Biomechanical evaluation of double stranded knot configurations in high strengths sutures and tapes

Biomechanical evaluation of double stranded knot configurations in high strengths sutures and tapes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Biomechanical evaluation of double stranded knot configurations in high strengths sutures and tapes Mehar Dhillon, Tatjana Pastor, Ivan Zderic, Sarina Hebsacker, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4286165/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose : Recently, a new dynamic high-strength round suture (DC) was introduced featuring a salt-infused silicone core attracting water in a fluid environment to preserve tissue approximation which is also available in tape form (DT). The aims of this study were to (1) assess the influence of securing throw number on knot security of two double-stranded knot configurations (Cow-hitch and Nice-knot) tied with either dynamic (DC and DT) or conventional round sutures (FW) and conventional suture tapes (ST), and (2) compare the ultimate force and knot slippage of (a) Cow-hitch and Nice-knot and (b) DC and DT versus FW and ST when used with their minimal number of needed securing throws. Methods : Seven specimens of each FW, ST, DC and DT were considered for tying with Cow-hitch or Nice-knots. The base of these Cow-hitch and Nice-knots were secured with surgeons’ knots using 1–3 alternating throws. Tensile tests were conducted under physiologic conditions to evaluate knot slippage, ultimate force at rupture, and minimum number of throws ensuring 100% knot security. Results : For both Cow-hitch and Nice-knots, 100 % security was achieved with 2 securing throws for DC, DT, ST, and with 3 securing throws for FW. With these minimum numbers of securing throws, ultimate force was significantly higher for Nice-knots versus Cow-hitch tied with DT (p=0.001) and slippage was significantly less with Nice-knots versus Cow-hitch tied with DC (p=0.019). Conclusions : The minimum number of securing throws required to achieve 100% security was 2 with DC, DT and ST for both with Cow-hitch and Nice-knots configurations, in contrast to FW where 3 securing throws were needed. With these minimum numbers of securing throws, Nice-knots were associated with significantly higher ultimate forces when using DT and lower slippage with DC versus Cow-hitch knots. Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Since the introduction of high-strength sutures to orthopaedic surgery, they are successfully used to repair ligaments, tendons and even bones in various procedures. For many years, the surgeons´ knot has been the gold standard in traditional open techniques ( Figure 1M ). However, in order to enhance reproducibility, knot security, and size, novel suture and knot configurations were required [1]. Compared to the surgeons` knot, double-stranded knots are biomechanically stronger, stiffer, less bulky, and can preserve applied tension during tying better than conventional knots [2]. Therefore, they are suitable in orthopaedic procedures requiring resistance to high tensile forces, e.g., when using cerclage sutures for fracture fixation [3], as well as during tubercle refixation after fracture hemiarthroplasty [4] or lateral clavicle fracture stabilization [5]. Although various double-stranded knot configurations are described in the literature, in a biomechanical study by Meyer et al. reported that Cow-hitch and Nice-knots are the best performing and technically most simple knots, best suited to exploit the enormous mechanical capabilities of modern high-strength suture materials [2] ( Figure 1 ). However, these double-stranded knots need to be secured with surgeons` knots in order to prevent their unraveling, however, as no data exist on how many surgeons’ knots are necessary for this prevention in the current literature, Mayer et al. used 5 securing throws without evaluating the security of using fewer [2]. Besides advances in knot configurations, a technical development took place for conventional round high strength sutures, such as e.g. FibreWire (FW; Arthrex, Munich, Germany). In addition, tapes—such as SutureTape (ST; Arthrex, Munich, Germany)—have been introduced with higher tensile strength increasing both the pressure area of a sutured tendon to the bone and the pullout forces through a sutured tendon [6]. Furthermore, knots tied with this tape are smaller than those with traditional round sutures, reducing the amount of foreign material in the human body. Recently, a new high-strength suture—DynaCord (DC; DePuy Synthes, Zuchwil, Switzerland)—was introduced, also available in tape form—DynaTape (DT; DePuy