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 Umut Akgun
Mustafa Karahan
Pietro S. Randelli
João Espregueira-Mendes
Editors

Knots in
Orthopedic Surgery
Open and Arthroscopic
Techniques

123
Knots in Orthopedic Surgery
Umut Akgun
Mustafa Karahan
Pietro S. Randelli
João Espregueira-Mendes
Editors

Knots in Orthopedic
Surgery
Open and Arthroscopic Techniques
Editors
Umut Akgun Mustafa Karahan
Dept. of Orthopedics and Traumatology Dept. of Orthopedics and Traumatology
Acıbadem Mehmet Ali Aydınlar Acıbadem Mehmet Ali Aydınlar
University University
Ataşehir, Istanbul Ataşehir, Istanbul
Turkey Turkey

Pietro S. Randelli João Espregueira-Mendes

Istituto Ortopedico Gaetano Pini Clínica do Dragão
University of Milan Espregueira-Mendes Sports Centre
Italy Porto
Portugal

ISBN 978-3-662-56107-2    ISBN 978-3-662-56108-9 (eBook)

https://doi.org/10.1007/978-3-662-56108-9

Library of Congress Control Number: 2018930240

© ESSKA 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer-Verlag GmbH, DE
The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany
Any success I have had is thanks to my
beloved Yasemin, Zeynep and Ali.
U.A.
Preface by Umut Akgun

Knots were being used since the beginning of human life. Mankind used dif-
ferent types of knots to survive in nature. In those years, many knots were
described for constructing, fishing, climbing, and sailing. Perfection in tying
knots saved many lives on the mountains and the sea. As an irreplaceable tool
of civilization, it was also used in surgery.
Knot tying is an essential step in almost every orthopedic procedure. Knots are
needed for a wide spectrum of procedures from a simple skin closure to a com-
plex shoulder arthroscopy. Some textbooks cover few aspects of knots according
to their scope. The aim of this book is to provide a complete source for orthopedic
surgeons about knot tying from basic science to clinical practice.
Knot tying starts with correct selection of the material. In the first step, read-
ers will learn the materials used in sutures and their biomechanical properties.
The second step will be the essential biomechanics of knot tying and the failure
modes. After completion of basics, readers will find a technical chapter includ-
ing many open and arthroscopic knots. All knots are described in detail by a
step-by-step manner including their clinical aspects, tips, and tricks. Readers
can also find current literature regarding knots and suture materials.
We would like to thank the ESSKA Board and all the authors who made a
great effort to bring this project to life. Let’s tie some knots....

Umut Akgun
Istanbul, Turkey

Yasemin, Zeynep, Ali and Duman

vii
Preface by Mustafa Karahan

Orthopedic sports surgery consists of various complex skills which would

take years to acquire. Throwing a safe and secure knot is the most basic skill
which could have a high cost if failed. Therefore, learning to throw an effi-
cient knot early in residency is fundamental to having a successful surgical
training. This book puts the basic science of surgical knots into spotlight, and
through a variety of chapters, it effectively discloses the full technique behind
open and arthroscopic knots.

Istanbul, Turkey Mustafa Karahan

ix
Preface by Pietro S. Randelli

Dear colleagues and readers,

Since long time ago, all surgeons approaching open or arthroscopic tech-
niques had to face with knots.
The knot represents most of the time the conclusion of a successful proce-
dure and even more one of the most delicate passages of surgical technique.
Thus, all of us recognize the importance of dominating this matter in order
to treat in the best way our patients. I remember several overseas flights with
a rope between my hands training about knots.
The sources to be updated and trained about knots are scarce, not clear,
and incomplete. For this reason, when Prof. Karahan and Dr. Umut Akgun
had the idea to write this book, I was honored to be included among the edi-
tors and to contribute to its concept and contents.
The book is divided into several parts. An initial basic science part is nec-
essary to choose the right material for each surgery and to understand
mechanical and biological properties of those materials. Then the open and
arthroscopic techniques to manage knots are well described and finally a lit-
erature review is concluding the book.
The full Esska board is grateful to Prof. Karahan, Dr. Akgun, and Prof.
Espregueira Mendes for this book and we hope you’ll enjoy it.
Warm regards,

San Donato Milanese, Italy Pietro S. Randelli

xi
Preface by João Espregueira-Mendes

Education should lead the way to proficiency and take doctors to superior
standards of medical care, contributing, therefore, to better outcomes for
patients. This book is an asset for the noble mission of medical education and
the advance of techniques within this particular and important field.
The readers will profit from it. Certainly, it will add substantial knowledge
and leverage the acquisition of skills to achieve a more safe and effective
intervention with the patients. The contents of this book are the result of a
group of leading and skillful professionals that constantly seek for improve-
ments within scientific research, clinical practice, and education. This drive
for daily achievements and knowledge share is a warranty that, in the present
and future, higher expectancies from society on medical performance are to
be met.
I am grateful to all the contributors who carried into this book so much of
hard work, talent, and commitment. It is very clear that the most important
and inspiring compliment will be conveyed from all those who go a step fur-
ther in their standard of care by getting acquainted with the content of the
book.
Sincere congratulations to all.

Porto, Portugal João Espregueira-Mendes

xiii
Contents

Part I Basic Sciences

1 Terminology������������������������������������������������������������������������������������    3
Simon Donell
2 Biological Properties of Suture Materials������������������������������������   11
Onur Başçı, Umut Akgun, and F. Alan Barber
3 Mechanical Properties of Suture Materials��������������������������������   21
Emrah Açan, Onur Hapa, and F. Alan Barber
4 Biomechanics in Knot Tying ��������������������������������������������������������   33
Roman Brzóska, Hubert Laprus, Piotr Michniowski,
and Paweł Ranosz
5 Failure Modes of Knots and Sutures��������������������������������������������   47
Ali Öçgüder and Michael Medvecky

Part II Open Knot Tying

6 Square Knot������������������������������������������������������������������������������������   55

Cengiz Yildirim, Fazli Levent Umur,
and João Espregueira-Mendes
7 Surgeon’s Knot ������������������������������������������������������������������������������   65
Katja Tecklenburg
8 Half Hitches������������������������������������������������������������������������������������   81
Radu Prejbeanu and Mihail-Lazar Mioc
9 Sliding Knots����������������������������������������������������������������������������������   91
Nuno Sevivas, Guilherme França, Nuno Oliveira,
Nuno Ferreira, Manuel Vieira da Silva, Renato Andrade,
and João Espregueira-Mendes
10 Fracture Reduction and Fixation by Knots��������������������������������   97
Baris Kocaoglu, Tekin Kerem Ulku, and Ata Can Atalar

xv
xvi Contents

Part III Arthroscopic Knot Tying

11 Arthroscopic Instruments ������������������������������������������������������������ 109
M. Ugur Ozbaydar, Kerem Bilsel, and Mehmet Kapicioglu
12 Soft Tissue Handling in Arthroscopic Surgery �������������������������� 117
Didier Guignand
13 Suture Manipulation in Arthroscopic Surgery �������������������������� 127
Urszula Zdanowicz and Michał Drwięga
14 Half Hitches������������������������������������������������������������������������������������ 143
Selim Ergün, Mahmut Enes Kayaalp, and Taner Güneş
15 Non-sliding (Static) Knots ������������������������������������������������������������ 153
Elmar Herbst, Masahito Yoshida, Gregory Gasbarro,
Stephenson Ikpe, and Volker Musahl
16 Sliding Knots���������������������������������������������������������������������������������� 161
Riccardo Compagnoni, Federico Cabitza, and Pietro S. Randelli

Part IV Literature Review

17 Literature Review of Suture Materials���������������������������������������� 177

Ersin Erçin and Mustafa Karahan
18 Literature Review of Arthroscopic Knots����������������������������������� 181
Maristella F. Saccomanno and Giuseppe Milano

Index�������������������������������������������������������������������������������������������������������� 189
 Part I
Basic Sciences
 Terminology
1
Simon Donell

When we hold back out of laziness, that is when we tie ourselves into knots of boredom
(Walter Annenberg 1908–2002, American Publisher)

Knots are integral to orthopedics, not only as part knot clearly is a fastening made by a loop,
of the repair of tissues but also as a component of although a suture can become tangled!
traction equipment. A stitch or suture is a loop
of thread or yarn resulting from the passing of a
needle. In surgery its function is to hold or bind 1.1 History
tissues together. For the suture to maintain its
function, it is secured by a knot. The word “knot” It is not possible to weave cloth without a
has a number of meanings in the English lan- knowledge of knots. Knots are needed to make
guage. It can be: nets or sail a boat and for ancient man to build a
house. In early times they were used for count-
1. Fastening made by looping a piece of string, ing and by the Inca for record making and as a
rope, etc. on itself and tightening it memory aid. They therefore predate history.
2. Tangled mass in something Our knowledge of knots and the terms used
3. Knob, protuberance, or node in a stem, branch, come from sailing. A fishing net is a series of
or root knots, and there are many types of knots and
4. Unpleasant feeling of tightness or tension in a uses for them. Surgeons only need to know a
part of the body few knots aimed at binding tissues together or
5. Small tightly packed group of people sealing off hollow tubes.
6. Unit of speed equivalent to one nautical mile Eyed needles for suturing have been found in
per hour archaeological sites dating from around 30,000
7. Small, relatively short-billed sandpiper (bird)
BC, but the first detailed description of knots
was by the Greek physician Heraklas in the first
The verb “to knot” can mean “to fasten with a century AD [1]. He wrote a book called From
knot,” “to make something tangled,” or “to cause Heraklas that gives details of different knots
a muscle to become tense and hard.” A surgical that include (although named differently) the
reef (square in the USA) knot, cow hitch, and
clove hitch. He also described slings that were
used for applying traction in fracture and dislo-
S. Donell cation reduction. Nowadays there are many
Norwich Medical School, University of East Anglia,
Norwich, UK hundreds of different knots described for vari-
e-mail: [email protected] ous uses.

© ESSKA 2018 3
U. Akgun et al. (eds.), Knots in Orthopedic Surgery, https://doi.org/10.1007/978-3-662-56108-9_1
4 S. Donell

The reef knot is one of the oldest and is used the standing part being the section of suture
for hand-tying ligatures (using single- or doubled-­ between the knot and the standing end.
handed techniques). The first description of a sur- • The turn is a single pass behind or through an
geon’s knot (a reef knot with an initial double object. A round turn is the complete encircle-
turn) in the literature was in 1733 according to ment of the object and requires two passes.
the Merriam-Webster Dictionary but does not Likewise two round turns circle the object
give the reference. The surgeon’s knot lends itself twice and require three passes.
to an instrument-tying technique. • The working end (also called the working
limb) is the end of the suture being used to
make the knot. It is also called the “running
1.2 Components of a Knot end.” The working part is the section between
(Fig. 1.1) the knot and the working end.
• Half hitch is an incomplete knot formed by
• The bight is the middle part of the suture and passing the working limb of a suture round its
is any curved section, slack part, or loop standing limb and then through the loop. It is
between the ends. The term “in the bight” generally used to tie the sutures on a fixed
implies a U-shaped section of the suture which point such as an anchor. A single half hitch is
is itself being used in making a knot. Many not secure and can be easily untied.
knots can be tied either with the end or in the • A wrap (also known as a throw) is formed by
bight. weaving one limb of the suture on the opposite
• The ends of a suture are known as the limb or limb. A knot is composed of various configu-
thread. A suture has two independent limbs ration of wrap or throws snugged firmly
that are used to make a knot. against each other.
• A loop is a full circle formed by passing the • Neck is the transition points from the com-
working end over itself. The elbow is the two pleted knot to the loop.
crossing points created by an extra twist in a • Ears are the residual ends of a completed
loop. The diameter of the loop depends on the knot. Length of the ears may affect the secu-
desired tissue approximation. rity of the knot. Too short ears may decrease
• The standing end (also called post limb) is security, whereas too long ears may cause tis-
the end not involved in making the knot, with sue irritation.

a b
Half-hitch

Loop Neck
Wo

Limb
rki
ng
Post limb

lim

Limb
b

Wraps

Fig. 1.1 Components of a square knot (a) and a half hitch (b)
1 Terminology 5

1.3 Properties of Knots itself does not fail, it stops performing the
desired function.
1.3.1 Strength • Capsizing: To capsize (or spill) a knot is to
change its form and rearrange its parts, usu-
Knots weaken the suture since the bending, ally by pulling on specific ends in certain
crushing, and chafing forces that hold a knot in ways. This does not typically apply to surgical
place also unevenly stress the suture fibers and knots but is important in sailing and climbing.
ultimately lead to a reduction in strength. When • Sawing: The friction between two strands of
a knotted suture is strained to its breaking point, suture during the tying process. Excessive
it almost always fails at the knot or close to it, sawing weakens the material.
unless it is defective or damaged elsewhere. • Loop security: The ability of the suture loop
The relative knot strength, also called knot to stay tight as the knot is being tied.
­efficiency, is the breaking strength of a knotted • Knot security: The maximum load the knot is
suture in proportion to the breaking strength of able to support prior to breaking (fracture) or
the suture without the knot. Determining a pre- complete slippage. A perfect knot should hold
cise value for a particular knot is difficult till the suture breaks on the neck of the loop.
because many factors can affect a knot efficiency
test such as the material it is made from, the style To be secure a knot must be properly placed.
of suture, its size, whether it is wet or dry, how The security varies depending on the surgeon, the
rapidly it is loaded, or whether it is repeatedly speed of tying, and the situation found. Differences
loaded. The efficiency of common knots ranges are found between surgeons and within an indi-
between 40 and 80% of the suture’s original vidual surgeon’s knots. In addition to knot secu-
strength. rity, the loop must also be secure [2]. The latter is
different from knot security since a suture material
with a large elastic elongation (low elastic modu-
1.3.2 Security lus) can stretch, resulting in a loose loop even if the
knot is completely secure. The ideal knot would be
Even if the suture does not break, a knot may still easy to tie and reproducible and would not slip or
fail to hold. Knots that hold firm under a variety stretch before the tissue had healed. Other biome-
of adverse conditions are said to be more secure chanical terms that affect a tied knot are:
than those that do not. The main ways knots fail
to hold are: • Loop circumference: This can affect the ten-
sion force on the knot. A larger loop circum-
• Slipping: The load creates tension that pulls ference can increase the force on the knot
the suture back through the knot in the direc- because of the longer force arms.
tion of the load. If this continues far enough, • Coefficient of friction: This is used to measure
the working end passes into the knot and the the resistive forces encountered within the
knot unravels. suture limbs and between tissue during knot
Even with secure knots, slippage may occur tying.
when the knot is first put under real tension. • Strength: This is the suture’s resistance to
Tightening the knot fully and leaving the breakage.
suture ends long enough can reduce the risk of • Stiffness: This is the resistance to bending.
this. • Viscoelasticity: This is the deformation of the
• Sliding: In knots that are meant to grip tis- suture under strain which is reversible. This is
sues, failure can be defined as the knot moving usually important to compensate for tissue
relative to the gripped tissue. While the knot oedema as a result of tissue trauma.
6 S. Donell

