Purpose
To validate basic competency in arthroscopic knot tying using a unique simulator device
to compare the level of training needed for learning and tying the arthroscopic knot
by evaluating the tensile properties of the arthroscopic knots.
Methods
Three groups of surgeons of various experience levels (postgraduate year [PGY] 1,
PGY 3, and experienced surgeons) tied 2 different arthroscopic knots (Tennessee Slider,
considered easier, and Weston, considered more difficult) over a 10-week period. Each
group went through 3 separate stages of knot tying: stage 1, tying 8 knots without
cannula or knot pusher; stage 2, tying 12 knots with knot pusher; and stage 3, tying
20 knots with knot pusher through a cannula that simulates knot tying during surgery.
A single load-to-failure test was performed and ultimate clinical failure loads were
recorded. Time needed to tie each knot was also recorded.
Results
At stages 1 and 2, the PGY 1 group had a significantly weak knot tensile strength
(Tennessee Slider stage 1: 60 v 129 N, P = .001; Tennessee Slider stage 2: 69 v 132 N, P = .0029; Weston stage 1: 73 v 184 N, P = .0000; Weston stage 2: 125 v 173 N, P = .0045) and were slower (Weston: 56 v 30 seconds, P = .0010) than the experienced surgeon group for both knots. At stage 3, only the
initial 2 weeks of Tennessee Slider showed a significant difference between groups
1 and 3 (week 6: 87 v 118 N, P = .0492; week 7: 89 v 126, P = .01485). Even though the Tennessee Slider knot is one of the easier arthroscopic
knots to learn to tie, the results showed a slow trend of improvement in this knot-tying
skill for group 1 after each stage.
Conclusions
The data validated an important learning effect in all trainees in arthroscopic knot
tying over a 10-week period and showed that inexperienced trainees will be able to
improve their knot-tying skill with training in 3 stages with a simulator environment.
Clinical Relevance
The findings of this study indicated the importance of hands-on experience in performing
arthroscopic knot tying, as determined by both knot performance and ultimate suture
loop strength. In addition, each orthopaedic resident learned and developed his or
her arthroscopic knot-tying skills and provided a foundation for his or her future
practice in orthopaedic medicine.
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References
- Ease of tying arthroscopic knots.J Shoulder Elbow Surg. 2007; 16: 438-442
- Significance of the internal locking mechanism for loop security enhancement in the arthroscopic knot.Arthroscopy. 2001; 17: 850-855
- Pullout strength of knotless suture anchors.Arthroscopy. 2005; 21: 81-85
- Elongation of arthroscopically tied knots.Am J Sports Med. 1997; 25: 113-117
- Knot security: How many throws does it really take?.Orthopedics. 2012; 35: e532-e537
- The outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique.J Bone Joint Surg Am. 2007; 89: 1533-1541
- Arthroscopic rotator cuff repair with double row fixation.J Bone Joint Surg Am. 2007; 89: 1248-1257
- Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study.J Bone Joint Surg Am. 2007; 89: 953-960
- The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears.J Bone Joint Surg Am. 2004; 86: 219-224
- Arthroscopic repair of full-thickness tears of the rotator cuff: 2- to 14-year follow-up.Arthroscopy. 2002; 18: 136-144
- Knot strength varies widely among expert arthroscopists.Am J Sports Med. 2014; 42: 1978-1984
- Metric development for an arthroscopic bankart procedure: Assessment of face and content validity.Arthroscopy. 2015; 31: 1430-1440
- The Bankart performance metrics combined with a shoulder model simulator create a precise and accurate training tool for measuring surgeon skill.Arthroscopy. 2015; 31: 1639-1654
- 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
- Magellan and Copernicus: Arthroscopy Association of North America seeking excellence in education.Arthroscopy. 2015; 31: 1428-1429
- Virtual reality simulation for the operating room: Proficiency-based training as a paradigm shift in surgical skills training.Ann Surg. 2005; 241: 364-372
- Objective assessment of knot-tying proficiency with the fundamentals of arthroscopic surgery training program workstation and knot tester.Arthroscopy. 2015; 31: 1872-1879
- Arthroscopic knot typing techniques.Arthroscopy. 1999; 15: 515-521
- Failure characteristics of various arthroscopically tied knots.Clin Orthop Relat Res. 2003; 408: 311-318
- Arthroscopic suture tying: A comparison of knot types and suture materials.Arthroscopy. 2001; 17: 348-352
- The SMC knot—A new slip knot with locking mechanism.Arthroscopy. 2000; 16: 563-565
- Nicky's knot—A new slip knot for arthroscopic surgery.Arthroscopy. 1998; 14: 109-110
- Technical note: A “new” arthroscopic sliding knot.Orthop Clin North Am. 2001; 32: 525-526
- The giant knot: A new one-way self-locking secured arthroscopic slip knot.Arthroscopy. 1999; 15: 451-452