Synthes, Zuchwil, Switzerland)—featuring a salt-infused silicone core attracting water- in a fluid environment. In the human body, this suture expands radially due to swelling of the core, leading to self-tensioning because of braid shortening. This new dynamic suture technology preserves consistent tissue approximation between the repaired structures and needs fewer throws to achieve 100% knot security in surgeons` knots as compared to the conventional suture material (4 instead of 7 throws) [7]. Therefore, the aims of this study were to (1) assess the influence of securing knot number on knot security of two double-stranded knot configurations—Cow-hitch and Nice-knot—tied with two different high strength round sutures—DC and FW—and two different high strength suture tapes—DT and ST, (2) to compare the biomechanical competence in terms of ultimate force and knot slippage of the novel dynamic suture and suture tape versus the conventional round suture and suture tape (at their minimal number of needed securing throws), and (3) to compare the biomechanical competence in terms of ultimate force and knot slippage of the two double-stranded knot configurations (Cow-hitch and Nice-knot) at their minimal number of needed securing throws. It was hypothesized that (1) the novel dynamic suture and suture tape require less than the proposed 5 securing throws by Meyers at al. to achieve knot security in double stranded knot configurations, (2) tapes require less securing throws than round sutures, and (3) the biomechanical competence of the two double-stranded knot configurations Cow-hitch and Nice-knot are comparable. Methods Specimens and Preparation The four high-strength sutures and tapes were assigned to eight groups combined in two clusters—tape and cord. Group DT was paired with Group ST (cluster tape), and Group DC—with Group FW (cluster cord). Both clusters were further divided in two subgroups considering the two best performing double-stranded knot configurations (Cow-hitch and Nice-knot) as described by Meyer et al. [2]. Each group and subgroup were investigated by knotting the base of the double stranded suture (Cow-hitch or Nice-knot) secured by surgeons’ knots with 1, 2 and 3 alternating throws separately ( Figure 1 ). Seven specimens in each group, subgroup and throw number of securing surgeons’ knots were considered. Accordingly, 168 samples were tested in the current study. All knots were tied by a single surgeon using a custom-made device including a spring scale (Pesola, Schindellegi, Switzerland) with accuracy of 1 N and capacity of 100 N ( Figure 2 ) to ensure a reproducible knot tying force of 50 N. This force was chosen as it demonstrated well seated surgeons’ knots with minimal slippage in a biomechanical investigation [8]. All knots were tied on a custom-made suture holder consisting of 2 roller bearings positioned at 20 mm to minimize friction during biomechanical testing. Propper knot seating was confirmed by visual inspection of every specimen. Subsequently, suture ends were cut at 5 mm to the last throw of the securing surgeons’ knot and two black markings were made on both sides of the suture directly adjacent to the double stranded knot for knot slippage evaluation after biomechanical testing ( Figure 3 ). Prior to testing every specimen was soaked for 24 hours in 200 ml physiologic saline solution at 37.5° mixed with 30 g of subcutaneous human fat obtained from the thigh of a 78-year-old male donor to simulate in-vivo conditions. Mechanical testing Mechanical testing was performed using an electromechanical material testing machine (Instron 5866, Norwood, MA, USA) equipped with a 1 kN load cell. The specimen holder was attached to the base of a custom-made medium container, filled with 200 ml physiologic saline solution at 37.5°C mixed with 30 g of subcutaneous human fat and fixed to the machine base ( Figure 3 ). A third custom-made roller bearing was attached to the machine actuator and hooked under the double stranded suture. All specimens were preloaded at 1 N to allow for settlement of the knots. Subsequently, quasi-static ramped tension was applied by moving the machine actuator at a rate of 0.1 mm/s until failure, the latter defined as either completely unraveling of the knot with total slippage of one suture end or suture rupture. Data acquisition and analysis Machine data in terms of axial load and axial displacement were acquired at a rate of 32 Hz. The ultimate force was determined from the force-displacement curve of each test. Slippage was defined as travelled distance of both markers relative to the base of the double stranded knot. Suture unraveling was defined as total slippage