• Abrasion resistance: This is the durability of place are releasing the tension. Monofilaments
the suture. Metallic anchor eyelets, instru- have a low coefficient of friction, and so the
ments, and bone edges can easily damage the knot tends to loosen on release as a result of its
sutures. New-generation sutures have higher memory.
abrasion resistance.
• Creep: This is the deformation of a solid mate- • Monofilament: Describes a suture made of a
rial under constant loads. single strand or filament.
• Multifilament: Describes a suture made of
Other problems to consider include the load to several braided or twisted strands or
failure, cyclic loading, yield load, and elongation. filaments.
To understand fully the various processes that • Absorption rate: Measures how quickly a
affect the tying of a specific material and create suture is absorbed or broken down by the
strong and efficient knot needs detailed biome- body. It refers only to the presence or absence
chanical investigation and analyses. Suffice it to of suture material and not to the amount of
say, understanding the basic principles is all that strength remaining in the suture.
is needed for the clinician. • Breaking strength retention (BSR):
Measures the tensile strength retained by the
suture in vivo over time.
1.3.3 Knot Handling • Tensile strength: The measured kilograms of
tension that a suture can withstand before
The ease of tying a knot depends on a number of breaking.
factors related to the construction of the suture
material. The suture material chosen should opti-
mise the combination of strength, uniformity, and 1.4  eneral Principles of Knot
G
hand: Tying

• Hand relates to the feel of the suture in the Certain principles apply to the tying of all knots
surgeon’s hand along with the smoothness of and suture materials.
its passage through tissue, the ease of tying
and snugging it down, and the final firmness • Tie the knot firmly so that slipping is virtu-
of the knot. ally impossible. The simplest knot for the
• Extensibility is the amount of stretch during material should be chosen.
knot tying and its recovery after the release of • Keep the knot as small as possible to prevent
the strain. This allows the surgeon to feel an excessive amount of tissue reaction when
when the knot is snug. absorbable sutures are used or to minimise
• Memory is the property of the synthetic foreign body reaction to nonabsorbable
monofilament sutures to return to their origi- sutures. Ends should be cut as short as possi-
nal shape. This depends on the manufacturing ble but not so short as to risk loosening.
extrusion process and the packaging. • Avoid sawing; the friction between the strands
of suture.
• Avoid damaging the suture material. Avoid
1.3.4 Material the crushing or crimping by the surgical
instruments except when grasping the free end
Sutures can be monofilament or multifilament, of the suture.
smooth or braided (twisted), and made of natu- • Avoid excessive tension; otherwise, it will
ral or artificial materials. The braided multifila- cause suture breakage and may cut the tissue.
ment sutures are easier to tie as they have a high Practice in avoiding excessive tension leads to
coefficient of friction and the knot remains in successful use of finer-gauge materials.
1 Terminology 7

• When approximating tissues do not tie too

tightly; this may cause tissue strangulation.
• Maintain tension on one end of the suture
after the first loop is tied. This avoids loosen-
ing of the throw if being tied.
• Make the final throw as nearly horizontal
as possible.
• Change stance or position in relation to the
patient in order to place a knot securely
and flat.
• Extra ties do not add to the strength of a
properly tied knot; they only contribute to its
bulk.
• Pull the two ends of the suture in opposite
directions with uniform rate and tension;
the knot will then be tied more securely. This
maneuver can be done on square and sur-
geon’s knot, not on the slip knots.

1.5 Types of Knots

The basic knots used in orthopedic surgery are:

Fig. 1.2 Square knot (above) versus granny knot (below).
Square knot has a symmetrical configuration, whereas
granny knot is asymmetrical
1.5.1 Static Knots

In these knots, surgeon should keep the initial tissue

tension between throws in order to prevent loosen- not in general use. Some static knots can be
ing. This can be achieved by the help of a surgical changed into a slip not by a simple maneuver. For
instrument or increasing the number of wraps. example, tensioning one limb of a square knot
forms a slip knot which consists of two half
• Reef (square) knot: used to tie the two ends hitches (Fig. 1.3).
of a single line together such that they will Besides sutures with knots, a number of
secure something that is unlikely to move devices and products are available to oppose tis-
much (Fig. 1.2). sues that avoid the use of knots. These can be, for
• Surgeon’s knot: a simple modification to the reef instance, barbed suture material, staples, fibrin
knot. It adds an extra twist when tying the first glue and knotless suture anchors mostly used in
throw, forming a double overhand knot. The addi- arthroscopic procedures [4].
tional turn provides more friction and decreases
loosening while the second half of the knot is tied.
1.5.2 Slip Knots
Note: the granny knot can be confused with
square knot. It has a different combination of These knots have a dynamic configuration; it is
throws and is mechanically inferior to the square possible to adjust the tension while making the
knot (Fig. 1.2). knot. Various combinations of half hitches are
Other knots have been described, e.g., the used in these knots. They are generally used for
two-strand-overhand locking (TSOL) [3], but are binding rope to an object.
8 S. Donell

Fig. 1.3 Left to right, pulling green limb of the square knot forms two half hitches on green limb

Fig. 1.4 Various slip knots. Left to right: half hitches on the same post (above is overhand; below is underhand), trac-
tion knot, bowline, half hitches on alternating posts

• Over- and underhand half hitches are basic • Revo is a well-known arthroscopic knot which
hitches that can be used to form different slip consists of five half hitches (Fig. 1.4).
knots (Fig. 1.4).
• Traction knot is a simple knot that can be
used for traction. It looks like a simpler form 1.5.3 Stoppers
of a bowline (Fig. 1.4).
• Bowline is a very simple knot that creates a This is a special subgroup of knots that are
fixed loop at the end of a rope. It is easy to tie mainly used to make a bulk on the end of a rope.
and untie even after being loaded. Its impor- They can be used to block the passage of the free
tance is reflected by some calling it the “King end of a suture through a hole on a bone or an
of knots” (Fig. 1.4). implant.
1 Terminology 9

a b

Fig. 1.5 Various stopper knots. (a) Figure of eight, (b) double overhand

• Figure-of-eight knot (Fig. 1.5). Knots are a key surgical skill. An understanding
• Double overhand knot (Fig. 1.5). of the types and their uses, the importance of the
suture materials used, and the manual skills to apply
them are fundamental for a successful outcome from
an operation. However, as Mahar et al. noted [5],
1.5.4 Bends despite differences between knot types, surgeons
should use the type of knot they are most comfort-
These knots are used to bind free ends of two dif- able with, rather than attempt a knot with which they
ferent ropes (Fig. 1.6). are unfamiliar in an effort to maximise security.
10 S. Donell

Fig. 1.6 Hunter’s bend that can be used to bind free ends of two different ropes

the square knot: a novel knotting technique for

References surgical use. J Bone Joint Surg Am. 2013;95:
1020–7.
1. Hage JJ. Heraklas on knots: sixteen surgical nooses 4. Lee S, Mahar A, Bynum K, Pedowitz R. Biomechanical
and knots from the first century A.D. World J Surg. comparison of bioabsorbable sutureless screw anchor
2008;32:648–55. versus suture anchor fixation for rotator cuff repair.
2. Livermore RW, Chong AC, Prohaska DJ, Cooke FW, Arthroscopy. 2005;21:43–7.
Jones TL. Knot security, loop security, and elonga- 5. Mahar AT, Moezzi DM, Serra-Hsu F, Pedowitz
tion of braided polyblend sutures used for arthroscopic RA. Comparison and performance characteristics of
knots. Am J Orthop (Belle Mead NJ). 2010;39:569–76. 3 different knots when tied with 2 suture materials
3. Zhao C, Hsu C-C, Moriya T, Thoreson AR, Cha used for shoulder arthroscopy. Arthroscopy. 2006;22:
SS, Moran SL, An K-N, Amadio PC. Beyond 614.e1–2.
 Biological Properties of Suture
Materials
2
Onur Başçı, Umut Akgun, and F. Alan Barber

Suture is a general term for all materials used to amount of degradation is dependent upon the
stitch torn tissues. Sutures can be synthetic or absorbability of the specific suture material.
natural and have a monofilament or braided con- Generally a suture that loses its tensile strength
struction. Through the history of mankind, vari- within 60 days is considered absorbable.
ous materials were tried to serve this purpose. However, the new generation of absorbable
Plants such as flax, hemp, and cotton and animal suture materials may hold their tensile properties
tissues such as hair, tendon, silk, and intestines far beyond this limit. The absorption rate may
are some examples. The oldest, known suture vary due to the suture composition or the tissue
was on a mummy in ancient Egypt on 1100 BC, sutured. Host reactions and infection also affect
and the first written description on surgical the absorption process. Nonabsorbable sutures
wound suturing belongs to the Indian physician do not biologically degrade but can also lose their
Sushruta in 500 BC. integrity over time. Sutures that are commonly
In this chapter, the biological properties of used in orthopedic procedures are listed in
commonly used suture materials will be dis- Table 2.1.
cussed. Sutures may cause different host reac- The biological response of the local tissues
tions in living tissues. While the suture remains against sutures can be influenced by different fac-
in the tissue, it can trigger the inflammation cas- tors (Table 2.2). The suture material and its
cade through different pathways such as degrada- absorbability, configuration, and size in particu-
tion, a foreign body reaction, an allergic reaction, lar are important. Natural materials such as cat-
or abrasion. Sutures can remain inert, be partially gut and silk are more immunogenic than synthetic
degraded, or be totally degraded by the host. The materials because they are degraded by proteoly-
sis in contrast to synthetic sutures, which are
degraded by hydrolysis. Hydrolysis is a less
O. Başçı immunogenic process compared to proteolysis.
9 Eylül University, İzmir, Turkey
e-mail: [email protected] Nonabsorbable sutures cause less inflammation
in contrast to absorbable sutures and usually
U. Akgun (*)
Acıbadem Mehmet Ali Aydınlar University, induce a fibrous layer formation around the
Istanbul, Turkey suture, which prevents a host response. More irri-
e-mail: [email protected] tation is seen with braided suture than with
F.A. Barber monofilament sutures. This can be explained by
Plano Orthopedic Sports Med Center, Plano, the surface topography of the suture. The smooth
TX, USA texture of monofilaments causes less response in
e-mail: [email protected]

© ESSKA 2018 11
U. Akgun et al. (eds.), Knots in Orthopedic Surgery, https://doi.org/10.1007/978-3-662-56108-9_2
12 O. Başçı et al.

Table 2.1 Biological and structural properties of common sutures used in orthopedic procedures
Brand name Material Architecture
Absorbable Dexon Polyglycolic acid Monofilament or braided
Dexon II Dexon coated with polycaprolate Monofilament or braided
Vicryl, polysorb Polyglactic acid—polyglactic 910 Braided
Vicryl rapide Different form of polyglactin 910 Braided
PDS Polyester poly (p-dioxanone) Monofilament
Maxon Polyglyconate Monofilament
Caprosyn Polyglytone P6211 Monofilament
Panacryl Caprolactone/glycolide Braided
Monocryl Poliglecaprone 25 Monofilament
Phantom fiber Poly-4-hydroxybutyrate Braided
Partially absorbable OrthoCord UHMWPE and polydioxanone Braided
Non-absorbable Ethibond Polypropylene Braided
Ethilon Aliphatic polymers Nylon 6 and Monofilament
Nylon 6,6
Fiber wire UHMWPE core with a braided jacket Braided
of polyester and UHMWPE
Force fiber UHMWPE Braided
HiFi UHMWPE Braided
MagnumWire UHMWPE Braided
MaxBraid UHMWPE Braided
Prolene Polypropylene Monofilament
TiCron Polyester Braided
UltraBraid UHMWPE Braided

Table 2.2 Effect of suture properties on local tissue reactions biological response to the suture material should
Local tissue reaction be limited because exuberant inflammatory reac-
Less More tions delay or prevent tissue healing, cause scar
Material of the Synthetic Natural formation, and predispose to infection.
suture
Architecture of Monofilament Braided
the suture 2.1 Nonabsorbable Sutures
Picks per inch in More Less
braided suture
Common nonabsorbable sutures used in ortho-
Twist angle in High Low
braided suture pedic procedures are listed in Table 2.1. Natural
Size of the suture Thinner Thicker materials like silk are not routinely used in
Type of suture Non-absorbable Absorbable orthopedic surgery because their foreign pro-
teins can cause severe reactions. Nowadays
the sutures most commonly used in orthopedic
the host. As discussed later in the text, the inter- procedures are synthetic. Synthetic sutures can
nal architecture of braided suture is another vari- be divided into two groups: monofilament and
able that may cause abrasion to the host tissue. braided. In monofilament group, Prolene and
Regardless of the material, as the suture size nylon are generally used for soft tissue approx-
increases so does the tissue reaction. In addition, imation, nerve, and vascular repairs. Braided
a true allergic response to a suture material may sutures in orthopedic surgery are generally
also occur. Foreign proteins found in natural used for tendon and ligament repairs and bone
materials usually trigger this type of response. fixations. Until the development of ultrahigh
Choosing the most appropriate suture for a molecular weight polyethylene (UHMWPE)
specific surgery is a very important issue. Any suture materials, braided polyester sutures such
2 Biological Properties of Suture Materials 13

