Reverse Flipping Technique: An Alternate Approach to Tie Reversing Half-Hitches on Alternating Posts Alexander C. M. Chong, M.S.A.E., M.S.M.E., Daniel J. Prohaska, M.D., and Ryan C. Pate, M.D.
Abstract: Arthroscopic knot tying requires practice and attention to detail, especially tying the 3 reversing half-hitches on alternating posts (RHAPs) in a knot. Mistakes can occur that result in an unintentional tension (>10 N) applied to the wrapping suture limb, and by placing tension in the wrong limb, the previously “flipped” half-hitch is converted from a series of RHAPs into a series of identical half-hitches on the same post, thereby producing insecure knots or suture loops. This was hypothesized to be a source of knot failure by knot slippage. This error can be avoided by using a technique we describe as “reverse flipping,” which purposely “flips” the half-hitch down at the main knot while tying the 3 RHAPs in a knot, and then the half-hitch is retightened using either a past-pointing or over-pointing technique. This way the surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed, and can also prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to “flip.” However, caution should be used when tensioning the half-hitches; overtensioning (>40 N) during past-pointing or over-pointing could also potentially “flip” the previous half-hitch that has already been tightened and cause potential knot failure.
D
uring arthroscopic surgery, the surgeon is commonly required to tie an arthroscopic knot that needs to slide through the arthroscopic cannula using a knot pusher, followed by a series of half-hitches on alternating posts to yield a secure knot capable of secure tissue fixation. It has been shown that at least 3 reversing half-hitches on alternating posts (RHAPs), after the placement of most types of sliding or nonsliding knots, are necessary for optimal knot integrity.1-4 Arthroscopic knot tying requires practice and attention to detail, especially tying the 3 RHAPs in a knot, mistakes can occur, such as pulling back the knot pusher either through the arthroscopic cannula or while tying the knot, or turning the suture around the
From the Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita (A.C.M.C., D.J.P., R.C.P.); Advanced Orthopaedics Associates (D.J.P.); and Robert J. Dole VA Medical Center (R.C.P.), Wichita, Kansas, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received August 20, 2015; accepted January 12, 2016. Address correspondence to Alexander C.M. Chong, M.S.A.E., M.S.M.E., Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, 929 N. Saint Francis, Wichita, KS 67214, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15811/$36.00 http://dx.doi.org/10.1016/j.eats.2016.01.012
post limb resulting in an unintentional tension applied to the wrapping suture limb, thus easily “flipped” the half-hitch and converts a series of RHAPs into a series of identical half-hitches on the same post, thereby reversing the kinking effect created by alternating posts, and that produce insecure knots or suture loops.5 This error can be avoided by using a technique of “flipping,” which “flips” the half-hitch after it is seated and tightened on the base knot, and then the half-hitch is retightened using either the past-pointing or over-pointing technique (Video 1).
Technique The knot-tying process begins by sliding the initial base knot, either nonsliding, sliding and locking, or sliding and nonlocking knot of the surgeon’s preference, down to the tissue using a knot pusher on the post limb. It is then tightened while maintaining tension on the post suture limb, and the remainder of the suture slack is pulled from the loop suture limb to tighten the base knot. A nonsliding knot has the application when suture limbs do not slide freely through either the anchor or soft tissue, whereas a sliding knot has the application when suture limbs slide freely through both the anchor and soft tissue. Our technique uses a single-hole knot pusher (Model number: 3910-500-730, Stryker, Mahwah, NJ) and a
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hemostat on one of the suture limbs, usually the post suture limb, for the entire knot-tying process, whereas it is implemented in both past-pointing and overpointing maneuvers to tighten the base knot and a series of half-hitches. The purposes for the use of the hemostat, which clamps at the end of the suture limb, are (1) to prevent the knot pusher from falling off or dropping during the knot-tying process, (2) to apply a small amount of tension onto the suture limb due to its weight, and (3) to use as an indicator of the suture limb as the post suture limb. The past-pointing maneuver essentially creates an opposing force on the knot by tensioning both suture limbs simultaneously in diverging directions, by use of a knot pusher, much in the way one would tie the knot by hand, whereas the over-pointing maneuver is whereby the opening of the knot pusher is advanced over the formed knot while maintaining tension on the post suture limb and pulling the loop limb to tighten the half-hitch.6,7 The half-hitch consists of a single turn usually around the post suture limb in either overhand or underhand configuration. An overhand configuration is formed when a loop is made so that the loop suture limb end is on top of the post suture limb, whereas an underhand configuration is formed when the loop suture limb end is placed under the post suture limb. The first half-hitch after the initial base knot is formed while maintaining tension on the post suture limb, then it is pushed down onto the base knot using the knot pusher until the loop is seated on the main knot, and finally it is tightened by using the over-pointing technique (Fig 1 A and B).