of one suture end through the knot—consequently preventing a suture rupture. Knot security was defined as the percentage of suture ruptures for each group, number of securing surgeons` throws and subgroup without unravelling. The minimum number of throws ensuring 100% knot security in each group and subgroup was registered. By using a digital caliper (Futuro, Brütsch/Rüegger, Urdorf, Switzerland) with an accuracy of 0.01 mm, the slippage distance was evaluated post testing by measuring the travelled distance of both markers relative to the base of the double stranded knot in all specimens demonstrating suture rupture as failure mode after biomechanical testing. In each cluster and subgroup, the ultimate force and slippage distance were compared. No comparison was made between round sutures and tapes as it is well known that tapes are made to resist higher loads until failure [6,9,10]. Statistical analysis was performed with SPSS software package (V27, IBM SPSS Statistics, IBM, Armonk, NY, USA). Differences between the suture types in terms of numbers of throws until achieved knot security were screened with Chi-Squared tests for both suture techniques. Shapiro-Wilk test was used to evaluate and prove normality of the data distribution for scale outcome measures. Outcomes regarding the two suture tapes, two suture materials and two used suture techniques were investigated with One-Way Analysis of Variance (ANOVA) with Bonferroni or Games-Howell post-hoc tests for multiple comparisons. Level of significance was set to 0.05 for all statistical tests. Results Knot security The minimum number of securing throws required to achieve 100% knot security—suture rupture in all 7 specimens—was 2 for DT, ST, and DC for both Cow-hitch and Nice-knots suture configurations. In contrast, 3 securing throws were needed for FW to achieve 100% knot security for both Cow-hitch and Nice-knot suture configurations ( Figure 4 ). All specimens secured with only one surgeons’ knot unraveled during mechanical testing. Ultimate force and slippage The results for ultimate force and slippage of all investigated specimens are summarized in Table 1. Comparing Nice-knot and Cow-hitch suture configurations when using the same material (DT, ST, DC or FW) with equal number of throws (2 or 3), significantly higher ultimate forces were registered for Nice-knots versus Cow-hitch for DT and FW with two throws (p ≤ 0.018), and significantly less slippage was observed for Nice-knots versus Cow-hitch for DC with two throws (p = 0.019), with no further detected significant differences in this regard (p ≥ 0.077). Comparing the influence of 2 versus 3 throws when using the same material to secure either Nice-knots or Cow-hitch suture configuration, significantly higher ultimate forces were registered for Nice-knots with FW and for Cow-hitch with either DT or FW secured with 3 throws (p ≤ 0.002), whereas significantly less slippage was observed for both Nice-knot and Cow-hitch with DT or FW secured with 3 throws (p ≤ 0.005), with no further detected significant differences in this regard (p ≥ 0.090). Comparing the influence of the dynamic (DT or DC) versus the corresponding conventional (ST or FW, respectively) suture material tied with equal number of throws (2 or 3), significantly higher ultimate forces were registered for Nice-knots with DT secured with 3 throws and DC secured with 2 or 3 throws, as well as for Cow-hitch with DC secured with 2 or 3 throws (p ≤ 0.048), whereas significantly less slippage was observed for Cow-hitch with both ST and DC secured with 2 throws, and for Nice-knots with DC secured with 2 throws (p ≤ 0.002), with no further detected significant differences in this regard (p ≥ 0.200). When the minimal number of needed securing throws was considered for a comparison between round sutures tied with the same configuration (Nice-knots or Cow-hitch), no significant differences were registered for both ultimate force and slippage when comparing DC with 2 throws versus FW with 3 throws (p ≥ 0.066). Discussion The current study evaluated the influence of throws number on knot security of two double-stranded knot configurations—Cow-hitch and Nice-knot—tied with two different high strength round sutures—DC and FW—and 2 different high strength suture tapes—DT and ST. Furthermore, the mechanical competence in terms of ultimate force and knot slippage of the novel dynamic suture and suture tape versus the conventional round suture and suture tape was evaluated. The results have clinical relevance as no standard exist in the current literature on how many throws of surgeons` knots are necessary to secure double stranded knot configurations. A