as Ethibond were commonly used for these MaxBraid, and UltraBraid [3]. Some braided
procedures. Nowadays different UHMWPE- sutures are coated with Teflon, silicone, or wax
containing sutures are preferred for tendon and to improve knot tying. These coatings may also
ligament repairs due to their high strength and affect the abrasiveness of sutures.
handling characteristics. Suture architecture may also cause an
Nonabsorbable sutures used in orthopedic increased predisposition toward infection. Fowler
procedures seldom cause significant host reac- et al. showed bacteria adhere less to monofila-
tions. However they are not trouble free. Some of ment sutures than to braided ones. The authors
these include tissue abrasion, infection, and for- reported that a barbed monofilament suture
eign body and allergic reactions. (Quill) caused less bacterial adherence com-
Abrasion is a mechanical irritation causing tis- pared to Vicryl and Vicryl Plus braided absorb-
sue inflammation. The architecture of the suture able sutures [4]. This suggests that monofilament
is the main factor in abrasion. Monofilament suture might be better suited for use in surgical
sutures are made of a single strand, whereas mul- areas which are prone to infection.
tifilaments are composed of several strands and Adverse events are occasionally reported with
usually braided. Nonabsorbable monofilament nonabsorbable sutures. A foreign body reaction
sutures such as Prolene (Ethicon, Somerville, is an early physiological response seen in all
NJ) made of polypropylene and Ethilon (Ethicon, types of sutures. Microscopically an inflamma-
Somerville, NJ) made of long-chain aliphatic tory zone forms around the suture composed pre-
polymers Nylon 6 and Nylon 6,6 cause mini- dominantly of multinucleated giant cells [5].
mal abrasion because of their smooth surface. While a normal healing response, this response in
However most of the braided sutures do cause some cases becomes severe and may result in
some degrees of abrasion due to their surface aseptic drainage. More intense foreign body reac-
topography [1, 2]. Braided sutures are woven by tions are commonly seen with absorbable sutures
twisted strands. Physical characteristics such as [6]. Esenyel et al. showed that a foreign body
picks per inch (PPI) and the twist angle of these reaction is more severe with braided polyester
strands affect tissue abrasiveness [3] (Fig. 2.1). than polypropylene and polyethylene suture [5].
As the PPI and twist angle decrease, abrasion of In an experimental study, Carr et al. compared
the tissue increases [3]. Williams et al. reported foreign body reactions for eight different braided
that the latest generation high-strength sutures sutures [7]: Ethibond (Ethicon, Somerville, NJ),
such as FiberWire, Phantom Fiber BioFiber, Ti-Cron (Tyco, Waltham, MA), HiFi (Linvatec,
Collagen Coated FiberWire, and Ti-Cron are Largo, FL), UltraBraid (Smith & Nephew,
more abrasive than OrthoCord, Force Fiber, Memphis, TN), MaxBraid (Biomet, Warsaw, IN),
OrthoCord (Mitek, Raynham, MA), MagnumWire
(Opus Medical, San Juan Capistrano, CA), and
FiberWire (Arthrex, Naples, FL). These authors
reported that MagnumWire and Ti-Cron demon-
strated a more intense inflammatory response
than the others in a rabbit model.
Twist angle Rarely delayed allergic reactions can occur. In
Gullet effect a case report, Al-Qattan and Kfoury reported a
delayed allergic reaction to polypropylene in a
flexor tendon repair [8]. In this special entity,
patients usually do not have a history of allergy to
sutures. In delayed allergic reactions, the main
Fig. 2.1 In a suture with fewer external fibers (lower histopathological findings are foamy histiocytes,
PPI), fibers must take a steeper angle to cover an inch of
lymphocytes, and plasma cells. A skin test is
suture (lower twist angle). Lower twist angle creates a
deeper groove between each bundle, like an increased gul- needed to confirm the diagnosis [8]. Suture
let depth on a saw blade removal is usually required for resolution.
14 O. Başçı et al.

For nonabsorbable sutures, monofilaments prior to use. This suture retains its tensile
such as nylon and Prolene cause less host reac- strength for 3–5 days [9].
tion than braided sutures like Ethibond or the
new generation of UHMWPE-containing sutures.
Natural materials such as silk can cause severe 2.2.2 Newer Materials
foreign body reaction because of their foreign
proteins. (a) Polyglycolic acid (Dexon), (Dexon II
Bicolor): Polyglycolic acid was the first syn-
thetic absorbable suture polymerized either
2.2 Absorbable Sutures directly or indirectly from glycolic acid.
Because of its predictable absorption charac-
Absorbable sutures degrade over time and there- teristics and low tissue reaction, it often
fore have a complex interaction with the host tis- replaced the use of catgut [10]. It maintains
sue. Depending upon the material, the time 89% of its tensile strength at 7 days, 63% at
needed for degradation may be as little as 6 days 14 days, and 17% at 21 days [11]. Full
up to several months. Other factors affecting the absorption of polyglycolic acid is reported to
time needed for suture degradation are the pres- occur in 90–120 days [12, 13]. Due to hydro-
ence of infection and the surgery site. Since the lytic absorption, Dexon has minimal tissue
historical catgut suture, many synthetic absorb- reaction, compared to surgical gut which is
able sutures have been developed. The common degraded by proteolytic enzymes [13].
absorbable sutures used in orthopedic surgery Polyglycolic acid is available as in a mono-
and their characteristics are listed below. filament and a braided form as well as either
coated or uncoated. Dexon II is the polycap-
rolate coated form allowing for easier han-
2.2.1 Older Materials (Chromic, Gut) dling and smoother knot tying. The coating
also decreases the risk of bacterial coloniza-
Catgut was the first absorbable suture. It is made tion [14]. Dexon sutures were also shown to
by twisting together purified strands of collagen maintain vascular integrity long enough to
taken from the submucosal or serosal layers of permit healing of small canine femoral vein
healthy ruminants’ (sheep, cattle, and goats) grafts and performed well compared to
small intestine or beef tendon. Amino and car- Prolene [15].
boxyl groups of collagen are sensitive to pH lev- (b) Polyglactic acid (polyglactin 910), (Vicryl,
els. Alterations in tissue pH may weaken the fiber Polysorb): Polyglactin 910, a copolymer of
structure, further causing loss of strength and glycolide and L-lactide, is a synthetic braided
mass in highly acidic and alkaline conditions. suture material mainly introduced to take the
Thus, the strands are treated with formaldehyde place of polyglycolic acid. The high concen-
to resist the pH alterations and enzymatic attack tration of the glycolide monomer in polygla-
and twisted together forming the “plain gut” ctin 910 (90:10 molar ratio of glycolic to
suture. When further processed with chromium levo-lactic acids) is crucial in maintaining
trioxide, “chromic gut” is created which is more the mechanical and degradation properties.
resistant to absorption and has less tissue The level of crystalline or amorphous struc-
reaction. tures impacts the tensile force and retention
The plain gut suture retains its tensile rate of the suture [13, 14, 16]. Less amor-
strength for 7–10 days and fully absorbs over phous structures result in longer strength
60–70 days. In contrast, chromic gut retains its retention times and stronger tensile proper-
tensile strength for 10–14 days. Fast-absorbing ties in sutures.
gut is created when plain gut suture is heated to The primary absorption of polyglactin
begin the collagen breakdown within the suture 910 occurs by hydrolysis. Because of its
2 Biological Properties of Suture Materials 15

hydrophobic properties, polyglycolic acid at 42 days with complete absorption by

maintains 75% of its strength at 2 weeks and hydrolysis observed between 180 and
50% at 3 weeks [13]. It is totally absorbed 210 days [25]. Maxon has 60% less rigidity
between 60–90 days [17]. The commer- than PDS and is significantly easier to handle
cially available polyglactin 910 is either [24]. Despite its prolonged absorption, tissue
dyed or undyed. If the violet or dyed ver- reactivity is usually minimal. Though more
sion is used, cutaneous applications should expensive than Vicryl or Dexon, it is consid-
be avoided because the colored suture ered as one of the best absorbable monofila-
may be visible clinically [18]. A lubricant ment sutures and applicable for large surgical
coated form with polyglactin 370 and cal- procedures on the trunk or extremities that
cium stearate is also available to ease tissue need prolonged, suture-based approximation
passage. Vicryl Rapide is another form of during healing.
polyglactin 910 for cutaneous usage. This (e) Polyglytone 6211 (Caprosyn): Polyglytone
suture is a partially hydrolyzed form and is composed of glycolide, caprolactone, tri-
does not need to be removed because it is methylene carbonate, and lactide. It can be
spontaneously absorbed within 7–14 days rapidly absorbed and degraded from the
[19]. body. Flexibility and superior handling in
(c) Polydioxanone (PDS): Polydioxanone (PDS knot tying are other advantageous properties.
II®) is a monofilament polymer manufactured It retains its tensile strength for 10 days and
from the polyester poly(p-dioxanone). The is absorbed within 56 days [26].
prolonged tensile strength of PDS is its most (f) Caprolactone/glycolide (Panacryl): Panacryl
important advantage over polyglycolic acid is an absorbable glycolide-l-lactide copoly-
(Dexon) and polyglactin 910 (Vicryl) [20]. mer suture. It provides significant long-term
PDS maintains 74% of its tensile strength at mechanical strength lasting over 6 months.
2 weeks, 50% after 4 weeks, and 25% after It retains about 90% of its original in vivo
6 weeks [21]. Traces of buried polydioxanone tensile strength at 6 weeks and 60% at
have been found in 6-month postimplantation 6 months [27]. Complete biodegradation
histologic preparations [22]. The primary occurs in 2.5 years. In terms of mechanical
usage of PDS is for tendon repair. Because properties, Panacryl is right in the middle
of its slower degradation, it has a low tissue of absorbable and nonabsorbable sutures.
reactivity maintaining its integrity even in the The suture is coated by ε-caprolactone/gly-
presence of an infection [19]. As a monofila- colide copolymer for facilitating tissue pas-
ment suture, it retains packaging memory and sage. The braided form allows for excellent
can remain relatively stiff and present diffi- suture handling and knot tying with a little
culties during knot tying [20, 22]. In subcutic- concern for knot security [28, 29]. These
ular suturing, polydioxanone was associated sutures are mainly used in tissues with slow
with a lower incidence of hypertrophic scar healing capacity and which demand high ten-
formation compared to polypropylene, nylon, sile strength such as tendons and ligaments.
and polyglycolic acid [23]. Patients with low tissue healing capacity like
(d) Polyglyconate (Maxon): Polyglyconate is a diabetics may also benefit from these sutures
synthetic, monofilament absorbable suture because of its prolonged strength retention.
material that is a copolymer of glycolic acid (g) Poliglecaprone 25 (Monocryl): Monocryl is
and trimethylene carbonate. It is superior to an absorbable monofilament suture which
PDS providing a more supple suture han- is a copolymer of glycolide and
dling and smooth knot formation while at the ε-caprolactone. At 7 days the suture retains
same time providing prolonged tensile 50–60% of its tensile strength. Absorption
strength [24]. It retains 81% of its tensile is completed by hydrolysis at approxi-
strength at 14 days, 59% at 28 days, and 30% mately 90 days post implantation [22]. The
16 O. Başçı et al.

initial tensile strength is significantly a low bacterial adherence potential compared

higher which allows the surgeon to choose with other high-tensile sutures [33].
a thinner suture size. Monocryl offers good
handling characteristics and low tissue
reactivity, providing a less reactive scar 2.3 Biologic Augmentations
when compared to Vicryl Rapide [30]. for Sutures
Moreover, poliglecaprone 25 has better
knot tying and knot security than other Tissue healing is a multifactorial process and
absorbable monofilament sutures [22]. Due there are still many questions. Suture type is a
to these characteristics, poliglecaprone 25 significant factor in healing. Various biological
has become the suture of choice especially materials have been used to increase the efficacy
in cosmetic cutaneous surgeries. of sutures in different ways. Several different bio-
(h) Phantom Fiber (Wright, Memphis, TN): It is logical enhancement strategies have been used
a high-strength absorbable suture composed with sutures.
of poly-4-hydroxybutyrate (P4HB) [3]. It
demonstrates approximately 200 N tensile (a) Butyric acid (BA): Butyric acid is a carbox-
strength at time zero. This suture can retain ylic acid, formed as a bacterial metabolic
50% of its initial strength for 3 months. Poly-­ product in the gut [34]. In its monobutyrate
4-­hydroxybutyrate (P4HB) is fully degraded state, butyric acid has a proangiogenic effect
to water and carbon dioxide in 12–18 months. by enhancing DNA transcriptional activity
Because of its high tensile strength, Phantom [34]. Leek et al. showed that butyric acid-­
Fiber is mainly used in tendon repairs. impregnated sutures improved early Achilles
tendon healing in a rabbit model [34].
(b) Polytribolate: It is a polymer of glycolide,
2.2.3 Partially Absorbable Suture epsilon-caprolactone, and poloxamer 188
(Vascufil, Covidien Inc., Mansfield, MA).
(a) OrthoCord (Mitek, Raynham, MA): It is a This material is used as a suture coat in order
partially absorbable suture, combining to accommodate fray resistance, easy han-
UHMWPE and polydioxanone [7, 16, 31]. dling, less tissue drag, and minimal memory
Depending upon the size, different amounts [35, 36].
of polydioxanone will be present. For (c) Growth factors and bioactive substrates:
instance, No.2 OrthoCord contains 38% Growth factors and bioactive substrates are
UHMWPE with 62% polydioxanone, while known to enhance tendon healing. Various
No. 2-0 OrthoCord contains 45% UHMWPE authors studied sutures coated with different
with 55% polydioxanone. This partially growth factors such as epidermal growth fac-
absorbable suture is also coated with poly- tor and basic fibroblast growth factor and
glactin 910 for improved suture handling. reported that the presence of growth factors
OrthoCord has several advantages including may facilitate tendon healing [37, 38].
its strength, low tissue abrasion, cut resis- Collagens and amino acids are examples of
tance, and flexibility. The main distinction of bioactive substrates. Kardestuncer et al. stud-
OrthoCord is the polydioxanone (PDS) core ied the effect of silk-RGD (arginine-glycine-­
making it partially absorbable. The tensile aspartic acid) on human tenocyte cultures
strength is equivalent to or slightly lower [39]. Their results suggest that the RGD sub-
than other UHMWPE-­containing sutures and strate with silk suture increases the adhesion
superior to completely biodegradable sutures and proliferation of tenocytes.
[1, 32]. Ninety-two percent of baseline ten- (d) Mesenchymal stem cells (MSCs): MSCs can
sile strength can be retained through 12 weeks effect healing. Pluripotent cells can produce
and 90% at 18 weeks. OrthoCord suture has endogenous growth factors and chemotactic
2 Biological Properties of Suture Materials 17

