Original Article| Volume 31, ISSUE 10, P1872-1879, October 2015

Objective Assessment of Knot-Tying Proficiency With the Fundamentals of Arthroscopic Surgery Training Program Workstation and Knot Tester


      To assess a new method for biomechanical assessment of arthroscopic knots and to establish proficiency benchmarks using the Fundamentals of Arthroscopic Surgery Training (FAST) Program workstation and knot tester.


      The first study group included 20 faculty at an Arthroscopy Association of North America resident arthroscopy course (19.9 ± 8.25 years in practice). The second group comprised 30 experienced surgeons attending an Arthroscopy Association of North America fall course (17.1 ± 19.3 years in practice). The training group included 44 postgraduate year 4 or 5 orthopaedic residents in a randomized, prospective study of proficiency-based training, with 3 subgroups: group A, standard training (n = 14); group B, workstation practice (n = 14); and group C, proficiency-based progression using the knot tester (n = 16). Each subject tied 5 arthroscopic knots backed up by 3 reversed hitches on alternating posts. Knots were tied under video control around a metal mandrel through a cannula within an opaque dome (FAST workstation). Each suture loop was stressed statically at 15 lb for 15 seconds. A calibrated sizer measured loop expansion. Knot failure was defined as 3 mm of loop expansion or greater.


      In the faculty group, 24% of knots “failed” under load. Performance was inconsistent: 12 faculty had all knots pass, whereas 2 had all knots fail. In the second group of practicing surgeons, 21% of the knots failed under load. Overall, 56 of 250 knots (22%) tied by experienced surgeons failed. For the postgraduate year 4 or 5 residents, the aggregate knot failure rate was 26% for the 220 knots tied. Group C residents had an 11% knot failure rate (half the overall faculty rate, P = .013).


      The FAST workstation and knot tester offer a simple and reproducible educational approach for enhancement of arthroscopic knot-tying skills. Our data suggest that there is significant room for improvement in the quality and consistency of these important arthroscopic skills, even for experienced arthroscopic surgeons.

      Level of Evidence

      Level II, prospective comparative study.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mishra D.K.
        • Cannon Jr., W.D.
        • Lucas D.J.
        • Belzer J.P.
        Elongation of arthroscopically tied knots.
        Am J Sports Med. 1997; 25: 113-117
        • Swan Jr., K.G.
        • Baldini T.
        • McCarty E.C.
        Arthroscopic suture material and knot type: An updated biomechanical analysis.
        Am J Sports Med. 2009; 37: 1578-1585
        • Hanypsiak B.T.
        • DeLong J.M.
        • Simmons L.
        • Lowe W.
        • Burkhart S.
        Knot strength varies widely among expert arthroscopists.
        Am J Sports Med. 2014; 42: 1978-1984
        • Abbi G.
        • Espinoza L.
        • Odell T.
        • Mahar A.
        • Pedowitz R.
        Evaluation of 5 knots and 2 suture materials for arthroscopic rotator cuff repair: Very strong sutures can still slip.
        Arthroscopy. 2006; 22: 38-43
      1. Baums MH, Sachs C, Kostuj T, Schmidt-Horlohé K, Schultz W, Klinger HM. Mechanical testing of different knot types using high-performance suture material. Knee Surg Sports Traumatol Arthrosc in press, available online 13 October, 2013. doi:10.1007/s00167-013-2711-9.

        • Ilahi O.A.
        • Younas S.A.
        • Alexander J.
        • Noble P.C.
        Cyclic testing of arthroscopic knot security.
        Arthroscopy. 2004; 20: 62-68
        • Ilahi O.A.
        • Younas S.A.
        • Ho D.M.
        • Noble P.C.
        Security of knots tied with Ethibond, Fiberwire, Orthocord, or Ultrabraid.
        Am J Sports Med. 2008; 36: 2407-2414
        • Mahar A.T.
        • Moezzi D.M.
        • Serra-Hsu F.
        • Pedowitz R.A.
        Comparison and performance characteristics of 3 different knots when tied with 2 suture materials used for shoulder arthroscopy.
        Arthroscopy. 2006; 22: 614.e1-614.e2
        • Riboh J.C.
        • Heckman D.S.
        • Glisson R.R.
        • Moorman III, C.T.
        Shortcuts in arthroscopic knot tying: Do they affect knot and loop security?.
        Am J Sports Med. 2012; 40: 1572-1577
        • Shah M.R.
        • Strauss E.J.
        • Kaplan K.
        • Jazrawi L.
        • Rosen J.
        Initial loop and knot security of arthroscopic knots using high-strength sutures.
        Arthroscopy. 2007; 23: 884-888
        • Gallagher A.G.
        • Ritter E.M.
        • Lederman A.B.
        • McClusky III, D.A.
        • Smith C.D.
        Video-assisted surgery represents more than a loss of three-dimensional vision.
        Am J Surg. 2005; 189: 76-80
        • Gallagher A.G.
        • Ritter E.M.
        • Champion H.
        • et al.
        Virtual reality simulation for the operating room: Proficiency-based training as a paradigm shift in surgical skills training.
        Ann Surg. 2005; 241: 364-372
        • Gallagher A.G.
        • O’Sullivan G.C.
        Fundamentals of surgical simulation; principles & practices.
        Springer Verlag, London2011
      2. Department of Health. A framework for technology enhanced learning. Available at Published 2011.

