicronExamplesofabsorbable monofilamentsuturesarePDSII polydiaxononeandMaxon polyglyconate 14 Braidedpolyesterhasincreasedpliability ductility ahighercoefficientoffrictionandgreaterstrengththandoesabsorbablemonofilamentBecausethebraidedsutureismorepliable thevolumeoftheknotisdecreasedandtheseknotscanbecinchedtighter KnotstiedwithEthibondwereshowntobestrongerwhencomparedtoPDSIIinseveralbiomechanicalstudiesHowever braidedpolyestermayfraywithexcessivehandling whichmayleadtosuturerupture 15 Braidedpolyestersuturemaybecoatedto improvesurgeonhandlingreducefrictionbetweenthesutureandsurroundingtissue whichcanleadthetissuedamagedecreasefrictionbetweensuturelimbs whichmayleadtofrayingHowever suturecoatingdecreasesthecoefficientoffrictionoftheknot whichtheoreticallyincreasestheriskofknotslippage 16 Knotstiedwithabsorbable monofilamentsuturesareeasiertoslidedownapostanddonotfrayThereislessfrictionbetweenthesutureandsurroundingtissueleadingtolesspotentialtissuedamagewhenthesutureispulledthroughthetissueabsorbablesuturesdissolveanddonotleaveknotsthatmaycauseapersistentinflammatoryreactionaftertissuehealingAbsorbablesuturescanapposetissueunderstressforapproximatelysixweekswithcompleteabsorptionoccurringinapproximatelysixmonths 17 However absorbablemonofilamentsuturesarehardertohandlethanpolyestermakingitmoredifficulttokeepknotstightandsecureAlso aabsorbablemonofilamentsuturewillfailearlierwithcyclicloadingthanpolyestersutureandmayexpandbyplasticdeformationmorethan30 ofitslengthbeforebreaking 18 Thesizeofthesutureisalsoafactorindeterminingaknot sholdingcapacityandalsothetensilestrengthofthesutureitselfClinicalfailureofallknotsandsuturetypesimprovedby100 whensuturesizewasincreasedby2gaugesUSP U S Pharmacopeia ThesizesuturemostcommonlyusedinarthroscopicsurgeryisNo 1orNo 2 19 KnotTypes Thereareavarietyofknotincludenonslidingknots slidingknots andlockingknots Nonslidingknotsareknotsthatdonotslidethoughthetissuesbeingapposed TheyincludethesquareknotandknotsconsistingofaseriesofhalfhitchesliketheRevoknot 34 Althoughthesquareknotfailsathigherloadsthandoseriesofhalfhitchesinhand tiedknots 38 thesquareknotisnotcommonlyusedarthroscopically 20 Thesquareknotisaflatknotinwhichbothstrandsenterandleavetheknotparalleltoeachother Fig 6 Inordertotieasquareknot symmetrictensionmustbesimultaneouslyappliedtoeachlimb whichisdifficulttodoarthroscopicallyIfasymmetrictensionisappliedtooneofthelimbs theknotconvertstotwononidenticalhalfhitchesThus mostarthroscopicsurgeonspreferusingaseriesofhalfhitches 21 FIGURE6 Squareknotconfiguration 22 Slidingknots liketheDuncanloop 27 areusefulinopposingtissueundertension Whiletyingaslidingknot thepoststrandisheldundertensionwhiletheloopstrandistiedaroundit Becausethepoststrandisnotincorporatedintothestructureoftheknot theknot oncetied caneasilymovedownthepostresultinginaslidingknotinsteadofaflatknotsuchasthesquareknot Oncetheslidingknotsareseated theyareoftenlockedwithaseriesofhalfhitches Someslidingknotspreferentiallyslideinonlyonedirection 23 AlockingknotisamodificationofaslidingknotAsimpleslidingknotcanloosenbeforeaseriesofhalfhitchesarethrownto lock theslidingknotinplacelockingknots alsoknownasflipknots havebeendevelopedtomaintaininitialloopsecuritythatdoesnotloosenwhentensionisremovedThepoststrand flips convertingtheloopstrandintothenewpoststrandandlockingtheknotintoplace AnexampleofalockingknotistheSMCknot lockingknotsdonotneedtobesupplementedwithaseriesofhalfhitchesTheauthorsofthismanualhavefoundlockingknotswithoutreinforcinghalfhitchestobeinferiorintensilestrengthtoknotsreinforcedwiththreereversedhalfhitchesonalternatingposts unpublisheddata 24 Lockingandslidingknotscanbeadvancedintothejointjustbypullingonthepost Thiscancausetensionattherepairsite whichcandamagethetissuebeingapposed Tensionattherepairsitecanbeminimizedbypushingtheknotaheadwiththeknotpusherwhilesimultaneouslypullingonthepostlimb