minimum number of securing throws should be used to reduce the amount of foreign material in patients’ bodies, possibly reducing the amount of disturbing hardware in patients’ bodies. Suture tapes are a further technical development of conventional round high strength sutures designed to maximize the pressure area of the sutured tendon and its insertion. Furthermore, they are designed to reduce the amount of foreign material in the human body, as knots tied with this tape are smaller than knots tied with conventional round high-strength sutures. Another advantage is the greater tendon pullout resistance of tapes compared to conventional round sutures [11,12]. Sufficient tissue approximation and footprint pressure are needed for optimal repair and healing capability [13,14]. Another technical evolution took place and led to the development of self-tightening high strength sutures, also available in tape form. However, up to now, there are no existing studies evaluating their biomechanical competence in double-stranded knot configurations. In recent times conventional high strength sutures and suture tapes are also used for fracture treatment as an alternative to metallic cerclage wires. Renner et al. reported comparable load to failure with fracture cerclage by a metallic wire and a non-metallic form in terms of tapes and sutures, however, the tightening force for metal wires was still higher allowing to actively reduce a fracture [3]. To overcome these downsides, new technical instruments were designed to assist with active fracture reduction using conventional high-strength sutures and tapes featuring a disposable tensioning device (e.g. FiberTape Cerclage System; Arthrex, Naples, FL, USA). These suture cerclages use double-stranded knot configurations featuring higher ultimate load to failure and less knot slippage in contrast to conventional sutures (e.g. surgeon`s knot) [2]. In this context Meyer et al. presented the Cow-Hitch and Nice-knot as best suture configuration for double-stranded knots as they are easy to tie and reveal the greatest loads to failure [2]. Another study further corroborated these findings and depicted FW as failing at higher load than metallic wire, however the authors concluded that these results depended on the used suture material but not on the used suture configuration [15]. In a systematic review, it was reported that non-metallic cerclage can replace metallic cerclage for treatment of soft tissue and fractures [16]. Furthermore, a cerclage performance analysis study concluded that all cerclage options (wires, cables, sutures and tapes) achieve reliable stability but differ in compression forces and non-metallic options provide more elasticity without losing their stability [17]. Thus, non-metallic cerclage options have become a norm and it is imperative to evaluate the strength in double stranded knot configurations using the novel dynamic suture materials (DC & DT), which already led to a reduced needed knot number in simple surgeons` knots to achieve 100 % knot security in a biomechanical study (4 knots DC vs 7 knots FW) [7]. Consequently, the primary research question of the current study was to assess the number of securing throws required for 100 % knot security in double-stranded sutures and tapes. In case of both tapes (DT, ST) and DC, 2 securing throws were found to be sufficient to achieve 100% knot security both in Cow-hitch and Nice-knot configurations. In contrast, FW required 3 securing throws with Cow-hitch and Nice-knots. Kelly et al. concluded in a biomechanical study that for Cow-hitch 3 throws of securing surgeons` knots are biomechanically robust and FW was with higher slippage [18]. These results were confirmed in the current study and FW also needed 3 securing throws to achieve 100 % knot security. Since 2 securing throws after double stranded Cow-hitch and Nice-knots are sufficient for both tapes (DT, ST), this may reduce the foreign body irritation due to cerclage fixation in regions lacking soft tissue cover and over prominent bones. Therefore, these findings may hold value in several orthopaedic procedures like during distal end clavicle fracture repair [5,19], acromioclavicular joint repair [20] or cerclage of arpe prosthesis implanted in the thumb [21]. In 2021 Laux et al. reported the stabilization of Neer-type V distal clavicle fractures using a novel Cow-hitch technique with FW secured with 4 surgeon`s throws, depicting promising results [19]. These fractures are comminuted, have limited screw purchase and 29% of them are with local irritation by the standard implant. The study revealed satisfactory results, however, increasing the number of