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Bushong EE, Janis JE. Knot Security 101: A Comprehensive Practical Review to Optimal Knot Configuration, Pulling Direction, Throw Count, and Tail Length. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6047. [PMID: 39139841 PMCID: PMC11319322 DOI: 10.1097/gox.0000000000006047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/05/2024] [Indexed: 08/15/2024]
Abstract
Background Knots are the weakest structural point in a suture line and inevitably weaken almost all suture materials. This practical review critically evaluates the factors, such as suture material properties, gauge, configuration, throw count, and tail length, that affect knot security. Methods A PubMed search between the years 1934 and 2023 identified relevant studies that addressed factors relating to knot security. Studies that investigated knots and sutures solely used in laparoscopic and arthroscopic surgery were excluded. Knot configurations assessed were the Aberdeen, sliding, square, and surgeon's. Results Eighty-six articles were included in this review article and demonstrated that knot security varies greatly between suture materials and gauge. Knot security also varies by configuration, throw count, conditions, tail length, and stitch type. Throw count differs by knot configuration, with the Aberdeen knot being most secure with three throws and one to two turns compared with three to five throws for surgeon's and square knots. The optimal tail length was 3 mm. Conclusions This practical review demonstrates that there are significant differences in knot security based on a variety of factors. It is challenging to propose an ideal knot because most studies did not evaluate knot security using a broad variety of suture materials, gauges, and throws for each of the most common knots. Although this review article demonstrated several applicable findings, additional robust studies are needed to simplify proposals.
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Affiliation(s)
- Elizabeth E. Bushong
- From the Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio
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Lim S, Lee DY, Doh G, Seo Y, Lim C, Yoon J, Eo S. Security Comparison of Various Surgical Knots Using Nylon Suture. Adv Skin Wound Care 2024; 37:354-359. [PMID: 38595155 DOI: 10.1097/asw.0000000000000123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To evaluate the strengths of various surgical knot techniques, including square knot, surgeon's knot, granny knot, and random knot with the same three throws. METHODS The authors tested each of the four knot techniques using four different gauges of nylon (polyamide [Ethicon]): 4-0, 5-0, 6-0, and 7-0. Each knot type was tested 20 times per nylon gauge, for a total of 320 knots tested. The authors used a static pull machine to measure elongation at yield and maximal force to break. RESULTS A comparison of elongation at yield revealed that the surgeon's knot was superior to the square knot, granny knot, and random knots across all gauges of nylons. Further, a comparison of maximal force to break revealed that the surgeon's knot was superior to the square knot, granny knot, and random knots when using 4-0, 5-0, and 6-0 nylon but not when using 7-0 nylon. CONCLUSIONS The surgeon's knot was the strongest, and random knot was the weakest when the authors used nylon 4-0, 5-0, and 6-0. While handling fine suture materials such as 7-0 nylon, knot failure appears to be unrelated to the knot technique used. This study provides not only fundamental guidance for tying surgical knots using nylon, but also a rational basis for an adequately strong knot choice in various fields of surgery.
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Affiliation(s)
- SooA Lim
- At DongGuk University International Hospital, DongGuk University School of Medicine, Seoul, South Korea, SooA Lim, MD, PhD, is Associate Professor, Department of Plastic and Reconstructive Surgery; Dong Yun Lee, MD, is Chief Resident, Department of Plastic and Reconstructive Surgery; GyeongHyeon Doh, MD, is Resident, Department of Plastic and Reconstructive Surgery; YeongKwon Seo, PhD, is Professor, Department of Biosystems; ChiYeon Lim, PhD, is Professor, Department of Statistics; JungSoo Yoon, MD, PhD, is Assistant Professor, Department of Plastic and Reconstructive Surgery; and SuRak Eo, MD, PhD is Professor, Department of Plastic and Reconstructive Surgery
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Guo HF, Hou XY, Dai WW, Liao DZ, Wen C. Influence of pulling direction on knot security: A laboratory research. Asian J Surg 2024; 47:420-424. [PMID: 37770357 DOI: 10.1016/j.asjsur.2023.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND When tying knots, some surgeons do not pay particular attention to the direction in which they pull to lay down throws. We examine to what extent does pulling direction influence on knot security. METHODS A total of 368 residents were instructed to tie knots with from 2 to 7 throws using silk braided suture in 3-0 gauge. The direction in which they pulled to lay down throws was recorded. Only the knots tied either by pulling in alternate directions (Group A) or in constant direction (Group C) from the first throw to the last were involved in statistical analysis. Tensile strength and untying rate of the knots were then measured for comparative analysis. RESULTS For knots with from 2 to 7 throws, the tensile strength of the ones from Group A was significantly higher than that of the ones from Group C (p < 0.05), respectively. For knots with from 5 to 7 throws, the untying rate of the ones from Group A was significantly lower than that of the ones from Group C (p < 0.05), respectively. For the unraveled knots with from 2 to 7 throws (except for the ones with 5 throws), the tensile strength of the ones from Group A was significantly higher than that of the ones from Group C (p < 0.05), respectively. CONCLUSION Pulling in constant direction results in inferior knot security. Surgeons must ascertain the influence of pulling direction on knot security, and try to achieve superior security with fewer throws to ensure patient safety.
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Affiliation(s)
- Hong-Feng Guo
- Department of Basic Operative Surgery, College of General Medicine, The First Affiliated Hospital of Army Medical University, China.
| | - Xiao-Yu Hou
- Department of Basic Operative Surgery, College of General Medicine, The First Affiliated Hospital of Army Medical University, China
| | - Wei-Wei Dai
- Department of Basic Operative Surgery, College of General Medicine, The First Affiliated Hospital of Army Medical University, China
| | - De-Zhi Liao
- Department of Basic Operative Surgery, College of General Medicine, The First Affiliated Hospital of Army Medical University, China
| | - Can Wen
- Department of Basic Operative Surgery, College of General Medicine, The First Affiliated Hospital of Army Medical University, China.