Withlockingandslidingknots itisimportantthatthelooplimbisatleasttwiceaslongasthepostlimb Ifitisnot whenpullingthepostlimbtoadvancetheknotthroughthecannulaandintothejoint theshortenedlooplimbmaybepulledintothecannulamakingitimpossibletosecuretheknot Whenusingaslidingorlockingknotconfiguration itisimportanttoensurethatthesutureslideseasilythroughthetissuebeingopposed Ifthesuturedoesnotslideeasily thesurgeonshouldconsiderusinganonslidingknot 25 KnotPushingandPulling Knotconfigurationscanbeeitherpushedorpulledintothejoint hearthroscopicknot tyingdeviceispositionedonthelooplimbandisadvancedpastthehalfhitchthuspullingtheloopoverthepostlimbintothejoint Fig 7A Thearthroscopicknot tyingdeviceispositionedonthepostlimbbehindtheknotthuspushingtheloopoverthepostlimbintothejoint Fig 7B 26 FIGURE7 A Knotpulling B Knotpushing 27 TyingHalfHitches Usingtheonehandknot tyingtechnique halfhitchescanbetiedeitherunderhandoroverhandThefollowinginstructionsdefineanunderhandloopandanoverhandloop 28 FIGURE8 A E Underhandhalfhitch 29 30 ConfigurationofHalfHitches Halfhitchescanbethrowninthesamedirection twosuccessiveoverhandhitches orcanbethrowninoppositedirections anoverhandhitchfollowedbyanunderhandhitch Halfhitchescanalsobetiedonoppositeposts TeraandAberg 37 developedanomenclaturefordescribingflatknots 31 PostSwitching FIGURE13 A Parallelloopandpostlimbs B Parallelloopandpostlimbswitha flat knot 32 FIGURE14 A Twistedloopandpostlimbs B Whentyingaknotwithtwistedpostandlooplimbs theknotdoesnotlie flat C Thefinalknotconfigurationwilllooseniftheknotistiedwhentheloopandpostlimbsaretwisted 33 ChanandBurkhartdescribedamayincreasethespeedoftheknot tyingprocessandalsohelplimittwistingofthesuturelimbs Onecan flip ahalfhitchbyreleasingtensiononthepostlimbandpullingonthelooplimb Whenthepostisswitched thedirectionofthehalfhitchisalsoreversed Theauthorsofthistechniquereportthatitiseasiertofliphalfhitchesusingmonofilamentbecauseitmorereadilyconvertstoaflatknot butitcanalsobedonewithbraidedsuture 34 Holdthepostinthenondominanthandandtheloopinthedominanthand Fig 15A Movetheoriginalpostforwardandaheadofthehalfhitch Applyparalleltractiononthepostandloopsimultaneouslyconvertingthehalfhitchtoaflatknot Fig 15B Applyaxialtractiontothelooplimbconvertingitintothenewpostlimbandthehalfhitchisreversed Fig 15C 35 PostSwitchingTechnique FIGURE15 A C Postswitchingtechnique 36 ArthroscopicKnot TyingTechniques Itisimportanttodetermineifthesutureslidesthroughthetissueandsutureanchorpriortoknottying Ifthesuturedoesnotreadilyslide aslidingorlockingknotshouldnotbeusedandanonslidingknotshouldbechosenOnlyonepairofsuturesshouldbewithintheworkingcannuladuringarthroscopicknottying Ifmorethanonepairofsuturesarewithintheworkingcannuladuringtying thereisahighlikelihoodthatthesutureswillbecometwistedandknottyingwillbecomequitetediousifnotimpossible Additionalsuturesshouldbeshuttledviaamonofilamentsuture lesstissueabrasion orbyanarthroscopicgraspertoanaccessoryportalTransparentcannulasarerecommendedforarthroscopicknottying Thesecannulasallowthesurgeontoseeifthereisanytwistingofthesuturestrandspriortoknottying 37 ThearthroscopicsurgeonshouldensurethatthereisnoredundantsofttissuearoundthetissuebeingapposedorinthepathofthesuturelimbsbecausethiswillimpedeknottyingandincreasethelikelihoodofknotfailureWhentyinghalfhitcheswithastandardsingle holeknotpusher thefirstthrowcommonlyslipswhentheknotpusherisremovedinpreparationforthesecondthrowWhenthesecondthrowisadvanced thereisachancethatthehitcheswilllockpriortocompleteappositionofthetissueTopreventthis thesurgeoncanthrowthefirsttwohitchesinthesamedirectionallowingthehitchestoslidedowntheposttoapposethetissueAnothermethodofpreventinginitiallooplooseningistouseadouble diameterknot pushingdevice suchastheArthrex6thtomaintaintensionontheinitialhitchwhilethrowingthesecondhitch 38 Non