securing throws did lead to foreign body irritation in patients and complains about the stiff knot on top of their clavicle [19]. Even though increasing the number of securing throws undoubtedly increases the knot security, there are certain disadvantages such as the amount of foreign material in the human body, patient discomfort, and the low contact area of the round suture braids in specific repair techniques. Furthermore, knot slippage is unavoidable when these sutures are heavily loaded, leading to a laxity of the suture with gap formation between the repaired structures [8]. Borbas et al. presented acromioclavicular joint stabilization with Cow-hitch knots using FW, reporting comparable results to double tightrope techniques with FW [20]. Another anatomical region with limited soft tissue coverage is the thumb, thus knot number reduction may hold value for patient comfort. A study revealed that out of 80 patients with arpe prosthesis, 21 required revisions due to fracture or dislocation for which traditionally metallic cerclage wires are used. Thus, in such cases the use of suture cerclage may hold great value and the number of securing throws matters for patient discomfort as well as knot security [21]. Taking into account the evaluated minimum number of securing throws for all four investigated suture materials in both evaluated double-stranded knot configurations, the following clinical approach might be recommended. Two securing throws for both tape sutures (ST and DT) and the dynamic round suture (DC) and 3 securing throws for the conventional round suture (FW). However, these numbers only focus on knot security leaving slippage and maximum load to failure aside. Comparing the influence of the dynamic (DT and DC) versus the conventional (ST and FW) suture material, significant findings were established in the current study using the minimal number of securing throws and tapes. Interestingly, in case of Nice-knot and Cow-hitch tied with 2 securing throws, significantly higher slippage was registered for DT compared to ST, however, no differences were found for maximum load. This difference in slippage was no longer detectable, when both tapes were secured with 3 throws for both Nice-knot and Cow-hitch. For round sutures tied with both Cow-hitch and Nice-knots and secured with the minimal number of securing knots (2 for DC and 3 for FW) no significant differences were found neither for slippage nor for maximum load. With these findings surgeons need to evaluate whether their sutures are positioned in regions of the human body covered with adequate soft tissues, but the sutures are maximally loaded (e.g. periprosthetic hip fracture) or whether the sutures are less loaded but positioned in exposed areas with only limited soft tissue coverage (e.g. thumb or clavicle). This should influence the surgeons` decision whether 2 or 3 securing throws should be used for tapes (DT, ST) and dynamic round sutures (DC) when slippage is expected. In contrast, double-stranded sutures with FW should always be secured with 3 throws. Furthermore, it must be considered that a proper knot tying technique is a basic requirement when surgeons want to use the evaluated minimal number of securing throws and more throws should be used in case the surgeon is uncertain. Double-stranded suture configurations are found to have higher load to failure than simpler surgeons’ knots with lower gap displacement and higher initial tension [22]. Furthermore, they reveal less slippage, have more contact surface to the bone, can therefore hold adequate compression to the repaired structures [19] and are mechanically stronger and stiffer than single stranded knot configurations [2]. The current study revealed differences between the evaluated double-stranded knot configurations Nice-knot and Cow-hitch, with a slightly better performance of Nice-knots, especially when DT is used and only 2 securing throws are tied. In the current literature several reports exist investigating these two double-stranded knot configurations. It has been previously reported by Meyer et al. that the Nice-Knot and Cow-hitch have comparable knot security and load resistance, and both were considered as optimal double-stranded knot configuration due to their ease to tie [2]. Cow-hitch tied with FW yielded similar mechanical resistance to failure as stainless steel cerclages, however, the authors used 5 surgeons` throws to secure the base of the Cow-hitch [3]. Furthermore, Gupta et al. reported that the Nice-knot tied with FW was comparable to wire cerclage with comparable compression properties [23]. During a comparison of various suture configurations by Peeters et