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Tobias K, Mulon PY, Daniels A, Sun X. Does quality of novice hand-tied square knots improve with repetition during a single training session? PeerJ 2022; 10:e14106. [PMID: 36187746 PMCID: PMC9521345 DOI: 10.7717/peerj.14106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/01/2022] [Indexed: 01/21/2023] Open
Abstract
Background Knot tying is a key surgical skill for novices, and repetition over several training sessions improves knot tying. This study examined the effects of repetition within a single training session on quality of knotted loops and compared results of novice trainees and experienced surgeons. Methods Using 0.55 mm nylon monofilament fishing line, novices and surgeons each hand-tied 20 knotted loops, using a 2=1=1=1 configuration (surgeon's throw and three square throws). Loops were mechanically tested with a single load to failure. Results All loops tolerated five newtons (N) preload. More than 70% of novice and surgeon knots failed by slipping or untying, and 8.8% of novice knots and 2.5% of surgeon's knots were considered dangerous. Surgeons' loops had less extension at preload, indicating better loop security. However, during single test to failure, there was no difference in mean extension or maximum load between surgeons and novices. There was no significant difference in results of mechanical testing or modes of failure for the first and last ten knotted loops, or the first, second, third, and fourth sets of knotted loops. Discussion With appropriate training, novices can construct knots as strong and secure as experienced surgeons. A large percentage of knotted loops are insecure under testing conditions; extra throws may be required when using large diameter monofilament nylon. Novices may require extra training in maintenance of loop security when constructing square knots. Tying more than five or 10 knotted loops within a single training session does not provide added benefits for novices.
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Affiliation(s)
- Karen Tobias
- Small Animal Clinical Sciences, University of Tennessee, Knoxville, Knoxville, TN, United States of America
| | - Pierre-Yves Mulon
- Department of Large Animal Clinical Sciences, University of Tennessee, Knoxville, Knoxville, TN, United States of America
| | - Alec Daniels
- Small Animal Clinical Sciences, University of Tennessee, Knoxville, Knoxville, TN, United States of America
| | - Xiaocun Sun
- Office of Information Technology, University of Tennessee Knoxville, Knoxville, TN, United States of America
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Abullais SS, AlOsman SS, AlQahtani SM, Khan AA, Nahid R, Basheer SA, Jameel AS. Effect of Common Mouthwashes on Mechanical Properties of Suture Materials Used in Dental Surgeries: A Laboratory Experiment. Polymers (Basel) 2022; 14:polym14122439. [PMID: 35746015 PMCID: PMC9227470 DOI: 10.3390/polym14122439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/25/2022] [Accepted: 06/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Sutures play a pivotal role in promoting healing in any surgical procedure. However, the versatile nature of the oral environment entails additional properties in the suture materials to assure uneventful healing. A surgeon needs to understand these delicate intricacies in the immediate postoperative phase and needs some kind of algorithm in the selection of sutures that suits the different surgical scenarios. Therefore, a study was designed to observe the effect of four different types of mouthwash, viz. Avohex, Aloedent, Parodontax and Betadine, on the mechanical properties of Vicryl (polyglactin 910), PTFE (polytetrafluoroethylene), Prolene (polypropylene) and Mersilk. Methods: A total of 288 suture samples were divided in four equal groups (72 = each group) and used for the experiments. Tensile load, tensile strength as well as percentage elongation of the suture materials were evaluated in the various stated media at 3rd, 7th, 10th and 14th days, which were compared with the controls. The results were analyzed statistically and inferences were drawn. Results: Mersilk in (Avohex, Parodontax and Betadine) solutions showed a statistically significant decrease in tensile load over time. All the sutures had the highest tensile strength in Parodontax and had the lowest in Betadine solution. Vicryl and PTFE presented significant percentage elongation over time as compared to Prolene and Mersilk. Conclusion: The author has given certain recommendations but also states that there is no standard rule for the use of a particular suture material in all clinical situations. However, the selection of the suture material should be based on the type of surgery and preferences of the surgeon.
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Affiliation(s)
- Shahabe Saquib Abullais
- Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia;
| | - Shaker Saleh AlOsman
- Inters, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (S.S.A.); (S.M.A.)
| | - Sultan Mansoor AlQahtani
- Inters, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia; (S.S.A.); (S.M.A.)
| | - Abdul Ahad Khan
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia;
- Correspondence: ; Tel.: +96-658-3576764
| | - Rakhshinda Nahid
- Department of Periodontology, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India;
| | - Sulphi Abdul Basheer
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha 61421, Saudi Arabia;
| | - Ahmad Saib Jameel
- Department of Prosthetic Dental Sciences, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia;
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Leibowitz R, Lim J, Blalock TW. Demonstrating the cotton-tipped applicator method to standardize dermatologic surgery suture tail length. JAAD Int 2022; 7:131-132. [PMID: 35497639 PMCID: PMC9043372 DOI: 10.1016/j.jdin.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Drabble E, Spanopoulou S, Sioka E, Politaki E, Paraskeva I, Palla E, Stockley L, Zacharoulis D. How to tie dangerous surgical knots: easily. Can we avoid this? BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2022; 3:e000091. [PMID: 35047808 PMCID: PMC8749257 DOI: 10.1136/bmjsit-2021-000091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/23/2021] [Indexed: 11/04/2022] Open
Abstract
Objective Secure knots are essential in all areas of surgical, medical and veterinary practice. Our hypothesis was that technique of formation of each layer of a surgical knot was important to its security. Design Equal numbers of knots were tied, by each of three groups, using three techniques, for each of four suture materials; a standard flat reef knot (FRK), knots tied under tension (TK) and knots laid without appropriate hand crossing (NHCK). Each knot technique was performed reproducibly, and tested by distraction with increasing force, till each material broke or the knot separated completely. Setting Temporary knot tying laboratory. Materials The suture materials were, 2/0 polyglactin 910 (Vicryl), 3/0 polydioxanone, 4/0 poliglecaprone 25 (Monocryl) and 1 nylon (Ethilon). Participants Three groups comprised, a senior surgeon, a resident surgeon and three medical students. Outcome measures Proportion of each knot type that slipped, degree of slippage and length of suture held in loop secured by each knot type. Results 20% of FRK tied with all suture materials slipped; all knots tied with the other two techniques, with all materials, slipped, TK (100%) and NHCK (100%). The quantitative degree of slip was significantly less for FRK (mean 6.3%–, 95% CI 2.2% to 10.4%) than for TK (mean 312%, 95% CI 280.0% to 344.0%) and NHCK (mean 113.0%, –95% CI 94.3% to 131.0%). The mean length of suture in loops held within (FRK mean 25.1 mm 95% CI 24.2 to 26.0 mm) was significantly greater than mean lengths held by the other techniques (TK mean 17.0 mm, 95% CI 16.3 to 17.7 mm), (NHCK mean 16.3 mm, 95% CI 15.9 to 16.7 mm). The latter two types of knot may have tightened more than anticipated, in comparison to FRK, with potential undue tissue tension. Conclusion Meticulous technique of knot tying is essential for secure knots, appropriate tissue tension and the security of anastomoses and haemostasis effected.