1st half-hitch
2nd half-hitch
3rd half-hitch
Tension is then deliberately applied to the loop suture limb until a “flip” occurs (Fig 1C), and then the halfhitch is retightened again by using the past-pointing technique (Fig 1D). The second half-hitch is placed over the post suture limb again, but then the post is switched by increasing tension on the loop suture limb (Fig 1E). By using the knot pusher the half-hitch is pushed down onto the base knot and then it is securely tightened by using the past-pointing technique (Fig 1F). Tension is then deliberately applied to the post suture limb until a “flip” occurs (Fig 1G), and then the half-hitch is retightened again by using the over-pointing technique (Fig 1H). The last half-hitch is then placed over the post suture limb again while maintaining tension on the post suture limb; then it is pushed down onto the knot using the knot pusher and tighten by using the over-pointing technique (Fig 1 I and J). Tension is then deliberately applied to the loop suture limb until a “flip” occurs (Fig 1K), and then the half-hitch is retightened again by using the past-pointing technique (Fig 1L).
Discussion Switching the post limb between throws in a series of half-hitches has been shown to increase the knot security by increasing the friction and the internal interference.1-4 Chan and Burkhart8 developed an easy technique to switch post by increasing tension on the suture limbs. However, slightly overtensioning the wrapping suture limb on a tightened half-hitch (>10 N) will cause the knot to flip back. We developed this
A
B
C
D
E
F
G
H
I
J
K
L
Fig 1. Reverse flipping technique steps. (A) The initial base knot of the surgeon’s preference is slid down to the tissue using a knot pusher on the post limb; the first half-hitch is formed while maintaining tension on the post suture limb, which is then pushed down onto the base knot using the knot pusher until the loop seats on the main knot. (B) The half-hitch is tightened by using the over-pointing technique. (C) Tension then deliberately applies to the loop suture limb until a “flip” occurs. (D) The half-hitch is retightened again by using the past-pointing technique. (E) The second half-hitch is placed over the post suture limb again, but then the post switches by increasing tension on the loop suture limb. (F) The second half-hitch is tightened by using the past-pointing technique. (G) Tension then deliberately applies to the post limb until a “flip” occurs. (H) The half-hitch is retightened again by using the over-pointing technique. (I) The last half-hitch is then placed over the post suture limb again while maintaining tension on the post limb. (J) The half-hitch is retightened again by using the over-pointing technique. (K) Tension then deliberately applies to the loop limb until a “flip” occurs. (L) The half-hitch is retightened again by using the pastpointing technique.