      3. Angelo RL, Ryu RKN, Pedowitz RA, et al. A proficiency-based progression training curriculum coupled with a model simulator results in the acquisition of a superior arthroscopic Bankart skill set. Arthroscopy 2015;31:1854-1871.

        • Chan K.C.
        • Burkhart S.S.
        • Thiagarajan P.
        • Goh J.C.
        Optimization of stacked half-hitch knots for arthroscopic surgery.
        Arthroscopy. 2001; 17: 752-759
        • Lo I.K.
        • Burkhart S.S.
        • Chan K.C.
        • Athanasiou K.
        Arthroscopic knots: Determining the optimal balance of loop security and knot security.
        Arthroscopy. 2004; 20: 489-502
        • Burkhart S.S.
        • Wirth M.A.
        • Simonich M.
        • Salem D.
        • Lanctot D.
        • Athanasiou K.
        Knot security in simple sliding knots and its relationship to rotator cuff repair: How secure must the knot be?.
        Arthroscopy. 2000; 16: 202-207
        • Karam M.D.
        • Pedowitz R.A.
        • Natividad H.
        • Murray J.
        • Marsh J.L.
        Current and future use of surgical skills training laboratories in orthopaedic resident education: A national survey.
        J Bone Joint Surg Am. 2013; 95: e4
        • Pedowitz R.A.
        • Marsh J.L.
        Motor skills training in orthopaedic surgery: A paradigm shift toward a simulation-based educational curriculum.
        J Am Acad Orthop Surg. 2012; 20: 407-409
        • Thomas G.W.
        • Johns B.D.
        • Marsh J.L.
        • Anderson D.D.
        A review of the role of simulation in developing and accessing orthopaedic surgical skills.
        Iowa Orthop J. 2014; 34: 181-189
        • Cuschieri A.
        Whither minimal access surgery: Tribulations and expectations.
        Am J Surg. 1995; 169: 9-19
        • Krampe R.T.
        • Ericsson K.A.
        Maintaining excellence: Deliberate practice and elite performance in young and older pianists.
        J Exp Psychol Gen. 1996; 125: 331-359
        • Cheung J.J.
        • Rojas D.
        • Weber B.
        • Kapralos B.
        • Carnahan H.
        • Dubrowski A.
        Evaluation of tensiometric assessment as a measure of skill degradation.
        Stud Health Technol Inform. 2012; 173: 97-101
        • Ching S.S.
        • Mok C.W.
        • Koh Y.X.
        • Tan S.M.
        • Tan Y.K.
        Assessment of surgical trainees’ quality of knot-tying.
        J Surg Educ. 2013; 70: 48-54
        • Horeman T.
        • Blikkendaal M.D.
        • Feng D.
        • et al.
        Visual force feedback improves knot-tying security.
        J Surg Educ. 2014; 71: 133-141
        • Huang E.
        • Chern H.
        • O’Sullivan P.
        • et al.
        A better way to teach knot tying: A randomized controlled trial comparing the kinesthetic and traditional methods.
        Am J Surg. 2014; 208: 690-694
        • Hu Y.
        • Tiemann D.
        • Michael Brunt L.
        Video self-assessment of basic suturing and knot tying skills by novice trainees.
        J Surg Educ. 2013; 70: 279-283
        • Mashaud L.B.
        • Arain N.A.
        • Hogg D.C.
        • Scott D.J.
        Development, validation, and implementation of a cost-effective intermediate-level proficiency-based knot-tying and suturing curriculum for surgery residents.
        J Surg Educ. 2013; 70: 193-199
        • Rodrigues S.P.
        • Horeman T.
        • Sam P.
        • Dankelman J.
        • van den Dobbelsteen J.J.
        • Jansen F.W.
        Influence of visual force feedback on tissue handling in minimally invasive surgery.
        Br J Surg. 2014; 101: 1766-1773
        • van Empel P.J.
        • Verdam M.G.
        • Huirne J.A.
        • Bonjer H.J.
        • Meijerink W.J.
        • Scheele F.
        Open knot-tying skills: Resident skills assessed.
        J Obstet Gynaecol Res. 2013; 39: 1030-1036
        • van Leeuwen N.
        • Trimbos J.B.
        Strength of sliding knots in multifilament resorbable suture materials.
        Gynecol Surg. 2012; 9: 433-437
        • Wong I.H.
        • Denkers M.R.
        • Urquhart N.A.
        • Farrokhyar F.
        Systematic instruction of arthroscopic knot tying with the ArK Trainer: An objective evaluation tool.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 912-918
        • Wong I.H.
        • Denkers M.
        • Urquhart N.
        • Farrokhyar F.
        Construct validity testing of the Arthroscopic Knot Trainer (ArK).
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 906-911
      4. Committee on the Governance and Financing of Graduate Medical Education Board on Health Care Services Institute of Medicine Eden J. Berwick D. Wilensky G. Graduate medical education that meets the nation’s health needs. National Academies Press, Washington, DC2014
        • Asch D.A.
        • Weinstein D.F.
        Innovation in medical education.
        N Engl J Med. 2014; 371: 794-795