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Affiliation(s)
- Eric Drabble
- Clinical lead BSS course RCS England, Consultant Surgeon (retired), University ofPlymouth Hospitals NHS Trust, Plymouth, UK.,Royal College of Surgeons of England, London, London, UK.,Surgical Directorate, University of Plymouth Hospitals NHS Trust, Derriford Hospital, PlymouthPL6, Greece
| | - Sofia Spanopoulou
- Department of Plastic Surgery, Hopital Universitaire Henri Mondor, Paris, France
| | - Eleni Sioka
- Department of Surgery, IASO Hospital Thessalias, Larissa, Greece
| | - Ellie Politaki
- Surgical clinic B, General Hospital Georgios Gennimatas, Athens, Greece
| | - Ismini Paraskeva
- Department of General Surgery, University Hospital of Larissa, Mezourlo, Greece
| | - Effrosyni Palla
- Department of Otorhinolaryngology, University Hospital of Larissa, Mezourlo, Greece
| | - Lauren Stockley
- Department of Statistical Analysis, University of Plymouth, Plymouth, Devon, UK
| | - Dimitris Zacharoulis
- Department of Surgery, IASO Hospital Thessalias, Larissa, Greece.,Department of General Surgery, University Hospital of Larissa, Mezourlo, Greece
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Demars C, Minier K, Boland L. Lung perforation caused by suture ends as a complication of lung lobectomy in a dog. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Claire Demars
- Oncovet Veterinary Clinic of Referrals Villeneuve d'Ascq France
- Nordvet Veterinary Hospital Centre La Madeleine France
| | - Kévin Minier
- Oncovet Veterinary Clinic of Referrals Villeneuve d'Ascq France
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Ensminger WP, McIff T, Vopat B, Mullen S, Schroeppel JP. Mechanical Comparison of High-Strength Tape Suture Versus High-Strength Round Suture. Arthrosc Sports Med Rehabil 2021; 3:e1525-e1534. [PMID: 34712990 PMCID: PMC8527324 DOI: 10.1016/j.asmr.2021.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/16/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose To compare knot and loop characteristics of commonly used high-strength tapes and high-strength round sutures. Methods Twenty tied 30-mm loops were prepared for using suture-knot combinations of 4 common arthroscopic knots or a hand-tied surgeon’s knot and 7 sutures. Two tapes (BroadBand, SutureTape) and three no. 2 sutures (MaxBraid, FiberWire, DynaCord) were compared. Two additional larger tape sutures (FiberTape, PermaTape) not commonly tied arthroscopically were included in the hand-tied group. Each suture-knot combination was evaluated for loop integrity (single load to a specified elongation), knot security (plastic loop deformation with cyclic testing), loop security, and knot volume. Data were compared using analysis of variance followed by Tukey-Kramer post hoc tests. Results BroadBand and SutureTape demonstrated superior loop integrity compared to most no. 2 suture-knot combinations. FiberTape (430.48 ± 89.00 N) and PermaTape (545.16 ± 95.09 N) required significantly greater force to undergo 3 mm of displacement than all other hand-tied sutures (P < .001). All suture-knot configurations demonstrated significant plastic deformation (cyclic elongation) over 1000 cycles (P < 0.001). DynaCord displayed the best loop security except when paired with the Duncan loop. Overall, BroadBand and SutureTape had lower knot volumes compared to all other sutures. Conclusion This study exhibits the ability of narrow tape sutures to provide reliable tissue apposition and fixation in multiple suture-knot configurations, while decreasing the potential adverse effects accompanying knot prominence. Generally, BroadBand and SutureTape demonstrated an ideal balance of mechanical characteristics to achieve the optimal suture-knot construct among those tested. Dynacord displayed superior loop security and performed best among round sutures. PermaTape and FiberTape showed greater loop integrity, albeit to the detriment of loop security and knot volume. Clinical Relevance When securing a rotator cuff repair construct with a knot, one should have a basic understanding of the mechanical properties of the suture and knot being used to provide the best possible repair. This study will provide information about the mechanical characteristics of commonly used high-strength tape suture knots and loops to help determine what knot type may provide the best overall construct.