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REVERSE FLIPPING TECHNIQUE Table 1. Key Points, Tips, and Cautions for Using Reverse Flipping Technique
Table 2. Benefits and Pitfalls for Using the Reverse Flipping Technique
Key points: Proper tying of the 3 reversing half-hitches on alternating posts in an arthroscopic knot should be ensured. Proper tension required to tighten each half-hitch should be ensured. Each half-hitch should be well seated in the direction that it was intended to be placed. Understand the importance of the 3 reversing half-hitches on alternating posts to a successful stable arthroscopic knot. Tips: Be sure to use a single-hole knot pusher. Be sure to use a hemostat that clamps at the end of the suture limb (1) to prevent the knot pusher from falling off or dropping during the knot-tying process (2) to apply a small amount of tension onto the suture limb due to its weight (3) to use as an indicator of the suture limb as post suture limb. Use over-pointing and past-pointing techniques to tie the halfhitches. When a deliberate “flip” is required, pull on the loop suture limb with minimum force until a “flip” occurs. Tighten the half-hitch by maintaining minimum tension on the post suture limb first, and then pulling the loop limb to eliminate slack and tighten the half-hitch. Cautions: Overtensioning during past-pointing or over-pointing could potentially “flip” the previous half-hitch that has already been tightened without noticing. Should apply tension not more than 40 N (10 lb) of loads when tensioning the half-hitches.
Benefits: The surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed. Prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to “flip.” Pitfalls: Take a little longer time to tie an arthroscopic knot. Sometime it is hard to feel and/or see the “flip” occurs when a deliberate “flip” is required.
“reverse flipping” technique to purposely “flip” the half-hitch down at the knot while tying the 3 RHAPs in a knot (Table 1). Inadvertent mistakes can occur when tying a knot, such as pulling back the knot pusher while tying the next half-hitch throw or turning the suture around the post limb resulting in an unintentional tension applied to the wrapping limb; therefore, we suggest that, instead of creating the “flip” half-hitch outside the arthroscopic cannula, this technique intentionally “flip” the already tightened half-hitch and retighten it again. This way the surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed, and can also prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to “flip” (Table 2). However, caution should be used when tensioning the half-hitches; overtensioning during pastpointing or over-pointing could also potentially “flip” the previous half-hitch that has already been tightened without noticing. This situation should be avoided by applying tension not more than 40 N of loads (Table 1).
We believe that this technique may prevent the discrepancies of maximum clinical failure loads observed between orthopaedic surgeons,9-11 and thereby achieve a better outcome in arthroscopic surgeries that required knot tying.
References 1. Chan KC, Burkhart SS, Thiagarajan P, Goh JC. Optimization of stacked half-hitch knots for arthroscopic surgery. Arthroscopy 2001;17:752-759. 2. Kim SH, Yoo JC, Wang JH, Choi KW, Bae TS, Lee CY. Arthroscopic sliding knot: How many additional halfhitches are really needed? Arthroscopy 2005;21:405-411. 3. Lo IK, Burkhart SS, Chan KC, Athanasiou K. Arthroscopic knots: Determining the optimal balance of loop security and knot security. Arthroscopy 2004;20:489-502. 4. Loutzenheiser TD, Harryman DT II, Yung SW, France MP, Sidles JA. Optimizing arthroscopic knots. Arthroscopy 1995;11:199-206. 5. Meier JD, Meier SW. Over-pointing technique: An approach to past-pointing arthroscopic knots on alternating suture posts without alternating the knot pusher. Arthroscopy 2007;23:1358.e1-1358.e3. 6. Nottage WM, Lieurance RK. Arthroscopic knot typing techniques. Arthroscopy 1999;15:515-521. 7. Milia MJ, Peindl RD, Connor PM. Arthroscopic knot tying: The role of instrumentation in achieving knot security. Arthroscopy 2005;21:69-76. 8. Chan KC, Burkhart SS. How to switch posts without rethreading when tying half-hitches. Arthroscopy 1999;15: 444-450. 9. Pedowitz RA, Nicandri GT, Angelo RL, Ryu RK, Gallagher AG. Objective assessment of knot-tying proficiency with the fundamentals of arthroscopic surgery training program workstation and knot tester. Arthroscopy 2015;31:1872-1879. 10. Hanypsiak BT, DeLong JM, Simmons L, Lowe W, Burkhart S. Knot strength varies widely among expert arthroscopists. Am J Sports Med 2014;42:1978-1984. 11. Livermore RW, Chong AC, Prohaska DJ, Cooke FW, Jones TL. Knot security, loop security, and elongation of braided polyblend sutures used for arthroscopic knots. Am J Orthop 2010;39:569-576.