agents and differentiate into tenocytes. Yao phenethyl ester (CAPE), and quaternary
et al. studied the effect of Ethibond Excel ammonium compound (K21) are some new
braided polyester sutures (Ethicon Inc, coatings studied in the recent years with
Somerville, NJ) coated with MSCs and bio- good antimicrobial effects [45].
active substrate on Achilles tendon repair in (f) Nanoparticle suture coatings: Silver (AgNPs)
a rat model [40]. These authors concluded nanoparticles are commonly used in urinary
that MSC-­coated suture enhances the repair catheters and wound dressings. Silver’s anti-
strength in the early period but shows no sig- bacterial effect comes from reactive oxygen
nificant effect on the later stages. Adams species, which directly affects the DNA and
et al. also studied the effect of stem cell and cell membrane of the microorganisms. Rare
suture combination on Achilles tendon bacterial resistance and a lower risk of toxic-
repairs. They reported higher ultimate failure ity are advantages of silver nanoparticles.
strength with stem cell-coated sutures com- Zhang et al. studied the effect of silver
pared to suture-only repairs in a rat model nanoparticle-coated sutures [46]. The authors
[41]. used AgNP-covered absorbable sutures in
(e) Antibacterial suture coatings: Triclosan intestinal anastomoses in mice. Their results
(5-Chloro-2-(2,4-dichlorophenoxy)phenol) suggest that AgNP-coated sutures have good
is an antibacterial and antifungal agent that in vitro antibacterial efficacy and show sig-
has been used as a hospital scrub. Storch nificantly less inflammatory cell infiltration
et al. used triclosan-coated polyglactin 910 and better collagen deposition in the anasto-
(Vicryl Plus) suture in an animal study to mosis area. These authors also showed that
evaluate the antibacterial effect [42]. The these sutures provide better mechanical
authors showed that bacterial growth was properties in the anastomosis.
inhibited by triclosan coating without affect- (g) 1-Ethyl-3-(3-dimethylaminopropyl)carbodi-
ing the handling and absorbability of the imide hydrochloride (EDC): EDC (Sigma
suture. Chemical Co., St. Louis, MO) is a cross-­
Triclosan has also been used on other linking agent that covalently bonds collagen
suture materials including poliglecaprone 25 molecules. It therefore creates an eyelet of
(Monocryl Plus) and polydioxanone (PDS stiffer material that potentially resists suture
Plus). In vitro colonization experiments cutout [47]. In a recent study, Thoreson et al.
showed that triclosan has an antimicrobial tested the mechanical and cytotoxic proper-
effect against Staphylococcus aureus and ties of EDC-treated sutures [48]. They
Staphylococcus epidermidis [42, 43]. reported that EDC-treated 4-0 braided poly-
Li et al. studied the bactericidal and bacte- blend suture (FiberWire; Arthrex, Naples,
riostatic effects of amphiphilic polymer FL) provided better in vitro mechanical
poly[(aminoethyl methacrylate)-co-(butyl results in flexor tendons. They also showed
methacrylate)] (PAMBM)-coated sutures that a 10% EDC concentration is a threshold
[43]. These authors reported that PAMBM for cytotoxicity.
has a significant bactericidal activity on (h) Drug-eluting sutures: These sutures are
Staphylococcus aureus, while triclosan has produced using various methods includ-
mainly a bacteriostatic effect. ing surface coating by the dip method, by
Chitin is a natural polysaccharide with an grafting, or by an electrospinning process.
antibacterial effect. Shao et al. reported that Tetracycline, levofloxacin, and vancomycin
an absorbable diacetyl chitin-based suture are some antibiotics that can be used with
promotes skin regeneration with faster tissue sutures providing desired concentrations.
reconstruction and higher wound breaking Anti-­inflammatory and anesthetic agents can
strength on a linear incisional wound model also be used with common sutures. Weldon
[44]. Chlorhexidine, octenidine, caffeic acid et al. used bupivacaine with PLGA-based
18 O. Başçı et al.

sutures [49]. They reported these sutures Their data showed that inflammatory synovial
released all the drug over the course of fluid accelerates the mechanical disintegration of
12 days, while the sutures maintained 12% absorbable sutures. These results suggest that
of their initial tensile strength after 14 days nonabsorbable sutures may be the suture of
of incubation in vitro [49]. choice in meniscal repairs.
In a different study, Casalini et al. showed Barbed sutures are widely used in plastic and
that lidocaine can be delivered effectively general surgical procedures. The use of barbed
from a poly-e-caprolactone suture and pro- suture for surgical closure has been associated
vide an analgesic effect for approximately with lower operative times, equivalent wound
75 h [50]. Immunosuppressive agents can complication rate, and comparable cosmesis
also be delivered by sutures. Tacrolimus scores. In recent years, orthopedic surgeons have
(FK506, Astellas Pharma Inc., Tokyo, Japan) begun to use barbed sutures [4, 45, 53]. In a ther-
is an immunosuppressive agent that prevents apeutic study, Gililland et al. reported a slightly
intimal hyperplasia. In an experimental shorter surgery time in total knee arthroplasty
model, Morizumi et al. studied the effect of cases when barbed sutures were used for wound
tacrolimus-coated 7-0 polyvinylidene difluo- closure [53]. In the future, barbed sutures may be
ride (PVDF) sutures on porcine vascular preferred by more orthopedic surgeons.
anastomosis [51]. Their results showed that
the suture can effectively inhibit neointimal Conclusion
hyperplasia, the inflammatory response, and Suture materials have different biological
granulation tissue formation at the anastomo- properties and may cause various tissue
sis site [51]. responses. Proper suture selection will affect
(i) Smart sutures: Recent studies have been the clinical outcomes; therefore surgeons
focused on sutures with shape memory and should have sufficient amount of knowledge
electronic capabilities [45]. on these properties.

2.4 Clinical Performance

of Absorbable Sutures References
1. Wust DM, Meyer DC, Favre P, Gerber C. Mechanical
Newer absorbable materials show equal or better and handling properties of braided polyblend polyeth-
clinical results compared to nonabsorbable ylene sutures in comparison to braided polyester and
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2. Deranlot J, Maurel N, Diop A, et al. Abrasive proper-
cal procedures with good and predictable out- ties of braided polyblend sutures in cuff tendon repair:
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3. Williams JF, Patel SS, Baker DK, et al. Abrasiveness
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braided sutures in a contaminated wound model. Clin
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able suture materials in a rabbit model. Acta Orthop
sutures such as Vicryl, Dexon, and PDS may
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because of the rapid suture absorption [52]. drainage associated with polyglactine sutures used
2 Biological Properties of Suture Materials 19

for repair of Achilles tendon ruptures. Acta Orthop (Dexon) and Polydioxanone (PDS). Br J Plast Surg.
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8. Al-Qattan MM, Kfoury H. A delayed allergic reaction 1987;154(5):544–7.
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case report. J Hand Surg Am. 2015;40(7):1377–81. new synthetic monofilament absorbable suture made
9. Webster RC, McCollough EG, Giandello PR, from polytrimethylene carbonate. Surg Gynecol
Smith RC. Skin wound approximation with new Obstet. 1985;161(3):213–22.
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1985;111(8):517–9. JP. A double-blind controlled trial of polyglytone
10. Postlethwait RW. Polyglycolic acid surgical suture. 6211 versus poliglecaprone 25 for use in body con-
Arch Surg. 1970;101(4):489–94. touring. Ann Plast Surg. 2010;65(2):124–8.
11. Outlaw KK, Vela AR, O’Leary JP. Breaking strength 27. Wickham MQ, Wyland DJ, Glisson RR, Speer KP. A
and diameter of absorbable sutures after in vivo expo- biomechanical comparison of suture constructs used
sure in the rat. Am Surg. 1998;64(4):348–54. for coracoclavicular fixation. J South Orthop Assoc.
12. Herrmann JB, Kelly RJ, Higgins GA. Polyglycolic 2003;12(3):143–8.
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of a new absorbable suture material. Arch Surg. PJ. Dynamic loading of surgical knots. Surg Gynecol
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13. Craig PH, Williams JA, Davis KW, et al. A biologic 29. Trimbos JB, Van Rijssel EJ, Klopper PJ. Performance
comparison of polyglactin 910 and polyglycolic acid of sliding knots in monofilament and multifilament
synthetic absorbable sutures. Surg Gynecol Obstet. suture material. Obstet Gynecol. 1986;68(3):425–30.
1975;141(1):1–10. 30. Niessen FB, Spauwen PH, Kon M. The role of suture
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A. Physical, biological and handling characteristics of Vicryl-rapide. Ann Plast Surg. 1997;39(3):254–60.
surgical suture material: a comparison of four differ- 31. Barber FA, Herbert MA, Beavis RC. Cyclic load
ent multifilament absorbable sutures. Eur Surg Res. and failure behavior of arthroscopic knots and high
1997;29(1):52–61. strength sutures. Arthroscopy. 2009;25(2):192–9.
15. Ross G, Pavlides C, Long F, et al. Absorbable suture 32. Wright PB, Budoff JE, Yeh ML, Kelm ZS, Luo
materials for vascular anastomoses. Tensile strength ZP. Strength of damaged suture: an in vitro study.
and axial pressure studies using polyglycolic acid Arthroscopy. 2006;22(12):1270–75.e3.
sutures. Am Surg. 1981;47(12):541–7. 33. Masini BD, Stinner DJ, Waterman SM, Wenke
16. Barber FA, Herbert MA, Coons DA, Boothby JC. Bacterial adherence to high—tensile strength
MH. Sutures and suture anchors—update 2006. sutures. Arthroscopy. 2011;27(6):834–8.
Arthroscopy. 2006;22(10):1063.e1–9. 34. Leek BT, Tasto JP, Tibor LM, et al. Augmentation of
17. Conn J Jr, Oyasu R, Welsh M, Beal JM. Vicryl (poly- tendon healing with butyric acid-impregnated sutures:
glactin 910) synthetic absorbable sutures. Am J Surg. biomechanical evaluation in a rabbit model. Am J
1974;128(1):19–23. Sports Med. 2012;40(8):1762–71.
18. Aston SJ, Rees TD. Vicryl sutures. Aesthet Plast Surg. 35. Edlich RF, Gubler K, Wallis AG, et al. Wound clo-
1976;1(1):289–93. sure sutures and needles: a new perspective. J Environ
19. Hochberg J, Meyer KM, Marion MD. Suture choice Pathol Toxicol Oncol. 2010;29(4):339–61.
and other methods of skin closure. Surg Clin North 36. Rodeheaver GT, Beltran KA, Green CW, et al.
Am. 2009;89(3):627–41. Biomechanical and clinical performance of a new
20. Lerwick E. Studies on the efficacy and safety of synthetic monofilament absorbable suture. J Long
polydioxanone monofilament absorbable suture. Surg Term Eff Med Implants. 1996;6(3–4):181–98.
Gynecol Obstet. 1983;156(1):51–5. 37. Rohrich RJ, Trott SA, Love M, Beran SJ, Orenstein
21. Ray JA, Doddi N, Regula D, Williams JA, Melveger HH. Mersilene suture as a vehicle for delivery of
A. Polydioxanone (PDS), a novel monofilament growth factors in tendon repair. Plast Reconstr Surg.
synthetic absorbable suture. Surg Gynecol Obstet. 1999;104(6):1713–7.
1981;153(4):497–507. 38. Hamada Y, Katoh S, Hibino N, et al. Effects of mono-
22. Molea G, Schonauer F, Bifulco G, D’Angelo filament nylon coated with basic fibroblast growth
D. Comparative study on biocompatibility and factor on endogenous intrasynovial flexor tendon
absorption times of three absorbable monofilament healing. J Hand Surg Am. 2006;31(4):530–40.
suture materials (Polydioxanone, Poliglecaprone 25, 39. Kardestuncer T, McCarthy MB, Karageorgiou V,
Glycomer 631). Br J Plast Surg. 2000;53(2):137–41. Kaplan D, Gronowicz G. RGD-tethered silk substrate
23. Chantarasak ND, Milner RH. A comparison of scar stimulates the differentiation of human tendon cells.
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20 O. Başçı et al.

40. Yao J, Woon CY, Behn A, et al. The effect of suture 47. Zhao C, Sun YL, Zobitz ME, An KN, Amadio
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41. Adams SB Jr, Thorpe MA, Parks BG, et al. Stem cell-­ Surg Am. 2007;32(5):606–11.
bearing suture improves Achilles tendon healing in a 48. Thoreson AR, Hiwatari R, An KN, Amadio PC, Zhao
rat model. Foot Ankle Int. 2014;35(3):293–9. C. The effect of 1-ethyl-3-(3-dimethylaminopropyl)
42. Storch M, Perry LC, Davidson JM, Ward JJ. A carbodiimide suture coating on tendon repair strength
28-day study of the effect of Coated VICRYL* Plus and cell viability in a canine model. J Hand Surg Am.
Antibacterial Suture (coated polyglactin 910 suture 2015;40(10):1986–91.
with triclosan) on wound healing in guinea pig lin- 49. Weldon CB, Tsui JH, Shankarappa SA, et al.
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43. Li Y, Kumar KN, Dabkowski JM, et al. New 50. Casalini T, Masi M, Perale G. Drug eluting sutures:
bactericidal surgical suture coating. Langmuir. a model for in vivo estimations. Int J Pharm.
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44. Shao K, Han B, Gao J, et al. Fabrication and feasi- 51. Morizumi S, Suematsu Y, Gon S, Shimizu T. Inhibition
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Appl Biomater. 2016;104(1):116–25. 52. Barber FA, Gurwitz GS. Inflammatory synovial
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2016;104(6):1544–59. 53. Gililland JM, Anderson LA, Sun G, Erickson JA,
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 Mechanical Properties of Suture
Materials
3
Emrah Açan, Onur Hapa, and F. Alan Barber