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Affiliation(s)
- William P Ensminger
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Terence McIff
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Bryan Vopat
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Scott Mullen
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - J Paul Schroeppel
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, United States
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Jayasuriya NSS, Ratnapreya S, Kapugama K, Medawela RMSHB. Comment on "Why Is Mandibular Third Molar Coronectomy Successful Without Concurrent Root Canal Treatment?". J Oral Maxillofac Surg 2021; 79:737-738. [PMID: 33450193 DOI: 10.1016/j.joms.2020.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 11/17/2022]
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Conway RG, O'Neill N, Brown J, Kavic S. An educated guess - Distance estimation by surgeons. Surg Open Sci 2020; 2:113-116. [PMID: 33981983 PMCID: PMC8083008 DOI: 10.1016/j.sopen.2020.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Estimating distance is a common task in surgery, yet development of distance estimation ability receives little attention in surgical training. Although the Small bites versus large bites for closure of abdominal midline incisions (STITCH) trial reinforced the importance of suture spacing by demonstrating reduced incisional hernia incidence in placement of 5-mm fascial sutures over 1 cm, we hypothesize that neither trainee nor attending surgeons possess the ability to estimate these distances with accuracy. Methods We distributed a 4-question distance estimation exercise and a 6-question survey to resident and attending surgeons at a single academic medical center. The mean and the absolute error were compared using a t test. Results Most participants were trainees (44 vs 16 attendings, N = 60), and 27% used the metric system prior to undergraduate studies. The mean absolute errors for 5-mm and 1-cm mark placement were 1.40 and 2.07 mm, respectively. The 5-mm mark placement estimates ranged from 2.01 to 11.69 mm, and the 1-cm estimates ranged from 4.82 to 19.19 mm. There was no statistically significant difference in the estimates or absolute errors between trainees and attendings (5 mm P = .202; 1 cm P = .302). Conclusion These findings suggest that estimation of distance is a challenge, and development of this fundamental skill during surgical training may have important clinical consequences.
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Affiliation(s)
- R Gregory Conway
- University of Maryland, Department of Surgery, Baltimore, MD, USA
| | - Natalie O'Neill
- University of Maryland, Department of Surgery, Baltimore, MD, USA
| | - Jessica Brown
- University of Maryland, Department of Epidemiology and Public Health, Baltimore, MD, USA
| | - Stephen Kavic
- University of Maryland, Department of Surgery, Baltimore, MD, USA
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Varma SR, Jaber M, Fanas SA, Desai V, Al Razouk AM, Nasser S. Effect of Hyaluronic Acid in Modifying Tensile Strength of Nonabsorbable Suture Materials: An In Vitro Study. J Int Soc Prev Community Dent 2020; 10:16-20. [PMID: 32181217 PMCID: PMC7055341 DOI: 10.4103/jispcd.jispcd_343_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/01/2019] [Indexed: 11/28/2022] Open
Abstract
Background and Aims: In periodontics and other surgical disciplines, sutures play a detrimental role in healing of wound. The use of chemical adjuncts to boost healing has been experimented in recent years. The aim of this study was to evaluate the role of hyaluronic acid rinse in influencing the tensile strengths of commonly used sutures. Materials and Methods: Two commonly used nonabsorbable suture materials, silk and polyamide, were used for this in vitro study. Tensile strengths of the suture materials were determined by pre- and post-immersion in hyaluronic acid (test) and chlorhexidine (control). A Tinius Olsen Universal Testing Machine was used to assess the tensile strength of the samples. The variables were assessed for normality using the Kolmogorov–Smirnov test. The Wilcoxon signed rank test and Mann–Whitney U test (for quantitative data within two groups) were used for quantitative data comparison of all the clinical indicators. The level of significance was set at P ≤ 0.05. Results: Polyamide showed better stability in terms of tensile strength when compared to silk. Hyaluronic acid as a chemical adjunct did not alter the tensile strengths of both suture materials pre- and post-immersion. Conclusion: This in vitro study has shown a promising property of hyaluronic acid with relation to stabilization of tensile strength of suture materials, which needs to be evaluated in clinical settings.
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Affiliation(s)
- Sudhir R Varma
- Department of Periodontics, University of Science and Technology, Fujairah, UAE
| | - Mohammed Jaber
- Department of Oral & Maxillofacial Surgery, Ajman University of Science and Technology, Ajman, UAE
| | - Salim A Fanas
- Department of Periodontics, Ajman University of Science and Technology, Ajman, UAE
| | - Vijay Desai
- Department of Periodontics, Ajman University of Science and Technology, Ajman, UAE
| | - Arij M Al Razouk
- Department of General Dentistry, Ajman University of science and Technology, Ajman, UAE
| | - Sara Nasser
- Department of General Dentistry, Ajman University of science and Technology, Ajman, UAE
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Ge S, Ai L, Erdman AG, Song C. Endoscopic Closure of Large Defects With a Novel Clipping Device and a 4S-Modified Roeder Slipknot. J Med Device 2018. [DOI: 10.1115/1.4039753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Endoscopic closure is an essential procedure in gastrointestinal (GI) surgery, but currently it is difficult to close large defects endoscopically because of the lack of an appropriate device. Previously, we developed an endoscopic clipping device that has multifiring function and is equipped with an independent clamp. The goal of this study is to provide a new closure method with this device and 4S-modified Roeder (4SMR) slipknot. The feasibility of the closure method is examined by deploying two clips during one insertion onto the 4SMR slipknot to close a 5 cm full-thickness linear defect of an ex vivo porcine stomach from the center. Mechanical strengths of clip-knot closure and the slipknot as regards to tensioning forces are also evaluated. Specifically, the mechanical strength of the 4SMR slipknot is verified by mean peak forces to failure, while the knot is tensioning by 2.5, 5, 7.5, and 10 N force (n = 20 for each group), respectively. Experimental results indicate the clip-slipknot closure can withstand a distracting force of 6.3 ± 5.6 N. Tensioning force has a great influence on the mechanical strength of slipknot, with the mean peak force (tensioning force) being 7.1± 6.5, 16.3 ± 9.3, 18.9 ± 10.4, and 24.2 ± 12.0 N, respectively. The proposed closure method can be used for large defects. Tensioning force higher than 5 N is suitable to ensure a stronger 4SMR slipknot.