Abstract: Arthroscopic knot tying requires practice and attention to detail, especially tying the 3 reversing half-hitches on alternating posts (RHAPs) in a knot. Mistakes can occur that result in an unintentional tension (>10 N) applied to the wrapping suture limb, and by placing tension in the wrong limb, the previously “flipped” half-hitch is converted from a series of RHAPs into a series of identical half-hitches on the same post, thereby producing insecure knots or suture loops. This was hypothesized to be a source of knot failure by knot slippage. This error can be avoided by using a technique we describe as “reverse flipping,” which purposely “flips” the half-hitch down at the main knot while tying the 3 RHAPs in a knot, and then the half-hitch is retightened using either a past-pointing or over-pointing technique. This way the surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed, and can also prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to “flip.” However, caution should be used when tensioning the half-hitches; overtensioning (>40 N) during past-pointing or over-pointing could also potentially “flip” the previous half-hitch that has already been tightened and cause potential knot failure.
D
uring arthroscopic surgery, the surgeon is commonly required to tie an arthroscopic knot that needs to slide through the arthroscopic cannula using a knot pusher, followed by a series of half-hitches on alternating posts to yield a secure knot capable of secure tissue fixation. It has been shown that at least 3 reversing half-hitches on alternating posts (RHAPs), after the placement of most types of sliding or nonsliding knots, are necessary for optimal knot integrity.1-4 Arthroscopic knot tying requires practice and attention to detail, especially tying the 3 RHAPs in a knot, mistakes can occur, such as pulling back the knot pusher either through the arthroscopic cannula or while tying the knot, or turning the suture around the
From the Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita (A.C.M.C., D.J.P., R.C.P.); Advanced Orthopaedics Associates (D.J.P.); and Robert J. Dole VA Medical Center (R.C.P.), Wichita, Kansas, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received August 20, 2015; accepted January 12, 2016. Address correspondence to Alexander C.M. Chong, M.S.A.E., M.S.M.E., Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, 929 N. Saint Francis, Wichita, KS 67214, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15811/$36.00 http://dx.doi.org/10.1016/j.eats.2016.01.012
post limb resulting in an unintentional tension applied to the wrapping suture limb, thus easily “flipped” the half-hitch and converts a series of RHAPs into a series of identical half-hitches on the same post, thereby reversing the kinking effect created by alternating posts, and that produce insecure knots or suture loops.5 This error can be avoided by using a technique of “flipping,” which “flips” the half-hitch after it is seated and tightened on the base knot, and then the half-hitch is retightened using either the past-pointing or over-pointing technique (Video 1).
Technique The knot-tying process begins by sliding the initial base knot, either nonsliding, sliding and locking, or sliding and nonlocking knot of the surgeon’s preference, down to the tissue using a knot pusher on the post limb. It is then tightened while maintaining tension on the post suture limb, and the remainder of the suture slack is pulled from the loop suture limb to tighten the base knot. A nonsliding knot has the application when suture limbs do not slide freely through either the anchor or soft tissue, whereas a sliding knot has the application when suture limbs slide freely through both the anchor and soft tissue. Our technique uses a single-hole knot pusher (Model number: 3910-500-730, Stryker, Mahwah, NJ) and a
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hemostat on one of the suture limbs, usually the post suture limb, for the entire knot-tying process, whereas it is implemented in both past-pointing and overpointing maneuvers to tighten the base knot and a series of half-hitches. The purposes for the use of the hemostat, which clamps at the end of the suture limb, are (1) to prevent the knot pusher from falling off or dropping during the knot-tying process, (2) to apply a small amount of tension onto the suture limb due to its weight, and (3) to use as an indicator of the suture limb as the post suture limb. The past-pointing maneuver essentially creates an opposing force on the knot by tensioning both suture limbs simultaneously in diverging directions, by use of a knot pusher, much in the way one would tie the knot by hand, whereas the over-pointing maneuver is whereby the opening of the knot pusher is advanced over the formed knot while maintaining tension on the post suture limb and pulling the loop limb to tighten the half-hitch.6,7 The half-hitch consists of a single turn usually around the post suture limb in either overhand or underhand configuration. An overhand configuration is formed when a loop is made so that the loop suture limb end is on top of the post suture limb, whereas an underhand configuration is formed when the loop suture limb end is placed under the post suture limb. The first half-hitch after the initial base knot is formed while maintaining tension on the post suture limb, then it is pushed down onto the base knot using the knot pusher until the loop is seated on the main knot, and finally it is tightened by using the over-pointing technique (Fig 1 A and B).