Suture is a generic term for all materials used to using silk threads or catgut made from the twisted
bring severed body tissue together and to hold intestines of animals to suture severed tendons.
these tissues in their normal position until heal- Sutures were used in the Egyptian mummifica-
ing takes place. Suturing is the joining of tissues tion process as early as 1100 BC. Historical
with needle and thread. Security of the suture records report sutures used to close wounds in
repair is provided by a knot. This knot is formed India in as early as 500 BC. Many different mate-
by interlacing the two free ends of the suture at rials have been used as suture. These include
least twice to form a construct which will not strands of gold, silver, steel wire, silk, linen,
unravel when tension is placed upon the suture. hemp, and flax and strands of tree bark, animal,
The first knotting loop, called the approximation and human hair. More recently suture has been
loop, performs the actual suturing function by derived from the intestines of sheep and goats.
placing the tissue in apposition and fixing the Metal threads were introduced as a suture
wound edges in the desired position. All knots, material in the early nineteenth century. At that
no matter where, must be “locked” by additional time, the lack of a soft tissue reaction to the suture
throws for adequate security. All additional loops material was considered an advantage. However,
serve only to secure the approximating loop. metal threads had several major disadvantages.
Their stiffness made tying a knot more difficult,
suture breaking could easily occur, and as com-
3.1 The History of Suture mon in that era wound infections were an issue.
This was not addressed until Johnson & Johnson
Surgical sutures have been used for millennia and started manufacturing sterile sutures made of
date to as early as 3000 BC in Egypt. In 1600 BC, either catgut or silk.
the Greek surgeon Galen of Pergamon reported Toward the end of the nineteenth century, catgut
was the standard surgical suture material. As noted
by Galen, catgut suture was created from purified
collagen strands which were twisted together. The
E. Açan, M.D. • O. Hapa, M.D. collagen was harvested from small intestine serosa
Department of Orthopedics, Dokuz Eylul University or submucosa of cattle, sheep, or goats. Sometimes
Hospital, Izmır, Turkey beef tendon was also used. While catgut suture
F.A. Barber, M.D. (*) required 90 days for complete degradation by pro-
Plano Orthopedic Sports Medicine and Spine Center, teolytic enzymes, full tensile strength could not be
Plano, TX, USA maintained beyond 7 days. Catgut continued to be
e-mail: [email protected]

© ESSKA 2018 21
U. Akgun et al. (eds.), Knots in Orthopedic Surgery, https://doi.org/10.1007/978-3-662-56108-9_3
22 E. Açan et al.

a common suture until the development of syn- The following are basic definitions relevant to
thetic absorbable and nonabsorbable sutures. The the mechanical properties of a suture:
increased awareness of issues related to bovine Tensile strength—a material’s ability to resist
spongiform encephalopathy (mad cow disease) has deformation and breakage [1]
resulted in catgut being generally replaced by syn- Knot strength—force necessary to cause a
thetic absorbable polymers. knot to slip (related to the coefficient of static
With the development of the chemical industry friction and plasticity of a given material) [2]
in the early twentieth century, synthetic suture Breaking strength—limit of tensile strength at
materials were introduced. One of the first synthetic which suture failure occurs
threads (nylon) was developed in the early 1930s. It Knot-pull tensile strength—breaking strength
was followed by the introduction of the first syn- of knotted suture material (may be 10–40%
thetic absorbable fiber based on polyvinyl alcohol. weaker than the suture itself after deformation by
Later the first polyester fibers were introduced knot placement) [3]
which became known as Dacron. Polyglycolic acid Wound breaking strength—the tensile strength
(PGA) was discovered in the mid-1950s, but of a healing wound at which wound edge separa-
because of its sensitivity to degradation by hydroly- tion occurs [4]
sis, it is rapidly reabsorbed. This response can be Elasticity—ability of a material to regain its
slowed by coating it with other polymers such as original form and length after deformation [5, 6]
polycaprolactone and calcium stearate. A combina- Plasticity—ability to deform without breaking
tion of 90% PGA and 10% L-lactide was released in and to maintain a new form after relief of the
1974 as polyglactin 910. The suture is commer- deforming force [7]
cially known as Vicryl. Later in 1982 a more slowly Memory—inherent capability of suture to
degrading polymer polydioxanone was released as return to or maintain its original gross shape
the suture PDS. This suture retained significant (related to elasticity, plasticity, and diameter) [8, 9]
strength out to 6 weeks in comparison to the Pliability—ease of handling of suture material
2–3 weeks demonstrated by Vicryl. and ability to adjust knot tension and to secure
New nonabsorbable polymers also appeared knots (related to suture material, filament type,
in this time frame. A polypropylene polymer and diameter) [10]
suture was introduced in 1969 (Prolene). Braided Capillarity—extent to which absorbed fluid is
polyester sutures both uncoated (Mersilene) and transferred along the suture [11]
coated (Ethibond) were developed. Until the Abrasion—the wearing of a surface by fric-
release of the first ultrahigh molecular weight tion [12–14]
polyethylene-containing polymer (FiberWire),
the braided polyester sutures were the most com-
monly used nonabsorbable sutures. 3.3  he US Pharmacopeia
T
Standard

3.2 Different Mechanical The US Pharmacopeia (USP) system, established

Properties in 1937, seeks to promote public health by estab-
lishing official standards of quality and providing
The ideal suture material should have high tensile authoritative information for the use of medi-
strength, hold securely when knotted, be handled cines and other healthcare technologies. This
easily, not break unexpectedly, be flexible enough specifically includes the standardization of sizes
to be knotted, cause minimal tissue reaction, be and tensile strengths of suture materials, corre-
resistant to infection, and, if possible, biodegrade sponding to metric measures. A USP suture size
when tissue repair has reached satisfactory lev- denotes the diameter of the material, which is
els. Unfortunately, there is no ideal suture mate- stated numerically in zeroes, with a larger num-
rial that has all these properties. ber of zeroes indicating a smaller size of strand.
3 Mechanical Properties of Suture Materials 23

For example, 4-0 (meaning 0000) is smaller than Braided polyester sutures were a common
a size 3-0. The smaller the size, the less tensile point of failure. This lead to the development of
strength the strand will have. Modern sutures high-strength sutures containing ultrahigh molec-
range from #5 to #12-0. The actual diameter of ular weight polyethylene (UHMWPE) [15].
thread for a given USP size differs depending UHMWPE is used in many ways outside the
on the suture material class. However USP stan- medical industry. It is capable of absorbing large
dards also define the corresponding minimum-­ amounts of energy and is therefore used in bal-
maximum limits on average diameter (mm) and listic protection from bulletproof jackets to
maximum metric size (gauge no.) for all USP armored vehicles. It is 15 times stronger than
sizes. The tensile strength of a suture is the mea- steel, light enough that it floats on water, and
sured pounds of tension that the strand can with- commonly used in marine vessels.
stand before it breaks when knotted. The USP Despite a well-recognized need by arthroscopic
standards also define knot-pull tensile strength surgeons for a stronger suture with a small size,
(kgf/N) as the minimum strength for each indi- the established suture manufacturers did not
vidual strand and the average. Furthermore, the respond. They held to the USP strength standards
USP standards define the requirements for pack- for the various suture sizes. It took an arthroscopic
aging and storage, needle attachment, sterility, instrument company to change the status quo.
extractable color, and residual solvents. Arthrex came out with the first high-­ strength
While not as widespread as the USP classifi- suture FiberWire which was a combination of a
cation system, the European Pharmacopoeia (Ph. core of UHMWPE fibers surrounded by a braided
Eur.) system uses the metric system for classifi- polyester sheath much like a climbing rope [16,
cation of sutures based on the suture size. The Ph. 17]. The response was so favorable that orthope-
Eur. specifies a decimal classification and metric dic surgeons in particular switched rapidly to the
coding for the gauges. It quotes a thread diameter new suture type. Since FiberWire sutures could
of 1/10 mm, indicating that thread gauge of 3.5 only be found in Arthrex suture anchors, other
has a diameter of 0.35 mm. arthroscopic companies saw their suture anchor
sales decline. In an attempt to maintain the mar-
ket share, these other companies looked for an
3.4 Standards Change alternate UHMWPE-containing suture. A suture
made of braided UHMWPE fibers was produced
Suture materials are usually characterized by and sold to the other companies for their anchors.
their physicochemical composition and their con- With this consumer pressure, even the largest
struction. They can be absorbable or nonabsorb- suture manufacturers recognized that UHMWPE-
able, monofilament, or braided and made of a containing sutures were here to stay and devel-
single material or a blend of materials. oped their own products [17].
Adequate suture strength is needed in surgery. The new UHMWPE-containing sutures pro-
The initial nonabsorbable polymer sutures were vide high tensile strength, diminished breakage
braided multifilament structures (i.e., Ethibond/ during suture passage, and better handling and
Ti-Cron) which provided a nonreactive implant knot characteristics compared to traditional
with excellent strength especially when used in suture materials [15, 18–20].
open surgery. These sutures were based predomi- There are currently three different types of
nantly on polyester. As arthroscopic and endo- UHMWPE-containing sutures: the first is the
scopic techniques developed, suture breaking FiberWire which combines UHMWPE with
during knot tying became more of an issue. braided polyester; second is the pure braided
Arthroscopic equipment knot pushers increased UHMWPE such as UltraBraid, MaxBraid, Force
the stress placed on a suture during knot tying, Fiber, and Hi-Fi with no central core; and the
and even with size #2 suture present in many third type is the most recently introduced and
suture anchors, suture breaking was an issue. combines UHMWPE fibers with biodegradable
24 E. Açan et al.

polydioxanone and a polyglactin 910 coat for [23]. A comparison of the three major groups
improved suture handling (OrthoCord, Johnson of UHMWPE-containing suture (FiberWire,
and Johnson DePuy-Mitek, Raynham, MA). The braided UHMWPE, and OrthoCord) demon-
combination of polydioxanone and UHMWPE strated that braided UHMWPE is stronger in load
varies depending upon the OrthoCord suture to failure testing than FiberWire and OrthoCord
size. For instance, #2 OrthoCord has 68% in head to head testing but that all three types are
UHMWPE and 32% polydioxanone, while #2-0 significantly stronger than conventional braided
OrthoCord has 55% UHMWPE with 45% polyester sutures [17]. That being said, all three
polydioxanone [13]. are more than strong enough for arthroscopic
Tapes are the latest new development. In an clinical applications.
attempt to improve the strength of tissue repair,
Arthrex again lead the way by introducing a tape
product called FiberTape. This is an expanded 3.5.2 Knot-Pull Tensile Strength
version of FiberWire also containing a blend of
nonabsorbable UHMWPE filaments and braided The breaking strength of suture material is sig-
polyester. This 2-mm-wide tape provides a nificantly reduced by tying a knot. To increase
broader pressure footprint than regular suture knot strength, reinforcing the knot with three or
[21]. Other manufactures have followed this four reversed half hitches and alternating the post
trend by introducing tapes of their own made are required to ensure non-slippage of the knot
from braided UHMWPE. under tension [15, 18]. The actual strength of the
Larger sutures can certainly be expected to be knot varies with the suture material and its size.
stronger than smaller sutures, so it is no surprise Surgeon experience also has a significant effect
that a large tape will be stronger when compared on failure mode and tensile failure load.
side to side with a smaller suture. How this
applies to the clinical condition is currently under
study. Bisson and Manohar using a bovine infra- 3.5.3 Stiffness
spinatus model biomechanically compared No. 2
FiberWire suture to 2-mm FiberTape. At the Variations in suture stiffness may have clinical
suture-tendon interface, significant difference implications. A stiffer material may be more
was found in elongation, stiffness, and ultimate likely to cut through degenerative tissue. This
tensile load [21]. Gnandt et al. [22] used fresh may have clinical implications in that younger
frozen cadaver tendon specimens to compare the tissue may be more suitable to a stiffer suture
No. 2 suture with 2-mm tape performance across material, while more frail tissue is more suited to
four different suture techniques commonly used less stiff materials which “take up the slack”
in tendon repair. The tape had greater mean fail- rather than cut through.
ure loads.

3.5.4 Flexibility
3.5  he Mechanical Properties
T
of Sutures Flexibility is also known as pliability. This suture
characteristic refers to how easily the suture con-
3.5.1 Tensile Strength forms to variations in tissue or instrument inter-
action. A more pliable suture is easier to handle,
Tensile strength is the measurement of a mate- tie into a knot, and pass through tissue. A mono-
rial or tissue’s ability to resist deformation and filament suture often has a “memory” and resists
breakage. The presence of UHMWPE material deforming during knot tying. A braided suture
in a suture makes it significantly stronger than conforms to tissue variations more readily and is
those sutures which do not contain UHMWPE therefore more pliable or flexible.
3 Mechanical Properties of Suture Materials 25

Knot fixation is a determining factor of surgi- some sutures have less abrasion and some have
cal thread as it guarantees the security of the more. The performance of UHMWPE sutures is
suture and depends on the thread stiffness, coef- dependent in part on the type of knot tied and the
ficient of friction, elasticity, and plasticity. In stresses to which it is subjected.
addition to these parameters, knot fixation differs
according to whether the thread is monofilament
or braided. Monofilament sutures have a lower 3.5.6 Suture Slippage
coefficient of friction, glide more easily due to
their smooth surface, and are usually stiffer than In the treatment of soft tissue injuries, surgeons
braided ones. often have to repair injured soft tissues that
experience high loads and have suboptimal
blood supply [29]. In certain situations, such as
3.5.5 Knot and Loop Security in tendon and soft tissue repairs, a high load
event may result in suture failure in two ways:
Knot and loop security applies to how the suture slippage of the knots, resulting in gapping and
is used while tying a knot [3, 19, 24]. While the clinical failure, and catastrophic failure (break-
type of suture plays a role, the type of knot, the age) of the suture [25, 30]. With the knot slip-
skill of the surgeon, and the environment in page, gapping at the repair site would seem
which the knot is tied are also important. unlikely to heal [26, 31]. Several authors have
Knot security is the ability of the suture to used 3 mm of suture-­knot elongation to define
maintain knot strength without slippage and is clinical failure [25, 26, 30, 31].
inversely proportional to the memory of the The main source of concern is that the new
suture material because of a tendency to untie UHMWPE-containing sutures seem to slip more
their knots as they try to return to their kink form easily than braided polyester sutures [18]. This
[25]. A secure knot is one which breaks rather observation was confirmed, and different knot
than slips or becomes untied. This is dependent patterns have been tested to identify which knots
on the presence of friction, internal interference, are more appropriate for the UHMWPE-­
and slack between throws [26, 27]. Loop security containing sutures [15].
relates to how well the knot works. It is the ability Knots which have an internal locking mecha-
of the knot to maintain a tight suture loop as a nism perform better with less slipping in biome-
knot is tied [24, 26, 27]. Different suture materi- chanical testing of UHMWPE-containing suture.
als can affect both the knot security and loop Specifically Swan et al. reported that the sur-
security of different arthroscopic knots. More geon’s and SMC knots were superior [31].
abrasive suture materials generate more friction Pedowitz highlighted the performance of the San
between suture loops and can be expected to have Diego knot [18]. The take-home message of the
better loop security than less abrasive sutures. cyclic knot strength testing is that sliding knots
Lo et al. showed loop security for many of the without an internal locking mechanism
knot and suture configurations was not signifi- (Fisherman’s knot and Duncan’s loop) are more
cantly different but FiberWire consistently likely to slip in a submaximal level than those
showed the smallest loop circumference when knots with an internal locking mechanism (SMC,
compared with the other suture materials tested Tennessee slider, San Diego, surgeon’s knot).
[27]. Livermore et al. evaluated load to failure
and cyclic loading elongation of FiberWire,
Hi-Fi, OrthoCord, and UltraBraid in five differ- 3.5.7 Damaged Sutures
ent sliding arthroscopic knots. All knots elon-
gated less than 0.45 mm by the 1000th cycle but Damage to a suture may occur during suture pas-
showed higher suture slippage in the initial 50 sage or manipulation. Sharp-tipped penetrators,
cycles of loading [28]. The conclusion is that antegrade suture passers, knot-tying devices, and
26 E. Açan et al.