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Affiliation(s)
- Shuchen Ge
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
- Earl. E. Bakken Medical Devices Center, University of Minnesota, Minneapolis, MN 55455
| | - Liaoyuan Ai
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Arthur G. Erdman
- Earl. E. Bakken Medical Devices Center, University of Minnesota, Minneapolis, MN 55455
| | - Chengli Song
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China e-mail:
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Mistry R, McCleave MJ, Codrington J. Causes of Flexor Tendon Repair Failures in Two Common Repair Techniques: A Cadaver Study. J Hand Surg Asian Pac Vol 2016; 21:333-8. [PMID: 27595950 DOI: 10.1142/s2424835516500302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Flexor tendon repair failures have primarily been attributed to either core suture rupture or core suture pull out. Recent studies have suggested that knot unravelling may also cause failure of a tendon repair. The aim of this study was to investigate the causes of core suture failure in two types of common flexor tendon repairs. METHODS Twenty four cadaver tendons were divided into three groups of eight. Each group tested a specific flexor tendon repair. The repairs tested included an Adelaide repair using 4/0 Ethibond (Ethicon), an Adelaide repair using 4/0 Fiberwire (Arthrex) and the Tsai repair with 4/0 Fiberloop (Arthrex). The repaired tendons were pull-tested to failure. The mechanism of failure, maximum tensile strength and 2 mm gap force were recorded. RESULTS The predominant mode of failure was by the knot unravelling. This occurred in 50-88% of the tendon repairs. The sequence of failure was initiated with gapping at the repair site followed by failure of the epitendinous suture. Next the core suture knot unravels. Once the knot unravels, the suture thread slips out of the tendon resulting in the repair failure. Failures due to knot slippage occurred at a lower maximum tensile strength in Ethibond and Fiberloop sutures than failure due to core rupture or pull out. However, given the small number of tendons tested, this result was not significant. CONCLUSIONS This study has clearly demonstrated one of the main causes of flexor tendon repair failure in two common repair techniques is knot unravelling.
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Affiliation(s)
- Raakhi Mistry
- * Department of Plastic & Reconstructive Surgery, The University of Adelaide, The Royal Adelaide Hospital, Adelaide, Australia
| | - Michael John McCleave
- * Department of Plastic & Reconstructive Surgery, The University of Adelaide, The Royal Adelaide Hospital, Adelaide, Australia
| | - John Codrington
- † Department of Mechanical Engineering, The University of Adelaide, Adelaide, Australia
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Abellán D, Nart J, Pascual A, Cohen RE, Sanz-Moliner JD. Physical and Mechanical Evaluation of Five Suture Materials on Three Knot Configurations: An in Vitro Study. Polymers (Basel) 2016; 8:E147. [PMID: 30979247 PMCID: PMC6432448 DOI: 10.3390/polym8040147] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/21/2016] [Accepted: 03/25/2016] [Indexed: 11/24/2022] Open
Abstract
The aim of this study was to evaluate and compare the mechanical properties of five suture materials on three knot configurations when subjected to different physical conditions. Five 5-0 (silk, polyamide 6/66, polyglycolic acid, glycolide-e-caprolactone copolymer, polytetrafluoroethylene) suture materials were used. Ten samples per group of each material were used. Three knot configurations were compared A.2=1=1 (forward⁻forward⁻reverse), B.2=1=1 (forward⁻reverse⁻forward), C.1=2=1 (forward⁻forward⁻reverse). Mechanical properties (failure load, elongation, knot slippage/breakage) were measured using a universal testing machine. Samples were immersed in three different pH concentrations (4,7,9) at room temperature for 7 and 14 days. For the thermal cycle process, sutures were immersed in two water tanks at different temperatures (5 and 55 °C). Elongation and failure load were directly dependent on the suture material. Polyglycolic acid followed by glycolide-e-caprolactone copolymer showed the most knot failure load, while polytetrafluoroethylene showed the lowest (P < 0.001). Physical conditions had no effect on knot failure load (P = 0.494). Statistically significant differences were observed between knot configurations (P = 0.008). Additionally, individual assessment of suture material showed statistically significant results for combinations of particular knot configurations. Physical conditions, such as pH concentration and thermal cycle process, have no influence on suture mechanical properties. However, knot failure load depends on the suture material and knot configuration used. Consequently, specific suturing protocols might be recommended to obtain higher results of knot security.
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Affiliation(s)
- Desire Abellán
- Department of Periodontics, School of Dentistry, Universitat Internacional de Catalunya (UIC), Barcelona 08195, Spain.
| | - José Nart
- Department of Periodontics, School of Dentistry, Universitat Internacional de Catalunya (UIC), Barcelona 08195, Spain.
| | - Andrés Pascual
- Department of Periodontics, School of Dentistry, Universitat Internacional de Catalunya (UIC), Barcelona 08195, Spain.
| | - Robert E Cohen
- Department of Periodontics and Endodontics, University at Buffalo, Buffalo 14260, NY, USA.
| | - Javier D Sanz-Moliner
- Department of Periodontics, School of Dentistry, Universitat Internacional de Catalunya (UIC), Barcelona 08195, Spain.
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Comino F, Giusto G, Caramello V, Pagliara E, Bellino C, Gandini M. Ex vivo
comparison of the giant and transfixing knot in equine open and closed castration. Equine Vet J 2016; 48:765-769. [DOI: 10.1111/evj.12546] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 11/24/2015] [Indexed: 11/26/2022]
Affiliation(s)
- F. Comino
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
| | - G. Giusto
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
| | - V. Caramello
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
| | - E. Pagliara
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
| | - C. Bellino
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
| | - M. Gandini
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
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Lee JH, Lee SH. Modified interrupted suturing technique for preventing suture irritation. J Prosthet Dent 2015; 115:129-30. [PMID: 26384533 DOI: 10.1016/j.prosdent.2015.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/11/2015] [Accepted: 06/13/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Ju-Hyoung Lee
- Assistant Professor, Department of Dentistry, Catholic University of Daegu School of Medicine, Daegu, South Korea.