1st half-hitch
2nd half-hitch
3rd half-hitch
Tension is then deliberately applied to the loop suture limb until a “flip” occurs (Fig 1C), and then the halfhitch is retightened again by using the past-pointing technique (Fig 1D). The second half-hitch is placed over the post suture limb again, but then the post is switched by increasing tension on the loop suture limb (Fig 1E). By using the knot pusher the half-hitch is pushed down onto the base knot and then it is securely tightened by using the past-pointing technique (Fig 1F). Tension is then deliberately applied to the post suture limb until a “flip” occurs (Fig 1G), and then the half-hitch is retightened again by using the over-pointing technique (Fig 1H). The last half-hitch is then placed over the post suture limb again while maintaining tension on the post suture limb; then it is pushed down onto the knot using the knot pusher and tighten by using the over-pointing technique (Fig 1 I and J). Tension is then deliberately applied to the loop suture limb until a “flip” occurs (Fig 1K), and then the half-hitch is retightened again by using the past-pointing technique (Fig 1L).
Discussion Switching the post limb between throws in a series of half-hitches has been shown to increase the knot security by increasing the friction and the internal interference.1-4 Chan and Burkhart8 developed an easy technique to switch post by increasing tension on the suture limbs. However, slightly overtensioning the wrapping suture limb on a tightened half-hitch (>10 N) will cause the knot to flip back. We developed this
A
B
C
D
E
F
G
H
I
J
K
L
Fig 1. Reverse flipping technique steps. (A) The initial base knot of the surgeon’s preference is slid down to the tissue using a knot pusher on the post limb; the first half-hitch is formed while maintaining tension on the post suture limb, which is then pushed down onto the base knot using the knot pusher until the loop seats on the main knot. (B) The half-hitch is tightened by using the over-pointing technique. (C) Tension then deliberately applies to the loop suture limb until a “flip” occurs. (D) The half-hitch is retightened again by using the past-pointing technique. (E) The second half-hitch is placed over the post suture limb again, but then the post switches by increasing tension on the loop suture limb. (F) The second half-hitch is tightened by using the past-pointing technique. (G) Tension then deliberately applies to the post limb until a “flip” occurs. (H) The half-hitch is retightened again by using the over-pointing technique. (I) The last half-hitch is then placed over the post suture limb again while maintaining tension on the post limb. (J) The half-hitch is retightened again by using the over-pointing technique. (K) Tension then deliberately applies to the loop limb until a “flip” occurs. (L) The half-hitch is retightened again by using the pastpointing technique.
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REVERSE FLIPPING TECHNIQUE Table 1. Key Points, Tips, and Cautions for Using Reverse Flipping Technique
Table 2. Benefits and Pitfalls for Using the Reverse Flipping Technique
Key points: Proper tying of the 3 reversing half-hitches on alternating posts in an arthroscopic knot should be ensured. Proper tension required to tighten each half-hitch should be ensured. Each half-hitch should be well seated in the direction that it was intended to be placed. Understand the importance of the 3 reversing half-hitches on alternating posts to a successful stable arthroscopic knot. Tips: Be sure to use a single-hole knot pusher. Be sure to use a hemostat that clamps at the end of the suture limb (1) to prevent the knot pusher from falling off or dropping during the knot-tying process (2) to apply a small amount of tension onto the suture limb due to its weight (3) to use as an indicator of the suture limb as post suture limb. Use over-pointing and past-pointing techniques to tie the halfhitches. When a deliberate “flip” is required, pull on the loop suture limb with minimum force until a “flip” occurs. Tighten the half-hitch by maintaining minimum tension on the post suture limb first, and then pulling the loop limb to eliminate slack and tighten the half-hitch. Cautions: Overtensioning during past-pointing or over-pointing could potentially “flip” the previous half-hitch that has already been tightened without noticing. Should apply tension not more than 40 N (10 lb) of loads when tensioning the half-hitches.