SlidingKnots FIGURE16 A F Squareknot 39 RevoKnot TheRevoknotisaseriesofmultiplehalfhitchesmadebyalternatingthepostanddirectionofthehalfhitches TherehavebeenseveralmodificationstotheRevoknot FIGURE17 A H OriginalRevoknot 40 TheOriginalRevoknotconsistsoftworeversedhalfhitchesonanidenticalpostfollowedbypostswitchingandtworeversedhalfhitches Throwanoverhandlooparoundthepost Fig 17A Pulltheloopintothejointwiththeknotpusheronthelooplimb Fig 17B Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb Throwanunderhandlooparoundthesamepost Fig 17C Pulltheloopintothejointandseattheknotwiththeknotpusher Oncethetwohitchesareseated past pointtocinchtheknotdown Fig 17D Switchpostsandthrowanunderhandlooparoundthenewpost Fig 17E Pulltheloopintothejoint seattheknotwiththeknotpusher andpast pointtocinchtheknotdown Fig 17F Next throwanoverhandlooparoundthepost Fig 17G Pulltheloopintothejoint seattheknotwiththeknotpusher andpast pointtocinchtheknotdown Fig 17H 41 Snyder sKnot 42 43 Snyder sKnot 44 Snyder sisanothervariationoftheRevoknotThrowanoverhandlooparoundthepost Fig 18A Pulltheloopintothejointwiththeknotpusheronthelooplimb Fig 18B Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb Throwanunderhandlooparoundthesamepost Fig 18C Pulltheloopintothejointandseattheknotwiththeknotpusher Oncethetwohitchesareseated past pointtocinchtheknotdown Fig 18D Switchpostsandthrowanoverhandlooparoundthenewpost Fig 18E Pulltheloopintothejoint seattheknotwiththeknotpusher andpast pointtocinchtheknotdown Fig 18F Next throwanunderhandlooparoundthepost Fig 18G Pulltheloopintothejoint seattheknotwiththeknotpusher andpast pointtocinchtheknotdown Fig 18H Switchpostsandthrowanoverhandlooparoundthenewpost Fig 18I Pulltheloopintothejoint seattheknotwiththeknotpusher andpastpointtocinchtheknotdown Fig 18J 45 FIGURE19 A K Revoknot 46 47 ThecurrentRevoknotisamodificationoftheOriginalRevoknotThrowanunderhandlooparoundthepost Fig 19A Advancetheloopwiththeknotpusheronthelooplimbuntilthefirsthalfhitchisseated Fig 19B Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb Throwanotherunderhandlooparoundthesamepost Fig 19C Pulltheloopintothejointandseattheknotwiththeknotpusher Oncethetwohitchesareseated past pointtocinchtheknotdown Figs 19D E Throwanoverhandhalfhitcharoundthepostandadvancewiththeknotpusher Fig 19F Furthertensionbypastpointingandapplytensiononbothlimbswhileholdingthe Fig 19G Switchpostsandthrowanunderhandlooparoundthenewpost Fig 19H Pulltheloopintothejoint seattheknotwiththeknotpusher andpastpointtocinchtheknotdown Fig 19I Switchpostsandthrowanoverhandlooparoundthenewpost Fig 19J Pulltheloopintothejoint seattheknotwiththeknotpusher andpastpointtocinchtheknotdown Fig 19K 48 SlidingKnots OverhandThrow 49 DuncanLoop TheDuncanloopwasoriginallydescribedinthefishingliterature Uni Knot andhasbeenmodifiedforuseinarthroscopicsurgery ThearthroscopicDuncanloopisalsoknownastheFisherman sknotortheHangman sknotThedifferencebetweenthefishingknotandthearthroscopicknotisthedirectiontheloopstrandtravelsaroundthepost WhentyingthefishingDuncanloop onewrapsthelooplimbaroundthepostinadirectionawayfromthejoint TotiethemodifiedDuncanlooporHangman sknot thesurgeonsequentiallywrapsthelooplimbaroundthepostinadirectiontowardthejoint 50 FIGURE21 A F FishingDuncanloop 51 52 BerkleyDuncanLoopKnot 53 ArthroscopicDuncanLoop Hangman sKnot Fig 22 FIGURE22 A F ArthroscopicDuncanloop 54 Frenchknot FIGURE23 A H FIGURE23 A H Frenchknot 55 56 57 58 TheFrenchknot 22 isaslidingknotthatisamodificationoftheDuncanloop Makethepostlimbhalfaslongasthelooplimb Graspthesuturesbetweenthethumbandindexfingerofyournon dominanthand Fig 23A Createasmallcircleintheloopstrandbypassingtheloopoverthecombinedpostandloopstrandsandholditbetweenyourthumbandindexfinger Fig 23B Makeatotaloffourloopsaroundboththepostandthelooplimbstravelingtowardthejoint Fig 23C