| | - Seung Hyoung Lee
- Clinical Fellow, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Abstract
OBJECTIVE Surgical trainees may tie air knots, which have a questionable tensile strength and rate of untying. The purpose of this study was to determine the effect of an air knot on knot integrity. METHODS The 5 suture materials tested were 0-0 gauge coated polyethylene, polyglyconate, glycolide/lactide, polypropylene, and silk. The suture was tied between 2 hex screws 50 mm on center. The strands were tied using 5 square throws, and the knot tails were cut at 3-mm length. To create a standardized air knot, a round common nail measuring 3 mm in diameter was inserted between throws before tying square throw #3. The suture loop was positioned around the upper and lower hooks of the tensiometer so the location of the knot was roughly equidistant from the hooks. Ultimately, either the loop broke or the knot slipped. At that time, the peak tensile force as well as the outcome of the knot were recorded. RESULTS A total of 480 knots were tied. The presence of an air knot significantly lowered the tension at knot failure in the glycolide/lactide (P = 0.0003), polypropylene (P = 0.0005), and silk (P = 0.0001) knot configurations. Air knots had the same integrity as surgical knots when coated polyethylene and polyglyconate suture were used. Linear regression was performed and identified both suture material (P < 0.0001) and presence of an air knot (P < 0.0001) to be independently associated with a lower tension at failure. CONCLUSIONS Under laboratory conditions, an air knot may contribute to a lower tensile strength at failure for certain suture materials.
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Gandini M, Giusto G, Comino F, Pagliara E. Parallel alternating sliding knots are effective for ligation of mesenteric arteries during resection and anastomosis of the equine jejunum. BMC Vet Res 2014; 10 Suppl 1:S10. [PMID: 25238115 PMCID: PMC4122897 DOI: 10.1186/1746-6148-10-s1-s10] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background In literature only one article describes and compares methods of achieving hemostasis in equine mesenteric arteries during jejunal resection and anastomosis, and most textbooks favor ligating-dividing mechanical devices. The latter method cannot always be used, not least because the devices are expensive and in some cases even contra-indicated. Various types of knots, including sliding knots, are widely used to provide hemostasis in laparoscopy. The objective of this study was to compare a triple ligature for mesenteric vessels composed of three sliding knots with a triple ligature composed of a modified transfixing and two surgeon’s knots. Methods Portions of jejunum with associated mesenteric vessels were collected from 12 horses at a local abattoir. These were divided into 24 specimens containing five mesenteric arteries each. Each artery was closed with a triple ligature. In group A, a surgeon’s knot was used to tie the ligatures (two circumferential and one modified transfixing) while in group B all ligatures (three circumferential) were tied with a parallel alternating sliding knot. Both groups were divided ino two subgroups depending on suture material used (multifilament or monofilament suture material). Time to perform ligatures for every specimen were recorded and compared between groups. After closure, arteries were cannulated and intraluminal pressures were increased until ligature failure. Leaking pressures were recorded and compared between groups. Results Ligation of mesenteric arteries was significantly faster to perform with sliding knots than with surgeon’s knots, both with monofilament and multifilament suture material. With multifilament suture material, the leaking pressure of sliding knot ligatures was significantly higher than that of surgeon’s knot ligatures. With monofilament suture, there were no statistically significant differences in leaking pressure between ligature methods. Both ligating methods were stronger with monofilament suture material than with multifilament suture material. Conclusions Regardless of the ligature used, monofilament suture material performed better than multifilament suture material to achieve hemostatic knots. Independently of the suture material, the sliding knot is comparable or better than the surgeon’s knot in providing hemostasis, and is faster to perform.
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20
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Zhao C, Hsu CC, Moriya T, Thoreson AR, Cha SS, Moran SL, An KN, Amadio PC. Beyond the square knot: a novel knotting technique for surgical use. J Bone Joint Surg Am 2013; 95:1020-7. [PMID: 23780540 PMCID: PMC3748986 DOI: 10.2106/jbjs.k.01525] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Knot holding strength is essential to maintain wound closure and ensure tissue contact for healing. Knot unraveling can lead to severe complications, especially for high-tension closures such as tendon repairs, which have recently been reported to have knot unraveling rates as high as 86%. In the current study, a novel surgical knot, the two-strand-overhand locking (TSOL) knot, was designed and mechanically evaluated with use of different suture materials and knot configurations and in actual tendon repairs. METHODS The knot holding strength of the TSOL knot was compared with that of a 4-throw square knot with use of three different suture materials that are in common clinical use. With use of braided polyblend suture, the TSOL knot was also compared with five other surgical knot configurations. Finally, the strength of tendon repairs performed with use of the TSOL knot and a 4-throw square knot was studied. RESULTS Compared with the 4-throw square knot, the holding strength of the TSOL knot was 143% greater for braided polyblend, 216% greater for polydioxanone, and 118% greater for polyester suture, with a significantly lower knot unraveling rate compared with that of the 4-throw square knot regardless of suture material. The TSOL knot holding strength was also greater than that of the other surgical knot configurations. The strength and stiffness of tendon repairs with a TSOL knot were significantly increased over those of repairs with a 4-throw square knot. CONCLUSIONS The TSOL knot provided superior knot holding strength compared with some commonly used surgical knots. CLINICAL RELEVANCE The TSOL knot has potential clinical applications, especially when knot security is important and high loads are expected, as in tendon or ligament repairs.