Benefits: The surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed. Prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to “flip.” Pitfalls: Take a little longer time to tie an arthroscopic knot. Sometime it is hard to feel and/or see the “flip” occurs when a deliberate “flip” is required.
“reverse flipping” technique to purposely “flip” the half-hitch down at the knot while tying the 3 RHAPs in a knot (Table 1). Inadvertent mistakes can occur when tying a knot, such as pulling back the knot pusher while tying the next half-hitch throw or turning the suture around the post limb resulting in an unintentional tension applied to the wrapping limb; therefore, we suggest that, instead of creating the “flip” half-hitch outside the arthroscopic cannula, this technique intentionally “flip” the already tightened half-hitch and retighten it again. This way the surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed, and can also prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to “flip” (Table 2). However, caution should be used when tensioning the half-hitches; overtensioning during pastpointing or over-pointing could also potentially “flip” the previous half-hitch that has already been tightened without noticing. This situation should be avoided by applying tension not more than 40 N of loads (Table 1).
We believe that this technique may prevent the discrepancies of maximum clinical failure loads observed between orthopaedic surgeons,9-11 and thereby achieve a better outcome in arthroscopic surgeries that required knot tying.
References 1. Chan KC, Burkhart SS, Thiagarajan P, Goh JC. Optimization of stacked half-hitch knots for arthroscopic surgery. Arthroscopy 2001;17:752-759. 2. Kim SH, Yoo JC, Wang JH, Choi KW, Bae TS, Lee CY. Arthroscopic sliding knot: How many additional halfhitches are really needed? Arthroscopy 2005;21:405-411. 3. Lo IK, Burkhart SS, Chan KC, Athanasiou K. Arthroscopic knots: Determining the optimal balance of loop security and knot security. Arthroscopy 2004;20:489-502. 4. Loutzenheiser TD, Harryman DT II, Yung SW, France MP, Sidles JA. Optimizing arthroscopic knots. Arthroscopy 1995;11:199-206. 5. Meier JD, Meier SW. Over-pointing technique: An approach to past-pointing arthroscopic knots on alternating suture posts without alternating the knot pusher. Arthroscopy 2007;23:1358.e1-1358.e3. 6. Nottage WM, Lieurance RK. Arthroscopic knot typing techniques. Arthroscopy 1999;15:515-521. 7. Milia MJ, Peindl RD, Connor PM. Arthroscopic knot tying: The role of instrumentation in achieving knot security. Arthroscopy 2005;21:69-76. 8. Chan KC, Burkhart SS. How to switch posts without rethreading when tying half-hitches. Arthroscopy 1999;15: 444-450. 9. Pedowitz RA, Nicandri GT, Angelo RL, Ryu RK, Gallagher AG. Objective assessment of knot-tying proficiency with the fundamentals of arthroscopic surgery training program workstation and knot tester. Arthroscopy 2015;31:1872-1879. 10. Hanypsiak BT, DeLong JM, Simmons L, Lowe W, Burkhart S. Knot strength varies widely among expert arthroscopists. Am J Sports Med 2014;42:1978-1984. 11. Livermore RW, Chong AC, Prohaska DJ, Cooke FW, Jones TL. Knot security, loop security, and elongation of braided polyblend sutures used for arthroscopic knots. Am J Orthop 2010;39:569-576.