sharp bone edges can cause this damage [32, 33]. sion resistance. Sutures with UHMWPE cores
Wright et al. evaluated the mechanical proper- had significantly better performance than other
ties of damaged sutures [32]. Using a razor blade braided sutures. These resisted bending abra-
to cut 20% of the suture’s width No. 2 PDS, sion failure better and had higher resistance to
Ethibond, Tevdek, OrthoCord, and FiberWire tensile failure [13]. The superior performance of
were subjected to straight-line pulls. Not sur- UHMWPE suture to braided polyester was also
prisingly the UHMWPE-containing sutures demonstrated by others [27].
(OrthoCord and FiberWire) showed the highest Suture abrasion on tendon can be potentially
load to failure and ultimate tensile strength. It issignificant especially in rotator cuff surgery.
not surprising since these sutures start off being Williams et al. compared the abrasiveness of
stronger than the others tested. Suture stiffness eight high-strength sutures (FiberWire, Collagen
was not significantly affected by the cut [32]. The Coated FiberWire, OrthoCord, MaxBraid, Force
takeaway point is that the superior properties of Fiber, UltraBraid, Phantom Fiber BioFiber, and
UHMWPE-containing sutures are maintained Ti-Cron) and one monofilament as a control
even when cut. On the other hand, PDS which group (Surgipro). Each suture was cycled 50
had equivalent or superior strength with Ethibond times through the tendon, which was fixed to a
and Tevdek once cut was weakened significantly mechanical testing system under a constant load
more than all the other sutures. Monofilament in saline solution. Significant differences were
sutures seem more susceptible to a partial cut found. Collagen Coated FiberWire was the most
than braided sutures. abrasive of the high-strength sutures. Four of the
sutures (Collagen Coated FiberWire, Phantom
Fiber BioFiber, FiberWire, Ti-Cron) had a mean
3.5.8 Material Abrasion displacement rate greater than 0.150 mm/cm. The
remainder of the sutures had a mean displace-
Abrasion can be evaluated by considering the ment rate less than 0.050 mm/cm (OrthoCord,
impact of the suture on its environment or the Force Fiber, MaxBraid, UltraBraid). The signifi-
impact of the environment on the suture. High-­ cant displacement rate difference between these
strength UHMWPE-containing sutures have two groups (P < 0.0001) was related to both the
superior breaking strength and holding power but twist angle and the picks per inch [35].
are also more abrasive to the tissue (i.e., rotator Deranlot et al. compared abrasiveness in No. 2
cuff) and joint cartilage than monofilament FiberWire, FiberTape, OrthoCord, and Force
sutures [14, 34]. Different sutures have their own Fiber. Again OrthoCord and Force Fiber showed
abrasion profile. This abrasion may damage the a significantly lower abrasion than FiberWire and
anchor eyelet and adjacent bone or tendon tissue FiberTape (P < 0.05) and demonstrated the
as the suture cycled during placement or knot increased abrasive effects of FiberWire and
tying [33, 34]. This abrasion may also release FiberTape compared with OrthoCord and Force
potentially harmful wear particles into joints or Fiber [12].
the surrounding tissue leading to an adverse bio- The weakest part of a rotator cuff repair is the
logical reaction [13]. interface between the tendon and suture. The
Savage et al. investigated resistance to bending suture running through the tendon when tying a
abrasion fatigue and consequent failure in seven sliding locking knot may cause damage if the
different suture materials (FiberWire, UltraBraid, suture is too abrasive. Savage et al. evaluated the
MaxBraid, Ethibond Excel, OrthoCord, Force effect of sliding knots on the suture-tendon inter-
Fiber, Hi-Fi) [13]. The sutures were oscillated face comparing four stitches (simple-static,
over a stainless steel wire at low frequency until simple-­sliding, mattress-static, mattress-sliding)
load to failure, and changes in suture morphology tied in No.2 FiberWire. A mattress-static stitch
and the fatigue-failure method were recorded. (116 N) was significantly stronger than a
Suture structure had a significant effect on abra- mattress-­ sliding stitch (70 N; P < .001). The
3 Mechanical Properties of Suture Materials 27

ultimate loads for the simple-static (46 N) and the bone and have replaced transosseous sutures.
simple-­sliding (50 N) stitches were not statisti- Craft et al. compared the strength of classic tran-
cally different. Importantly after cyclic elonga- sosseous suture repair with suture anchors [40].
tion, the mattress-sliding stitch had more laxity No significant difference was seen between the
than the simple-static (P = 0.01) and simple-slid- strengths of repairs performed with the anchors
ing (P = 0.04) stitches [36]. The take-home mes- compared with the transosseous suture tech-
sage is that because of the “sawing” effect, sliding nique, and suture anchors were considered
a suture through the tissue weakens the suture-­ equivalent to more traditional suture-only tech-
tendon interface especially with a mattress stitch niques [40]. Burkhart et al. also compared suture
but not with a simple stitch. If the tissue quality is anchors to transosseous sutures and found
questionable or the repair may have more tension greater variability in the bone tunnels than the
in it than normal, a non-sliding knot is a better anchors suggesting that the anchor performed
choice than placing a sliding mattress stitch [36]. more consistently than the bone tunnel [41]. The
Lambrechts et al. compared the “cheese-wire” variable nature of older osteoporotic bone found
or “sawing” effect of No. 2 OrthoCord, Ethibond, with rotator cuff tears makes it more unsuited to
and FiberWire [37]. The distance of cut through consistently retain a suture during cyclic load-
in supraspinatus tendons for OrthoCord, ing. This finding was further supported by
Ethibond, and FiberWire was 2.9 mm, 3.2 mm, Barber et al. [15, 17].
and 4.2 mm, respectively. There was statistically Klinger et al. compared the open transosseous
significant less “cheese-wiring” in OrthoCord suture technique with modified Mason-Allen
suture than in FiberWire suture [37]. Kowalsky stitches (group 1) to double-loaded suture
et al. also noted the increased cutting through in a anchors with arthroscopic Mason-Allen stitches
tendon construct by the “cheese-wire” effect of (group 2) in sheep rotator cuff repairs harvested
FiberWire suture [14]. at intervals out to 26 weeks [42]. No significant
difference in load to failure and stiffness was
observed between the two treatment groups at 6,
3.5.9 Suture Memory 12, and 26 weeks. However, at time zero, the
suture anchor group had higher failure loads than
Suture memory is an inherent capability of suture the transosseous sutures. They concluded that a
to return to or maintain its original gross shape double-loaded suture anchor technique provides
[8, 9]. This is related to its elasticity, plasticity, superior stability [42]. Pietschmann et al. also
and diameter. Sutures with high memory are less compared transosseous sutures to suture anchors
pliable, maintain their original shape, and can be and found that suture anchors provided higher
more difficult to work with. In general, monofila- ultimate failure loads than transosseous double
ment sutures have more packaging memory than U-sutures both in healthy and osteopenic bone.
braided ones. Monofilament sutures such as They concluded that osteopenic bone does not
nylon, polypropylene, PDS, and Maxon have a constitute a valid indication for open surgery
high memory. Monocryl, Biosyn, Gore-Tex, and using transosseous sutures [43].
Pronova are monofilaments that are exceptions. Both Petri et al. and Ettinger et al. compared
suture anchors to transosseous sutures in quadri-
ceps tendon and patellar tendon ruptures in
3.5.10 Anchors or Bone Tunnels? cadaveric knees, respectively [44, 45]. Both stud-
ies demonstrated that tendon repairs with suture
Before Goble et al. developed the first suture anchors yielded significantly less gap formation
anchor in 1985, rotator cuff tendon sutures were during cyclic loading and resisted significantly
passed through transosseous tunnels in the higher ultimate failure loads than transosseous
greater tuberosity [38, 39]. Now, suture anchors sutures. The conclusions of both studies were
are the gold standard for soft tissue fixation to that the use of suture anchors yields significantly
28 E. Açan et al.

better biomechanical results than transosseous group using 0.9% saline. The 10 and 50% EDC
sutures in these locations [44, 45]. groups were significantly stronger than the con-
trol. The dead to live cell ratio was significantly
increased at all distances from the suture in the
3.5.11 Alternative “Suture Materials” 50% EDC-treated group. Suture treated with
10% EDC solution provided the best combina-
While the development of UHMWPE-containing tion of mechanical reinforcement and limited
sutures has significantly increased suture toxicity [53].
strength, the weakest point of a tendon-suture-­ Barbed suture is a knotless surgical suture
anchor-bone construct is still the tendon-suture with surface directional projections (barbs). The
interface [46]. Stronger suture or tape repairs fail suture can be easily passed through tissue in the
when the intact suture cuts through the tendon or direction opposite to the barb angle. When a
the tendon ruptures in mid-substance [47–49]. To force is applied in the opposite direction, the
try to address these issues, alternative materials suture barbs engage the surrounding tissue and
such as 1-ethyl-3-(3-dimethylaminopropyl)car- resist pullout [54]. Barbs along the entire length
bodiimide (EDC) hydrochloride and cyanoacry- of the suture provide multiple anchoring points
late have been developed. Cyanoacrylate, a tissue allowing a more uniform distribution of forces
adhesive, works as a glue and has been used in along the length of the suture [55].
dental, vascular, nerve, and skin repair for many The advantage of a barbed (knotless) suture is
years [50–52]. that bulky knots can be avoided decreasing the
Bresnahan et al. studied the tensile strength of cross-sectional area of a tendon repair and may
lacerations closed using cyanoacrylate, cyanoac- improve gliding through a pulley system. It elim-
rylate and subcutaneous sutures, percutaneous inates a knot which may be a weak point in the
sutures, and a combination of percutaneous and tendon repair because of decreased suture tensile
subcutaneous sutures. The cyanoacrylate adhe- strength. Knots placed between tendon ends
sive alone exhibited significantly less tensile decrease the approximation of the repair tissue.
strength at 4 days than the other methods. The This can be avoided with a barbed suture.
combination of percutaneous and subcutaneous A 2014 literature review of tendon repair with
sutures was the strongest [4]. barbed sutures found a statistically significant
EDC is a cross-link activating reagent that can higher failure load with barbed sutures than tradi-
facilitate the covalent bonding between carboxyl tional sutures in four reports [56–59], no signifi-
and amino groups such as those in collagen mol- cant difference in three [60–62], and one reporting
ecules [46, 53]. Several studies have evaluated its traditional sutures performed better [63]. Shah
effects on tissue repair. Zhao et al. investigated et al. emphasized the great variation in the repairs
the use of EDC and cyanoacrylate on the tendon-­ studied including the use of ex vivo studies [54].
suture interface strength in canine flexor tendons The review concluded that barbed suture have
repaired with the single loop technique [46]. theoretical advantages; however, due to the lack
Cyanoacrylate- and EDC-reinforced suture loops of uniform studies and live model data, no abso-
were 91% and 64% stronger, respectively, than lute conclusions can be made [54].
controls. The authors concluded that cyanoacry- There are also several studies in literature rel-
late and EDC improve the pullout failure strength evant to the comparison of barbed versus stan-
of single loop suture constructs [46]. Thoreson dard sutures for usage in total knee arthroplasty
et al. evaluated EDC suture coating on tendon (TKA). In prospective, randomized controlled
repair strength and cell viability in canines [53]. trials, Smith et al. and Gililland et al. compared
Three different concentrations of EDC (1, 10, or barbed and traditional knotted interrupted clo-
50%) diluted with saline were applied to 4-0 sures in TKA [64, 65]. Both studies reported
FiberWire suture. Pullout strength, stiffness, and decreased mean closure time and total closure
loop elongation were compared to a control cost with the barbed suture. Although Gililland
3 Mechanical Properties of Suture Materials 29

et al. [64] reported similar complication rates in 8. Kujala S, Pajala A, Kallioinen M, et al.
Biocompatibility and strength properties of niti-
both groups, Smith et al. [65] reported increased
nol shape memory alloy suture in rabbit tendon.
frequency and severity of wound complications Biomaterials. 2004;25(2):353–8.
with barbed sutures. The concern that barbs may 9. Moneim MS, Firoozbakhsh K, Mustapha AA, Larsen
act as a place for bacteria to hide was addressed K, Shahinpoor M. Flexor tendon repair using shape
memory alloy suture: a biomechanical evaluation.
by Fowler et al. [66]. Several commonly used
Clin Orthop Relat Res. 2002;402:251–9.
sutures were compared to a barbed monofilament 10. Ray JA, Doddi N, Regula D, Williams JA, Melveger
suture [66]. The barbed monofilament suture A. Polydioxanone (PDS), a novel monofilament
showed the least bacterial adherence. Another synthetic absorbable suture. Surg Gynecol Obstet.
1981;153(4):497–507.
retrospective study by Maheshwari et al. reported
11. Blomstedt B, Osterberg B. Fluid absorption and
no significant difference in complication rate or capillarity of suture materials. Acta Chir Scand.
wound closure time between conventional and 1977;143(2):67–70.
barbed sutures, but material costs were lower 12. Deranlot J, Maurel N, Diop A, et al. Abrasive proper-
ties of braided polyblend sutures in cuff tendon repair:
with barbed sutures in TKA [67].
an in vitro biomechanical study exploring regular and
tape sutures. Arthroscopy. 2014;30(12):1569–73.
Conclusion 13. Savage E, Hurren CJ, Slader S, et al. Bending and
Suture materials vary in strength, size, compo- abrasion fatigue of common suture materials used in
arthroscopic and open orthopedic surgery. J Orthop
sition, and performance. Their mechanical
Res. 2013;31(1):132–8.
properties influence their performance, and a 14. Kowalsky MS, Dellenbaugh SG, Erlichman DB, et al.
knowledge of these properties is required for Evaluation of suture abrasion against rotator cuff
the surgeon to fully appreciate how they will tendon and proximal humerus bone. Arthroscopy.
2008;24(3):329–34.
perform clinically.
15. Barber FA, Herbert MA, Beavis RC. Cyclic load
and failure behavior of arthroscopic knots and high
strength sutures. Arthroscopy. 2009;25(2):192–9.
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 Biomechanics in Knot Tying
4
Roman Brzóska, Hubert Laprus,
Piotr Michniowski, and Paweł Ranosz