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Affiliation(s)
- Chunfeng Zhao
- Biomechanics Laboratory, Department of Orthopaedics (C.Z., C.-C.H., T.M., A.R.T., S.L.M., K.-N.A., P.C.A.), and Biomedical Statistics and Bioinformatics (S.S.C.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Chung-Chen Hsu
- Biomechanics Laboratory, Department of Orthopaedics (C.Z., C.-C.H., T.M., A.R.T., S.L.M., K.-N.A., P.C.A.), and Biomedical Statistics and Bioinformatics (S.S.C.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Tamami Moriya
- Biomechanics Laboratory, Department of Orthopaedics (C.Z., C.-C.H., T.M., A.R.T., S.L.M., K.-N.A., P.C.A.), and Biomedical Statistics and Bioinformatics (S.S.C.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Andrew R. Thoreson
- Biomechanics Laboratory, Department of Orthopaedics (C.Z., C.-C.H., T.M., A.R.T., S.L.M., K.-N.A., P.C.A.), and Biomedical Statistics and Bioinformatics (S.S.C.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Steven S. Cha
- Biomechanics Laboratory, Department of Orthopaedics (C.Z., C.-C.H., T.M., A.R.T., S.L.M., K.-N.A., P.C.A.), and Biomedical Statistics and Bioinformatics (S.S.C.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Steven L. Moran
- Biomechanics Laboratory, Department of Orthopaedics (C.Z., C.-C.H., T.M., A.R.T., S.L.M., K.-N.A., P.C.A.), and Biomedical Statistics and Bioinformatics (S.S.C.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Kai-Nan An
- Biomechanics Laboratory, Department of Orthopaedics (C.Z., C.-C.H., T.M., A.R.T., S.L.M., K.-N.A., P.C.A.), and Biomedical Statistics and Bioinformatics (S.S.C.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Peter C. Amadio
- Biomechanics Laboratory, Department of Orthopaedics (C.Z., C.-C.H., T.M., A.R.T., S.L.M., K.-N.A., P.C.A.), and Biomedical Statistics and Bioinformatics (S.S.C.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
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Muffly TM, Espaillat-Rijo LM, Edwards AM, Horton A. Operating room fatigue: is your twentieth surgical knot as strong as your first? JOURNAL OF SURGICAL EDUCATION 2012; 69:215-217. [PMID: 22365868 DOI: 10.1016/j.jsurg.2011.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 09/14/2011] [Accepted: 09/09/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE This study aimed to determine the tensile strength in a series of 20 consecutively tied knots. Knot tying is a universally used technique in surgical procedures, and as such, knot integrity and security are essential. STUDY DESIGN Twenty was the number of knots chosen as this is the average number of knots required for a vaginal hysterectomy. We used 0-0 gauge, nonexpired, polyglactin 910 to tie 20 knots in succession with less than 20 seconds rest between knots. The knots were tied without a surgeon's knot and 4 additional square knots (1 = 1 = 1 = 1 = 1). The knots were tied by 2 obstetrician/gynecologists investigators over the period of 2 weeks to minimize fatigue. The sutures were then soaked in 0.9% sodium chloride for 60 seconds and subsequently transferred to a Chatillon LTCM-100 tensiometer (Ametek, Largo, Florida) where the tails were cut to 3 mm length. The force required to break the knots was recorded. To detect a difference over time while maintaining power of 80% with a type I error rate of 5%, a minimum of 17 series of knots were needed (thus, 340 total knots after tying 20 knots per series). To buffer against unanticipated variability in the tensile strengths over time, we rounded the number of knot series up to 20, so a total of 400 knots were tied. RESULTS A total of 800 knots were tied. All the sutures broke at the knot and 36% untied. For analyses, the data for each series of knots were collapsed into quarters (ie, knots 1-5, 6-10, 11-15, and 16-20). A repeated-measures analysis of variance found that there were no statistically significant differences between the four quartiles (p = 0.87). A paired samples t-test comparing the first knots in each series with the last knots in each series showed no difference (p = 0.99). Similarly, a paired samples t-test comparing the first 10 knots to the last 10 knots showed no difference over time (p = 0.8). To determine whether there was a change in likelihood of knots coming untied, as more knots were tied, Cochran's Q was used to look across the entire series of 20 knots. This analysis of proportions coming untied revealed no differences over time (p = 0.61). To compare across quarters, a Friedman test was used and similarly showed no change over time (p = 0.92). The different investigators were controlled for in the analysis as a covariate, which turned out to be statistically significant, p = 0.003. CONCLUSIONS Under laboratory conditions, the order of knots tied does not change the tensile strength of the material. This would infer that fatigue does not influence the tensile strength for a series of 20 knots; however, additional studies with a larger number of knots series may be warranted.
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Affiliation(s)
- Tyler M Muffly
- Section of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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22
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Muffly TM, Danford JM, Iqbal I, Barber MD. Assessment of four tissue models on knot tensile strength. JOURNAL OF SURGICAL EDUCATION 2012; 69:13-16. [PMID: 22208825 DOI: 10.1016/j.jsurg.2011.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 06/21/2011] [Accepted: 07/05/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To determine whether the tissue model onto which a knot is tied influences the knot's tensile strength. STUDY DESIGN Zero-gauge, nonexpired, silk, polyglactin 910, polydioxanone, and polypropylene sutures were tied on 4 different mock tissue models. The tissue models were standard metal hex head screw, uncooked chicken breast, a tube of packaged "string" cheese, and a cylinder of bubble wrap. The knots were tied without a surgeon's knot and with 4 additional square knots (1 = 1 = 1 = 1 = 1). The knots were tied by a single obstetrician/gynecologist investigator (J.M.D.) over the period of 1 week to minimize fatigue. We compared the knots when subjected to a tensiometer until the suture broke or untied. A minimum of 20 knots per group were needed to detect a moderate effect size with a power of 85% and a type I error rate of 5%. RESULTS A total of 407 knots were tied with 4 types of material (silk, polyglactin 910, polydioxanone, and polypropylene), using 4 different models (chicken, bubble wrap, cheese, and metal). Among the knot failures, 113 of 407 untied rather than broke (28%). No differences in the likelihood of knots coming untied between the different models (p = 0.34) or tension at failure (p = 0.81) were noted. A 4 × 4 factorial analysis of variance (ANOVA) was conducted to determine the effects of the suture material and model type on tension at failure and whether there was any interaction between the 2 factors. No significant difference was observed in the interaction between suture material and model type (p = 0.35), and no effect for model type was found (p = 0.22). CONCLUSIONS Tissue models that use materials more similar to human tissue do not seem to influence knot strength when compared with standard metal models. We propose that it is possible to have an accurate understanding of how knots withstand force and to simulate an in vivo environment by using low-cost, easily accessible natural and synthetic materials for the mechanism onto which the knot is tied.