Passthetailoftheloopstrandoverandthroughthesmallcircleintheloopstrandthatisheldbetweenthethumbandindexfinger Fig 23D Passthetailoftheloopstrandunderandthroughtheloopcirclecreatedbythedistalendoftheloopstrandandthecombinedlimbsoftheloopandpoststrands Fig 23E Pullonboththelooplimbandthepostlimbsymmetricallytotightentheknot Fig 23F Advancetheknotbypullingonthepostlimbwhilepushingtheknotdownwiththeknotpusheronthepoststrand Fig 23G Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching Fig 23H Throwanunderhandloopontheoriginalpost Tensionwiththeknotpusher Switchposts Throwanoverhandloopoverthenewpost Tensionwiththeknotpusher Switchposts Throwanunderhandloopontheoriginalpostagain Tensionwiththeknotpusher TheFrenchknotwasshowntohaveahigherloadtofailurewhencomparedtotheDuncanloopandtheRevoknot 59 RoederKnot TheRoederknotisaslidingknotthatisavariationoftheDuncanloop ItwasoriginallyusedintonsillectomysurgeryanddescribedintheGermanliteraturebyR derin1918Therehavebeenseveralmodificationsoftheknotthathavebeendescribedsincetheinitialdescriptionoftheknot ModificationsoftheRoederknotarecurrentlyusedinbothlaparoscopicandarthroscopicsurgery 60 FIGURE24 A G Roederknot 61 Thepostlimbshouldbeonehalfthelengthofthelooplimb Throwthefirstlooparoundthepostlimbandthenholdtheloopandposttogetherwiththethumbandindexfingerofthenon dominanthand Fig 24A Throwasecondlooparoundboththepostandlooplimbs Fig 24B Throwathirdlooparoundonlythepostlimbandbetweenthepostandloop Fig 24C Passthetailoftheloopbetweenthesecondandthirdturnsandinbetweenthelooplimbandthepostlimb Fig 24D Tensiontheknotbygentlypullingonboththepostandthelooplimbssimultaneously Fig 24E Whilepullingonthepostlimb pushtheknotintothejointwiththeknotpusheronthepoststrand Fig 24F Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching Fig 24G Throwanunderhandloopontheoriginalpost Tensionwiththeknotpusher Switchposts Throwanoverhandloopoverthenewpost Tensionwiththeknotpusher Switchposts Throwanunderhandloopontheoriginalpostagain Tensionwiththeknotpusher TheRoederknotwasshowntobeinferiortotheDuncanloopandtheSnyderknotinloadtoclinicalfailuretrialsbutastatisticalsignificancewasnotfound 26 62 Savoie ModifiedRoederKnot Fig 25 63 TheSavoie ModifiedRoederknotisalockingknotinsteadofaslipknotThepostlimbshouldbeonehalfthelengthofthelooplimb Throwanunderhandlooparoundthepoststrand Fig 25A Throwasecondlooparoundboththepostandlooplimbs Besuretoleaveasmall hole inthelooppriortothrowingthesecondloop Fig 25B Throwathirdlooparoundboththepostandlooplimbs Fig 25C Throwafourthlooparoundboththepostandlooplimbs Fig 25D Wrapthelooplimbaroundonlythepostandbringitawayfromthejoint Fig 25E Passthetailofthelooplimbbetweenthe hole madeinstepC Fig 25F Looselytensiontheknotbutdonotpullontheloopstrandorthiswillprematurelylocktheknot Fig 25G Whilepullingonthepostlimb pushtheknotintothejointwiththeknotpusheronthepoststrand Whentheknotisseated pushdownontheknotpushertoholdtheknotinplaceandwhilemaintainingtensiononthepoststrand pullontheloopstrandtolocktheknot Thiswillpreventtheknotfromlooseningoncetensionisreleasedfromthestrands Fig 25H Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching Fig 25I 64 Lieurance ModifiedRoederKnot Fig 26 FIGURE26 A H Lieurance ModifiedRoederknot 65 TheLieurance ModifiedRoederknotisalockingknotinsteadofaslipknotThepostlimbshouldbeonehalfthelengthofthelooplimb Throwanoverhandlooparoundonlythepoststrand Fig 26A Throwasecondloopacrossboththepostandlooplimbs Fig 26B Throwathirdloopacrossboththepostandlooplimbs Fig 26C Wrapthelooplimbaroundthepostonlyandbringitbetweenthepostandlooplimbs Fig 26D Passthetailofthelooplimboverandthroughtheinitialloopmadebythepostandlooplimbs Fig 26E Looselytensiontheknotbutdonotpullontheloopstrandorthiswillprematurelylocktheknot Fig 26F Whilepullingonthepostlimb pushtheknotintothejointwiththeknotpusheronthepoststrand Whentheknotisseated pushdow