- The double-twist knot: A new arthroscopic sliding knot.Arthroscopy. 2002; 18: 815-820
- Evaluation of 5 knots and 2 suture materials for arthroscopic rotator cuff repair: Very strong sutures can still slip.Arthroscopy. 2006; 22: 38-43
- The DMD knot: A new locking, flip knot.J Surg Orthop Adv. 2008; 17: 115-118
- Biomechanical performance of traditional arthroscopic knots versus slippage-proof knots.Arthroscopy. 2013; 29: 1175-1181
- The slippage-proof knot: A new, nonstacking, arthroscopic, sliding locking knot with a lag bight.Orthopedics. 2007; 30: 349-350
- A new clinch knot.Obstet Gynecol. 1991; 78: 144-147
- A comparison of operative times in arthroscopic ACL reconstruction between orthopaedic faculty and residents: The financial impact of orthopaedic surgical training in the operating room.Iowa Orthop J. 2001; 21: 31-35
- The financial impact of teaching surgical residents in the operating room.Am J Surg. 1999; 177: 28-32
- How much guidance is given in the operating room? Factors influencing faculty self-reports, resident perceptions, and faculty/resident agreement.Surgery. 2014; 156: 797-803
- Teaching in the operating room: Results of a national survey.J Surg Educ. 2012; 69: 643-649
- Simulation for teaching orthopaedic residents in a competency-based curriculum: Do the benefits justify the increased costs?.Clin Orthop Relat Res. September 3, 2015; ([Epub ahead of print])
- Shoulder arthroscopy simulator performance correlates with resident and shoulder arthroscopy experience.J Bone Joint Surg Am. 2012; 94: e160
- Arthroscopic basic task performance in shoulder simulator model correlates with similar task performance in cadavers.J Bone Joint Surg Am. 2011; 93: e1271-e1275
- Individual skill progression on a virtual reality simulator for shoulder arthroscopy: A 3-year follow-up study.Am J Sports Med. 2008; 36: 1139-1142
- Simulation in orthopaedic education: An overview of theory and practice.J Bone Joint Surg Am. 2006; 88: 1405-1411
- Arthroscopic knots: Determining the optimal balance of loop security and knot security.Arthroscopy. 2004; 20: 489-502
- In vitro and in situ characterization of arthroscopic loop security and knot security of braided polyblend sutures: A biomechanical study.Am J Orthop (Belle Mead NJ). 2015; 44: 176-182
- Knot security, loop security, and elongation of braided polyblend sutures used for arthroscopic knots.Am J Orthop (Belle Mead NJ). 2010; 39: 569-576
- Loop securities of arthroscopic sliding-knot techniques when the suture loop is not evenly tensioned.Arthroscopy. 2013; 29: 1380-1386
- Optimizing arthroscopic knots.Arthroscopy. 1995; 11: 199-206
- A comparison of ultrasonic suture welding and traditional knot tying.Am J Sports Med. 2001; 29: 297-299
- Technical considerations in manual and instrument tying techniques.J Emerg Med. 1992; 10: 469-480
- Influence of emergency physician's tying technique on knot security.J Emerg Med. 1992; 10: 309-316
- Optimizing arthroscopic knots using braided or monofilament suture.Arthroscopy. 1998; 14: 57-65
- Optimization of stacked half-hitch knots for arthroscopic surgery.Arthroscopy. 2001; 17: 752-759
- Arthroscopic sliding knot: How many additional half-hitches are really needed?.Arthroscopy. 2005; 21: 405-411
- Knot security in simple sliding knots and its relationship to rotator cuff repair: How secure must the knot be?.Arthroscopy. 2000; 16: 202-207
- Cyclic testing of arthroscopic knot security.Arthroscopy. 2004; 20: 62-68
- Loop security as a determinant of tissue fixation security.Arthroscopy. 1998; 14: 773-776
- Optimal configuration of arthroscopic sliding knots backed up with multiple half-hitches.Knee Surg Sports Traumatol Arthrosc. 2008; 16: 787-793
- Optimization of the racking hitch knot: How many half hitches and which suture material provide the greatest security?.Clin Orthop Relat Res. 2014; 472: 1930-1935
- How to switch posts without rethreading when tying half-hitches.Arthroscopy. 1999; 15: 444-450
- 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.e13
Article Info
Publication History
Published online: April 23, 2016
Accepted:
January 18,
2016
Received:
June 1,
2015
Footnotes
The authors report the following potential conflict of interest or source of funding: This study did receive suture materials from DePuy Mitek (Warsaw, IN) for use in this study. However, DePuy Mitek had no role in the collection, analysis, and interpretation of data, writing of the manuscript, or decision to submit the manuscript for publication. This study also did not receive any payments or other personal benefits or a commitment or agreements that were related in any way to the subject of the research that we conducted in connection with the research.
Investigation performed at the Via Christi Health–Orthopaedic Research Institute at Wichita, KS, U.S.A.
See commentary on page 1400
Identification
Copyright
© 2016 by the Arthroscopy Association of North America