Biomechanics in knot tying is a crucial part of diameter, before any load is applied. In general,
knowledge about forces affecting the results of the term describes the ability of the basic knot to
surgical procedures. As the knot is the very secure the suture loop in position and protect it
important part of almost every operation, incor- against elongation. It refers to the capacity to keep
rect tying of sutures can lead to failure of the pro- the suture loop close once tension is released on
cedures and decreasing the rate of good results. the post strand and the knot is tied as well as gives
In the chapter all basic terms and processes influ- an idea of readapting of the tissue margins.
encing the strength and effectiveness of surgical The importance of loop security was initially
knots tying will be explained. emphasized by Burkhart et al. [2] and further
examined in other studies. Loop security is the
measure of tightness of the suture loop because a
4.1  oop Security, Loop
L loose suture loop will not hold tissue apposed
Elongation, and Loop regardless of the force to ultimate failure [3]. The
Circumference method of Lo et al. [4] was used to determine
loop security (see below).
A lot of definitions of loop security could be Loop security depends on tensile properties,
found in current literature. One of the simplest such as failure load, elasticity, or plasticity of the
explanations of loop security is the ability to suture material, which in turn determines suture
maintain a tight suture loop when a knot is tied elongation. Sliding knots are favored over sur-
[1]. The term can also be explained as the ability geon’s knots when using polyblend suture mate-
of the suture loop to stay tight as the knot is being rial to avoid poor loop security that leaves
tied. Another definition found in the literature is significant gaps in the repair approaching clinical
that loop security is the ability to conserve loop failure before the load is applied [5]. Loop secu-
rity, which refers to the initial tightness of the
knot, is also dependent on the initial throws [6].
The loop security is used as the marker of knot
R. Brzóska (*) • H. Laprus • P. Ranosz quality, but direct measurement of loop security
Department of Orthopedics, St Luke’s Hospital, is impractical in the laboratory. Some authors
Bielsko-Biała, Poland have suggested an indirect measure of loop
e-mail: [email protected] ­security: the change in loop circumference after
P. Michniowski it is transferred to a material testing system and
Department of Orthopedics, EMC “Zdrowie” tensioned to 5 N [7]. According to this way of
Hospital in Kwidzyn, Kwidzyn, Poland

© ESSKA 2018 33
U. Akgun et al. (eds.), Knots in Orthopedic Surgery, https://doi.org/10.1007/978-3-662-56108-9_4
34 R. Brzóska et al.

thinking, loop circumference is a parameter to By increased popularity of polyester- and

describe knot failure during load testing—elon- polyblend-braided sutures, providing superior
gation of the original loop circumference (for strength compared with traditional suture materi-
instance, 3 mm) during subsequent load to failure als, arthroscopic soft-tissue repair has changed in
is considered a failure. the past few years. The mentioned sutures allow
Loop elongation is tightly connected to loop easier knot tying with decreased risk for suture
security, and it refers to the maximum displace- failure and give excellent loop security for tissue
ment or growth in length of the knotted loop at stabilization. Most new-generation sutures have
peak load under cyclic loading. A suture loop that been shown to have similar tensile strengths.
is loose will cause loss of tissue apposition no FiberWire (Arthrex, Naples, Florida), Herculine
matter how tight the knot is tied [8]. (Linvatec, Largo, Florida), Orthocord (DePuy
Results describing the analysis of loop elon- Mitek, Warsaw, Indiana), and Ultrabraid (Smith
gation in the comparative study by Li X et al. & Nephew, Memphis, Tennessee) have attempted
are consistent with those reported by the others. to differentiate themselves in the ability to throw
In the study Duncan and Snyder knots as well as arthroscopic sliding knots with more ease and
four types of sutures were compared. The security [10].
authors show that Duncan knots appeared to
have a greater loop elongation than Snyder
knots when tied with Maxon and Tycron [8]. In 4.2 Knot Security
another comparative study, authors surprisingly
observed no changes in loop circumference Knot security is defined as the effectiveness of
when using PDS suture as the effect of elasticity the knot in resisting slippage when a load is
of the suture [9]. applied [1]. Namely, the knot security is the
Direct measurement of loop security is chal- measure of the strength of a knot. It refers to the
lenging. Loop security is a measure of the knot’s maximum load the knot is able to support prior
ability to maintain a tight suture loop as the knot to breaking (fracture) or complete slippage.
was tied and was defined by the circumference Many studies have shown that loop-holding
of the loop at 5 N preload and was calculated by capacity and knot security are influenced by the
the formula described by Lo et al. [4]. The type of knot, the knot configuration, the type of
smaller the loop diameter correlates to greater suture material, and the size and coating of the
loop security [3]. suture, as well the technique used for the knot
As mentioned above, the most commonly [1]. Another definition often used in the litera-
accepted surrogate measurement in the litera- ture is that knot security refers to a knot’s capac-
ture is a change in loop circumference after ity to maintain its integrity, without loosening or
applying a load of 5 N. All knots tested in the breaking, in the face of significant loads. The
laboratory are removed from the dowel and mentioned loads may be rapidly increasing lin-
placed on the MTS crossheads. The crosshead ear loads or low-­level repetitive loads [11]. It is
displacement is measured and used to calculate important to note that the definition of the knot
the loop circumference as described by Lo et al.: security consists of the information that knot-
loop circumference = (2 × crosshead displace- slip resistance under distractive load (tensile
ment) + (4 × rod radius) + rod circumference. force) once the knot is completed and locked
Loop security is calculated as the difference with successive half-hitch throw. It is attributed
between the loop circumference at 5 N and the by friction, internal interference, suture pliabil-
circumference of the knot-tying dowel (30 mm) ity, and slack between throws [12].
[7]. As Baumgarten et al. revealed, locking Knot security is affected by the knot type and
knots were not shown to have improved loop configuration but also is highly dependent on the
security when compared to non-locking knots individual surgeon. As Hanypsiak et al. [13]
for both Ethibond and PDS [3]. revealed, substantial variation and inconsisten-
4 Biomechanics in Knot Tying 35

cies in knot tying occurred not only between tensile strength over time under a tensile load for
knots tied by different surgeons but also between absorbable sutures [16, 17].
knots tied by the same surgeon on the same The failure of the knot can occur in the way of
occasion. breaking, slippage, or unraveling, and the knot
The appropriate “knot security” means the configuration plays a role. Lutchman et al. con-
lower rate of knot slippage or unraveling as the firm that 3-1-1 knot (a modification of a surgeon’s
result of: knot) break at a statistically significantly higher
tensile force than do slipknots and thus have a
1. Obtaining and maintaining tension on suture higher ultimate tensile strength [18]. On the other
strands during tying hand, no differences were found while compar-
2. Correct knot-tying technique ing the security of knots tied with or without
3. Appropriate knot construction or “geometry” instruments. All loops that failed via suture
(knot configuration). breakage failed just adjacent to the knot and not
within the knot where the hemostat had been
Also knot-tying speed and force can affect applied, meaning that no material failed at the
knot security [14]. site of instrumentation. No significant difference
One of the most important determinants of in mode of failure was found between instru-
knot security is the tightness of the suture loop or mented and noninstrumented suture groups for
the “loop length.” The term could be explained as any analyzed material [19].
the presence of shorter loop lengths or absence of It has been demonstrated that knot security
“gaps” between loops. In some conditions the is a function of knot configuration including
longer loop length coupled with a propensity to the number of throws used to make the knot as
unravel may be critically important, especially in well as the size and type of suture materials
instances where close tissue approximation plays [8, 20]. Xi Li et al. showed that comparing
a significant role [15]. Snyder to Duncan with four types of sutures
According to study by Burkhart and col- (PDS, Biosyn, Prolene, Surgidac), the highest
leagues, the factors that are the most important in mean knot security values were achieved by
tying a tight knot are friction, internal interfer- tying Snyder knots with Biosyn and Surgidac
ence, slack between loops, wraps or half hitches sutures, but similar differences were not found
of the knot. Internal interference can be increased with the same suture materials when tied in
by reversing direction of the half hitches or by Duncan knots [8]. Jo et al showed that sliding
changing the posts. Slack can be eliminated by knots perform better in terms of security when
past-pointing with the knot pusher as each half backed up with different number and type of
hitch is tightened [2]. half hitches [9].
Type of the suture also plays a role in knot Knot security describes the tensile strength of
security: knots tied with non-monofilament a basic knot that is secured with locking half
suture could create a construction with shorter hitches in both open and arthroscopic knots. The
loop lengths than those tied with monofilament security of arthroscopic knot types is the subject
thread. Although some believes that lower coef- of controversial debate in the literature. The
ficient of friction which characterise monofila- results of various knot’s loop security measure-
ment suture can allow to obtain a wider knot. It is ment confirmed believes of many authors, that
well proven that stretching of the knot when significantly higher pressure and tension are gen-
being tied and elasticity of the suture material erated when constructing an arthroscopic basic
could have negative effect for general knot secu- knot using a knot pusher. This gives the basic
rity. This is supported by some investigators, knot more secure seating in comparison with a
showing that there is an increased risk of knot hand-tied technique and consequently results in
slippage among nonabsorbable monofilament better loop security. Moreover, it confirms the
suture materials over braided and a decrease in security of the locking mechanism of arthroscopic
36 R. Brzóska et al.

knot types. Nevertheless, the placement of rein- It is common knowledge that arthroscopic
forcing half hitches is vital to the knot security of soft-tissue repairs undergo many cycles of ten-
arthroscopic as well as openly tied knots [21]. sioning and relaxation before significant tissue
Burkhart et al. have shown that loop security is as healing occurs, and knot security under cyclic
important as knot security. A loop that is initially loads is essential for good results after these
loose will fail to the same extent as a tight loop repairs. Ilahi et al. stated that post switching and
whose knot slips [2]. reversal of loop direction are crucial to
In many studies evaluation of knot security was arthroscopic knot security [10].
described by determining the response to both Livemore et al. stated that while comparing
load to failure and cyclic loading [10]. However, many suture materials and knot configurations,
cyclic loading is more representative of the physi- the Weston knot with 3 RHAPs using Ultrabraid
ologic loads encountered as a result of repair provided the best loop and knot security in both
reconstruction, and this parameter is taken into the load-to-clinical-failure test and the cyclic
consideration while analyzing the knot security. loading test when compared with all other knot
Namely, knot security (resistance to loosening configurations and suture materials tested [10].
or breaking) and loop security (tightness of the
initial loop) play a key role in maintaining the
knot. The ideal knot configuration would maxi- 4.3 Elongation
mize knot security and loop security with little to
no variation in tying technique [22]. In assessment of the repaired construct, the term
Loop security should be maximized to ensure of elongation plays the important role. It is
repair integrity when tension is released on the defined as the average maximum displacement of
post strand before the knot is locked with half a knotted suture loop at the peak load during
hitches. Final knot security should be high to cyclic loading [9]. Elongation can be defined as
maintain tissue approximation after repair. well as “gapping” of the construct, analyzed in
Ideally, a knot with less material should be used cyclical loading in biomechanical tests [24].
as long as this approach does not compromise Initial elongation is the elongation after precon-
knot security, because this may decrease the risk ditioning, while total elongation is an elongation
of complications due to foreign material in an after defined numbers of cycles in biomechanical
enclosed space, such as suture impingement in analysis [25].
the subacromial space [23]. Suture elongation is determined by failure
Knot failure can occur because of suture slip- load, elasticity, or plasticity of the suture mate-
page or suture breakage. The type of knot affects rial. The meaning of a term is opposite to the loop
80% of the force required for slippage and only security, which is the ability to conserve loop
20% of the force required for rupture. Therefore, diameter before any load is applied [3]. The unit
a proper knot configuration can eliminate the of elongation is millimeter, and elongation more
slippage as a cause of suture failure. Three reverse than 3 mm is defined as clinical failure [21]. This
half hitches (RHAPs) on alternating posts con- is considered an amount of suture loop elonga-
vert the failure mode from slippage to suture tion that might be associated with biological
breakage. An adequate number and configuration healing failure at the tendon–bone interface after
of RHAPs result in a greater internal suture resis- rotator cuff repair [26]. Sometimes elongation is
tance, increasing the loop security and the knot expressed in percentages.
security. Elongation is a term that could be divided into
Analysis of the knot may be assessed by two subtypes: loop elongation or knot ­elongation;
measuring loop security (loop circumference, both play a basic role in stability of the construct.
e.g., at 5 N) and knot security (highest load to Maximum elongation refers to the maximum
failure at a crosshead displacement of, for displacement of a stressed knotted suture loop
instance, 3 mm) [9]. either when the suture breaks and the knot remain
4 Biomechanics in Knot Tying 37