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Affiliation(s)
- Tyler M Muffly
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Muffly TM, Couri B, Edwards A, Kow N, Bonham AJ, Paraíso MFR. Effect of petroleum gauze packing on the mechanical properties of suture materials. JOURNAL OF SURGICAL EDUCATION 2012; 69:37-40. [PMID: 22208830 DOI: 10.1016/j.jsurg.2011.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 05/29/2011] [Accepted: 06/27/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To test the tensile properties of knotted suture made of 4 different suture materials and exposed to petroleum gauze. STUDY DESIGN We tested the tensile strength of United States Pharmacopeia size 0-0 gauge polydioxanone, polyglyconate, glycolide/lactide copolymer, and silk when exposed to petroleum packing or saline. Suture materials were randomized, and knots were tied and then evaluated via tensiometer to the point of knot failure. RESULTS A total of 285 knots were tied in 8 groups based on material and exposure to saline or petroleum gauze. We found that petroleum exposure knots failed at a mean of 116.7 N (SD = 31.5) and that saline soaked knots failed at 123.8 N (SD = 32.0). We conducted a 4 × 2 factorial analysis of variance, finding knots exposed to petroleum failed at a statistically significantly lower tensile strengths than saline soaked knots (p = 0.002). CONCLUSION Petroleum-exposed sutures fail at lower tensions than saline-exposed sutures.
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Affiliation(s)
- Tyler M Muffly
- Section of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland 44195 Ohio, USA
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Muffly TM, Kow N, Iqbal I, Barber MD. Minimum number of throws needed for knot security. JOURNAL OF SURGICAL EDUCATION 2011; 68:130-133. [PMID: 21338970 DOI: 10.1016/j.jsurg.2010.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 10/26/2010] [Accepted: 11/07/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE The purpose of the study was to determine the optimal number of throws to ensure knot security. STUDY DESIGN Knots were tied with 3, 4, 5, or 6 square throws with 0-gauge coated polyester, polydioxanone, polypropylene, and polyglactin 910. The suture was soaked in 0.9% sodium chloride and subsequently transferred to a tensiometer and broken. RESULTS A total of 225 knots were tied. Regardless of the suture type, tension at failure for knots with 4 throws, 5 throws, and 6 throws was higher than tension at failure of knots with only 3 throws (p < 0.05 for each). We found no difference in the tensile strength between knots with 4, 5, or 6 throws (p > 0.05 for each). Knots with 4 throws were significantly more likely to come untied than knots with 5 or 6 throws (p < 0.01). CONCLUSIONS Under laboratory conditions, the ideal knot has 5 throws to maximize tensile strength and rate of untying. This finding does not seem to vary by type of suture material.
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Affiliation(s)
- Tyler M Muffly
- Center for Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Muffly TM, Baquero P, Bonham AJ. Knot integrity as a function of suture expiration. JOURNAL OF SURGICAL EDUCATION 2011; 68:29-31. [PMID: 21292212 DOI: 10.1016/j.jsurg.2010.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 09/30/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To test the integrity of knots tied with expired suture and non-expired suture, using 5 different suture materials. STUDY DESIGN Knots were tied using expired and non-expired chromic catgut, polyglactin 910, polydioxanone, silk, or coated polyester. Expired sutures were a mean of 10.5 years past the date of expiration stamped on the packaging. Suture packaging was inspected for any flaws or humidity. There were 116 knots with expired suture and 109 non-expired knots. All knots were tied by hand. Suture was soaked in 0.9% sodium chloride for 60 seconds and subsequently transferred to a tensiometer where the tails of the knots were cut to 3 mm length. We compared the tensile strength of knots using a tensiometer to pull the knots until the suture broke or untied. A minimum of 30 knots were needed in order to detect a statistically significant main effect for expired and non-expired sutures with 80% power and a 5% chance of type I error. RESULTS A total of 225 knots were tied. Overall, we found no difference in mean tension between expired suture (77.5 ± 31.7 N) and non-expired suture at failure (81.9 ± 30.2 N). All the sutures broke at the knot and none untied. Expired chromic and polydioxanone were significantly weaker than the non-expired suture of the same material (p = 0.002 and p = 0.001, respectively). There was no statistically significant difference in tensile strength between expired absorbable or permanent suture materials. Based on a univariate analysis of variance ([SCAP]ANOVA)[R] there was no difference in the tension at failure between expired and non-expired sutures with suture packet as a covariate. No suture untied when knotted with expired suture. CONCLUSIONS Under laboratory conditions, expired chromic and polydioxanone sutures broke at lower tensile strength than non-expired sutures of the same material.
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Affiliation(s)
- Tyler M Muffly
- Center of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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26
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Muffly TM, Boyce J, Kieweg SL, Bonham AJ. Tensile strength of a surgeon's or a square knot. JOURNAL OF SURGICAL EDUCATION 2010; 67:222-6. [PMID: 20816357 PMCID: PMC4167833 DOI: 10.1016/j.jsurg.2010.06.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 06/07/2010] [Accepted: 06/15/2010] [Indexed: 05/14/2023]
Abstract
OBJECTIVE To test the integrity of surgeon's knots and flat square knots using 4 different suture materials. STUDY DESIGN Chromic catgut, polyglactin 910, silk, and polydioxanone sutures were tied in the 2 types of knot configurations. For all sutures, a 0-gauge United States Pharmacopeia suture was used. Knots were tied by a single investigator (J.B.). The suture was soaked in 0.9% sodium chloride for 60 s and subsequently transferred to a tensiometer where the tails were cut to 3-mm length. We compared the knots, measuring knot strength with a tensiometer until the sutures broke or untied. RESULTS A total of 119 throws were tied. We found no difference in mean tension at failure between a surgeon's knot (79.7 N) and a flat square knot (82.9 N). Using a chi(2) test, we did not find a statistically significant difference in the likelihood of knots coming untied between surgeon's knots (29%) and flat square knots (38%). CONCLUSIONS Under laboratory conditions, surgeon's knots and flat square knots did not differ in tension at failure or in likelihood of untying.
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Affiliation(s)
- Tyler M Muffly
- Center of Urogynecology and Pelvic Floor Disorders, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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