100
intact or when the knot slips completely off the
end of the suture. It is described as the difference 90

between length of the construct with some pre- 80

load (in Newton) and the peak length at the

Elongation in percent
70
defined cycle [27]. Peak-to-peak elongation is 60
defined as the difference between the length of
50
the construct at the peak of the first and defined
40
numbers of cycles [27]. In many papers the
authors revealed that for PDS sutures, the maxi- 30

mum elongation was greater than 5 mm regard- 20

less of which knot configuration was tested. This 10

degree of loop displacement is well beyond the 0
3 mm limit assumed to represent clinical failure Fiberwire Herculine Orthocord Ultrabraid Ethibond PDS

by loss of apposition [8]. Fig. 4.1 Mean elongation at failure of a single suture
As mentioned above, cyclic testing that can strand with straight loading without a knot. Orthocord
simulate postoperative conditions is inseparable had the highest elongation among the new polyblend
with biomechanical assessment of elongation. sutures, whereas PDS II performed with an even higher
elongation [33]
First, cyclic elongation should be determined,
defined as the relative increase in segment length
from the peak load of the first cycle to the peak force to clinical failure, as they provide mea-
load of the final cycle of testing. Another one is sures of the knot performance at low-force load-
elongation amplitude, defined as the peak to val- ing [3]. On the other hand, under load, some
ley measurement of the segment elongation for elongation at the knot always will take place, as
the final test cycle [28]. Load elongation curves the result of self-seating of the knot. Even exces-
are used to calculate structural properties of the sive pulling on the knot does not prevent knot
examined tissue [29]. slippage if there are a too small number of square
A knot tied with an absorbable monofilament knots [32].
suture elongates progressively when subjected to In comparative analysis of six common surgi-
repetitive stress, whereas in a knot tied with a cal materials, Wüst et al. revealed that PDS has
nonabsorbable braided suture, the elongation is the highest elongation rate and Orthocord had the
negligible [30]. However, Savage et al. have highest elongation at failure of the braided sutures
shown in the biomechanical study that there are and was therefore particularly apt to provide a
quite important differences between particular snug adaptation [33] (Fig. 4.1).
types of arthroscopic knots. No differences were
observed in cyclic elongation between simple
stitches with static and sliding knots. The only 4.4 Friction
difference was the mattress stitch with a sliding
knot having a greater cyclic elongation than the The definition of friction implies that it is the
simple stitches with static and sliding knots [31]. force that causes a moving object to slow down
Elongation of the suture loop and knot slip- when it is touching another object. The suture’s
page (loop failure) can lead to failure of the con- coefficient of friction is a measure of forces
struct, as well as the suture breakage due to the encountered by contact of the surfaces of the
material failure [12]. As revealed by Baumgarten suture material during construction of the knot.
et al., there are many differences in elongation in Next to internal interference and slack between
different types of surgical knots. Although a lot loops of the knot, suture friction is an important
of parameters can be taken into consideration in factor affecting knot security [6]. By the impact
biomechanical analysis, those of special impor- on knot security, friction indirectly affects satis-
tance are cyclic elongation, loop security, and fying clinical outcome. Properties such as
38 R. Brzóska et al.

c­ oefficient of friction, tensile strength, and others who compared the biomechanical properties of
affect the ultimate strength of a knot and the effi- 11 commonly used sutures in orthopedics, the
cacy of various knot configurations to resist slip- highest stiffness was calculated for 5 FiberWire
page under load [11]. Friction depends among and the lowest for 2-0 Vicryl [38]. The stiffness
others on the type of suture material used in knot of material used in UHMWPE sutures leads to
tying. According to Loutzenheiser et al., using more knot slippage. This property gives knots
braided, nonabsorbable suture and by reversing constructed with UHMWPE suture material a
direction of the half hitches and reversing posts, higher tendency for slippage. According to
it is possible to maximize friction and internal Barber et al., even backing up knots using four
interference [12]. reversed half hitches on alternating posts does
not guarantee definitive knot security when tying
knots with this material [36, 37].
4.5 Strength

Knot strength is the term strictly related to knot 4.7 Elasticity and Viscoelasticity
security. It can be defined as knot’s resistance to
breakage. According to Burkhart et al. to maxi- The variability between the suture materials for
mize the strength of arthroscopic knot used in each knot represents differences in elasticity,
rotator cuff repair, all sliding knots (locking or flexibility, and surface frictional properties of the
non-locking) should be followed up by a mini- different suture materials. Elasticity, stress, and
mum of three reverse half hitches on alternating strain are the tensile characteristics of a material
posts. Moreover, the load per suture for a stan- used to tie the knot. The term “elasticity” is a
dard 4 cm tear is suggested to range from 37.7 to measure of the stress required to effect a standard
60.4 N. It depends on the number of suture elongation of the distance between the clamps in
anchors and sutures within each construct [34]. biomechanical testing prior to reverse slippage of
Knot tensile strength is a measure of the force the knot and could be defined as stress-to-strain
that suture can withstand before it breaks when ratio. In the biomechanical analysis of five knots
knotted. Tensile strength is measured by the time performed by Shimi et al. the authors revealed
it takes for suturing material to lose 70–80% of that silk, polyamide, and Dacron manifested sim-
its initial strength. Initial tensile strength is a ilar elasticity in all the knots examined [39]. This
measure of the amount of tension applied in a was lower than the elasticity of lactomer and
horizontal plane necessary to break the suturing polydioxanone. On the other hand, Melzer and
material [35]. Barber et al. proved that newer Roeder knots had similar elasticity for the liga-
high-strength sutures composed of ultrahigh ture materials tested, but this was lower than the
molecular weight polyethylene (UHMWPE) elasticity of Tayside, Cross square, and Blood
show improved biomechanical properties includ- knots. From the mentioned analysis, it is known
ing greater tensile strength and provide higher as well that slipknots tied with materials of small
resistance for suture breakage [36, 37]. diameter (2/0) tend to be more elastic than those
tied with thicker materials (1/0, 0/0) although the
differences between ligature sizes for this vari-
4.6 Stiffness able were not significant in the investigation.
Elasticity is one of well-known parameter in
The suture’s stiffness reflects its resistance to load-to-failure tests in biomechanical studies
bending and it is an important parameter that when assessing knot, and it is inversely related to
affects knot security. It is known that monofila- its ability to stack. For the knots of a similar con-
ment sutures are usually stiffer than braided ones figuration (for instance, Melzer and Roeder
and an increase in suture size significantly knots), a similar “knot elasticity” could be
increases its stiffness. According to Najibi et al. observed. For these two knots, less stress is
4 Biomechanics in Knot Tying 39

required to effect a standard elongation since geon’s fingers by cutting with polyblend sutures
some of the energy is expanded in incremental could be attributed to stronger knot tightening by
stacking of the knots [39]. However, it is an obvi- the surgeon. However, in the laboratory setting,
ous fact that different suture materials give a dif- the occurrence of injuries was not significantly
ferent elasticity according to used material. Silk, higher with the polyblend sutures than with
polyamide, and Dacron are relatively inelastic Ethibond [33].
materials and were found to have a lower elastic- Viscoelasticity is the property of materi-
ity than polydioxanone or lactomer in all the als that exhibit both viscous and elastic char-
knots examined in the analysis by Shimi et al. acteristics when undergoing deformation. The
Polydioxanone exhibited the highest elasticity in response of many materials depends not only
all the knots. As expected, the smaller-­diameter on the load magnitude but also on its duration
suture materials resulted in slightly more elastic and time course. Deformations lag behind the
knots [39]. load, and the indenter continues penetrating into
It is important to note that elasticity can alter the specimen even under constant load. Such
after sitting a knot in a human body, as the effect materials are called viscoelastic or viscoelas-
of hydration causing swelling of the material and tic–plastic (Fig. 4.2). Parameters, characterizing
changing of the surface frictional properties, tor- viscoelastic–plastic properties, can be estimated
sional stiffness, and elasticity to varying extent from a simple five-step procedure. In the first
depending on the nature and composition of the step (I), the indenter is rapidly loaded to the
ligature material [39]. As a result of its higher nominal load. Then, a long dwell under this
elasticity, a well-known Orthocord tended to load follows (II), then rapid unloading to a very
offer subjectively more elastic tension for knot- low load (III), followed by a long time under
ting than FiberWire and Herculine. This and the this load (IV), and finally unloading to zero (V).
findings of a trend toward better results in knot The response during dwell II provides the base
slide ability in comparison to Ultrabraid and in for the determination of viscoelastic and visco-
the general handling ability compared with plastic parameters. In principle, the back creep
FiberWire seem to be the reasons for a better in the low-load dwell IV could also be used for
overall ranking of Orthocord in the subjective the determination of viscoelastic parameters.
testing of suture properties. With the best results However, due to irreversible processes around
for each tested handling property, Orthocord per- a pointed indenter during loading, the unload-
formed better than FiberWire and Ultrabraid in ing imprint profile differs from that during load-
the summary of all handling qualities. The sub- ing, and the extraction of material parameters
jective impression of greater injuries to the sur- from dwell IV requires a special procedure.

h (µm)
2
1.8 III
II
1.6
1.4 IV
1.2
h (µm)

1 I
0.8
0.6
0.4
Fig. 4.2 Chart
0.2
explaining viscoelastic
materials maintenance 0
on loading in five 0 500 1000 1500 2000 2500
steps [40] t (s)
40 R. Brzóska et al.

1.2
Nevertheless, this period can be used for verifi-
cation of the duration of reversible viscoelastic 1

processes [40]. 0.8

h (µm)
Important factors in analyzing viscoelasticity 0.6

of suture materials (polymers) are: 0.4

0.2
1. Creep (time-dependent deformation that 0
occurs during application of constant load) 0 100 200 300 400 500 600 700
t (s)
2. Relaxation (time-dependent decrease in load
Ticron Ethilon Prolene
that occurs during application of constant
deformation) Fig. 4.3 Stress relaxation curves of Ticron, Prolene, and
3. Strain rate dependence (material property Ethilon sutures [40]
dependence on rate at which loading occurs)
4. Material recovery (ability of suture to return
to original size after removal of load) to Prolene and showed no significant tempera-
ture effects.
In many investigations MagnumWire, Ethibond, Differences between knot types’ viscoelastic
FiberWire, Orthocord, and Force Fiber were com- properties were analyzed by Vaibhav and col-
pared and evaluated. In results FiberWire showed leagues [42]. After testing of viscoelastic proper-
the greatest stiffness, smallest initial extension, and ties of six common arthroscopic sliding knots
smallest creep during creep testing and the smallest (Tennessee slider, Roeder knot, SMC knot,
peak-to-peak d­isplacement during cyclic testing. Duncan loop, Weston knot, and Nicky’s knot),
Orthocord showed the smallest relaxed elongation the authors concluded that stress relaxation and
on both creep and cyclic testing [41]. These data knot types were similar, except Roeder knot
have many clinical relevance. It should be noted which presented significant increase of relaxation
that mechanical properties of the suture interfere and elongation. Furthermore, results lead to con-
with tissue directly and have an increased effect on clusion that suture material is responsible for at
healing and rehabilitation process. The stiffness of least 75% of the stress relaxation. These results
sutures may in fact be correlated with a higher like- suggest as well that using knotless techniques for
lihood of repair failure, because of cutting effect of securing the rotator cuff will not change the stress
stiff materials. That is why using stiffer than usual relaxation characteristics of the suture bridge as
materials should be promoted for adequate and less it relates to the knot.
intense rehabilitation process.
In the investigations analyzing stress relax-
ation of the materials, Vizesi et al. [40] have com- 4.8 Abrasion Resistance
pared (Fig. 4.3):
Abrasion resistance as the ability of materials to
1. Prolene – a monofilament polypropylene withstand the effects of abrasion was hardly stud-
2. Ethilon – a monofilament nylon ied in the field of surgery. Most studies focused
3. Ticron – a braided polyester fiber on abrasion resistance of suture materials or
influence of different factors on abrasion effects
Prolene has the largest stress relaxation of the sutures. Nowadays it is a well-known fact
ratios (ratio of force from the initial 2 mm dis- that suture abrasion differs according to the:
placement to the force after the 10-min stress
relaxation period) with a significant increase 1. Suture material
in the body temperature group. Both Ethilon 2. Anchor type
and Ticron exhibited significantly lower 3. Knot type
amounts of stress relaxation when compared 4. Testing conditions
4 Biomechanics in Knot Tying 41

As a result of studies comparing monofilaments Type of the anchor is another factor influenc-
and braided materials, it was proven on soft-tissue ing risk of abrasion. In metallic anchors the sur-
testing that the monofilament sutures showed the faces tended to be rough with sharp edges and the
least amount of abrasion, followed by the braided absorbable implants typically had smoother
polyblend and then the braided polyester sutures. edges. As a result sutures for the absorbable
On bone testing the braided polyblend sutures devices tended not to abrade or break when sub-
showed significantly increased suture failure resis- jected to cyclic loads [44].
tance through a trans-osseous tunnel [43]. The results suggest unambiguously that mate-
According to the results of comparative inves- rial of suture, anchor type, knot type, and intraop-
tigation of FiberWire and Ethibond By Lo et al. it erative conditions have influence on suture
is known that FiberWire has superior resistance breakage and finally effect of reconstruction in
to abrasion when compared with Ethibond under continuance. As mentioned above, it should be
all anchors in common clinical using [4]. underlined that suture breakage might occur dur-
However it was also shown that Orthocord ing knot tying secondary to abrasion from the
braided suture was by far the least abrasive and anchor eyelet as well [11]. If a suture abrasion is
therefore had the least cutting effect on the present, the second anchor should be placed to
absorbable anchors. Higher abrasion resistance protect the first knot.
of the sutures can be unfortunately the risk factor
of cartilage injury. A study showed that intraar-
ticular placement of the high strength braided 4.9  tatic Creep and Dynamic
S
material caused significantly more cartilage Creep
injury by friction than the monofilament degrad-
able suture [25]. All in all, we have to remember Static creep is a physical property of materials
that suture eyelets formed from biodegradable that results in progressive deformation when a
materials can fail even at low numbers of cycles, constant load is applied over time; it allows soft
as a result of cutting by the suture going through tissues to tolerate applied loads by lengthening
the biodegradable eyelet during cyclic loading [45]. It is defined as time-dependent deformation
[11]. However, there are plenty of factors which during application of constant load. In the inves-
can change the pace of failing. tigations by Vizesi et al. [40], the authors have
Testing conditions also have relevant influ- compared Prolene (a monofilament polypropyl-
ence on results of abrasion resistance of the ene), Ethilon (a monofilament nylon), and Ticron
sutures. In wet conditions or using lubricate, (a braided polyester fiber) (Figs. 4.4 and 4.5).
sutures failed at significantly higher cycles of The largest creep ratio (ratio of total ­displacement
loading when compared with dry conditions. after the 10-min creep period to the initial dis-
What is more, suture-to-anchor angle may play a
role as well, and an angle of 45° increases suture 2
abrasion in biomechanical testing. 1.8
Influence of knot type on suture abrasion was 1.6
1.4
Creep ratio

analyzed in the investigation by Longo and col- 1.2

leagues, when they have compared sliding knots 1
0.8
with others. They revealed that sliding knots had 0.6
many advantages because that kind of knot can 0.4
0.2
be slid down the post limb without allowing the 0
loop to loosen. However, one should be careful Ethiilon Prolene Ticron
Suture
with that type of knots, because there is a risk of
Room temp Body temp
sliding the suture through the tissue, or along the
anchor, causing abrasion and weakening of the Fig. 4.4 Creep ratios of Ethilon, Prolene, and Ticron
suture itself [5]. sutures in various temperatures [40]
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