al., Nice-knot was found to be the best one due to its self-gliding and locking principle showing least elongation [16]. However, the Cow-hitch was not evaluated in their biomechanical study. Several clinical reports on Nice-knots and Cow-hitch are available, yielding excellent results in cerclage treatment of periprosthetic fractures [3], fracture hemiarthroplasty [24], greater tuberosity repair in reverse total shoulder arthroplasty [4], all-suture distal clavicle fracture repair [5,19], and acromioclavicular joint repair [20]. However, there is a lack of literature evaluating the novel dynamic self-tightening suture materials in clinical scenarios. It was hypothesized that the dynamic self-tightening effect of DC and DT might compensate for inevitable occurring knot slippage, however, future clinical research must confirm this in vivo and demonstrate a benefit for patients. Several limitations of the current study must be considered. First, only 7 specimens per knot configuration, suture material and number of securing throws were tested, restricting the generalization of the study findings. Second, it was not possible to completely simulate in vivo situations after an arthroscopy or open surgery in a real human with different conditions of the fluid in the joint. However, 37.5°C warm physiologic NaCl solution was used to simulate the conditions in the early postoperative phase and fat was used to represent the contact of the suture with the subcutaneous fat, with full fat coverage simulating the worst-case scenario. Second, slipped distance was measured by a single surgeon using a caliper, which might have biased the results. Finally, only one suture diameter of 4 different materials was investigated using 2 different knot configurations, limiting the transferability of the results to other clinical problems requiring thinner sutures. Strengths of this study include knot tying by a single surgeon. This allowed to exclude potential inter-operator differences since knots tied by different surgeons might behave differently. Moreover, a standardized setup was used to allow reproducibility and a more realistic testing condition using physiologic saline mixed with body fat utilized in contrast to most biomechanical studies on suture materials performed in dry conditions only. Future research should focus on the dynamic sutures and suture tapes in a clinical setup to observe their patient acceptability. It has already been established that the double-stranded sutures are comparable to metallic cerclage and further studies should be conducted to report the compression achieved by these sutures so that the disadvantages of metallic implants like implant failure, inadequate implant purchase and implant prominence can be tackled by using non-metallic sutures. Future biomechanical research is needed to evaluate the tested suture configurations (Nice-not and Cow-hitch), suture forms (round suture and tape), number of securing throws and used materials (dynamic and conventional) in a more realistic biomechanical test setup using a cyclic loading protocol. Furthermore, biomechanical research should quantify the amount of shortening when the repaired structures are under tension. Conclusions The minimum number of securing throws required to achieve 100% knot security was 2 with DC, DT and ST for both Cow-hitch and Nice-knots configurations, in contrast to FW where 3 securing throws were needed. With these minimum numbers of securing throws, Nice-knots were associated with significantly higher ultimate forces when using DT and lower slippage with DC versus Cow-hitch knots. Declarations Ethics approval and consent to participate. All procedures performed in this study were followed in accordance with relevant guidelines. This study was approved by the institutional internal review board, based on the approval of the specimens' delivery by Science Care Ethics Committee. The donor gave their informed consent inherent within the donation of the anatomical gift statement during their lifetime, as registered by Science Care. Conflict of interests The authors declare that they have no competing interests. Funding The authors are not compensated and there are no other institutional subsidies, corporate affiliations, or funding sources supporting this work. This study was performed with the assistance of the AO Foundation. Authors' contributions MD, TaP, BG, IZ and ToP: designed the study. MD, SH and TaP prepared the specimens. TaP, IZ and MD performed biomechanical testing. IZ obtained data from the machine. BG and IZ performed statistical analysis. TaP, BG, IZ, SH and ToP interpreted results. GR supervised the study. TaP, SH and MD wrote the original draft of the manuscript, which was next revised in detail first by IZ and BG, BL and ToP. Subsequent drafts were prepared by all authors. All authors read and approved the final manuscript. Acknowledgements This investigation was performed with the assistance of the AO Foundation. Meetings This study will be presented at the EFORT and EORS congresses 2024. References Lo IKY, Burkhart SS, Chan KC, Athanasiou K. Arthroscopic knots: determining the optimal balance of loop security and knot security. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2004;20:489–502. Meyer DC, Bachmann E, Lädermann A, Lajtai G, Jentzsch T. The best knot and suture configurations for high-strength suture material. An in vitro biomechanical study. Orthop Traumatol Surg Res OTSR. 2018;104:1277–82. Renner N, Wieser K, Lajtai G, Morrey ME, Meyer DC. Stainless steel wire versus FiberWire suture cerclage fixation to stabilize the humerus in total shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23:1568–74. Grubhofer F, Bachmann E, Gerber C, Wieser K, Ernstbrunner L, Warner JJ, et al. Cow-hitch-suture cerclage for fixation of the greater tuberosity in fracture RTSA. JSES Int. 2021;5:270–6. Laux CJ, Borbas P, Villefort C, Hofstede S, Ernstbrunner L, Wieser K. Fixation of distal clavicle fractures with coracoclavicular instability: a comparative biomechanical study in human cadavers. JSES Int. 2022;6:144–8. Borbas P, Fischer L, Ernstbrunner L, Hoch A, Bachmann E, Bouaicha S, et al. High-Strength Suture Tapes Are Biomechanically Stronger Than High-Strength Sutures Used in Rotator Cuff Repair. Arthrosc Sports Med Rehabil. 2021;3:e873–80. van Knegsel KP, Zderic I, Kastner P, Varga P, Knobe M, Berk T, et al. Knot holding capacity of two different high-strength sutures-a biomechanical analysis. Int Orthop. 2023; Neuhofer S, Wieser K, Lajtai G, Müller D, Gerber C, Meyer DC. Surgical knot tightening: how much pull is necessary? Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2014;22:2849–55. 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:e1525–34. Rapp CM, Koueiter DM, Bojnowski J, Kalma J, Wiater B, Kurdziel MD, et al. Are Suture Tape Knots as Secure as Standard Suture? A Biomechanical Study. Orthop J Sports Med. 2021;9:23259671211045411. Ono Y, Joly DA, Thornton GM, Lo IKY. Mechanical and imaging evaluation of the effect of sutures on tendons: tape sutures are protective to suture pulling through tendon. J Shoulder Elbow Surg. 2018;27:1705–10. Owens BD, Algeri J, Liang V, DeFroda S. Rotator cuff tendon tissue cut-through comparison between 2 high-tensile strength sutures. J Shoulder Elbow Surg. 2019;28:1897–902. Hohmann E, König A, Kat C-J, Glatt V, Tetsworth K, Keough N. Single- versus double-row repair for full-thickness rotator cuff tears using suture anchors. A systematic review and meta-analysis of basic biomechanical studies. Eur J Orthop Surg Traumatol Orthop Traumatol. 2018;28:859–68. Gelberman RH, Boyer MI, Brodt MD, Winters SC, Silva MJ. The effect of gap formation at the repair site on the strength and excursion of intrasynovial flexor tendons. An experimental study on the early stages of tendon-healing in dogs. J Bone Joint Surg Am. 1999;81:975–82. Westberg SE, Acklin YP, Hoxha S, Ayranci C, Adeeb S, Bouliane M. Is suture comparable to wire for cerclage fixation? A biomechanical analysis. Shoulder Elb. 2019;11:225–32. Peeters I, Depover A, Van Tongel A, De Wilde L. A review of metallic and non-metallic cerclage in orthopaedic surgery: Is there still a place for metallic cerclage? Injury. 2019;50:1627–33. Hägerich LM, Dyrna FGE, Katthagen JC, Michel PA, Heilmann LF, Frank A, et al. Cerclage performance analysis - a biomechanical comparison of different techniques and materials. BMC Musculoskelet Disord. 2022;23:1037. Kelly JD, Vaishnav S, Saunders BM, Schrumpf MA. Optimization of the Racking Hitch Knot: How Many Half Hitches and Which Suture Material Provide the Greatest Security? Clin Orthop. 2014;472:1930–5. Laux CJ, Villefort C, El Nashar R, Farei-Campagna JM, Grubhofer F, Bouaicha S, et al. Stand-alone coracoclavicular suture repair achieves very good results in unstable distal clavicle fractures at a minimum follow-up of 1 year. J Shoulder Elbow Surg. 2021;30:2090–6. Borbas P, Angelella D, Laux CJ, Bachmann E, Ernstbrunner L, Bouaicha S, et al. Acromioclavicular joint stabilization with a double cow-hitch technique compared to a double tight-rope: a biomechanical study. Arch Orthop Trauma Surg. 2022;142:1309–15. Dumartinet-Gibaud R, Bigorre N, Raimbeau G, Jeudy J, Saint Cast Y. Arpe total joint arthroplasty for trapeziometacarpal osteoarthritis: 80 thumbs in 63 patients with a minimum of 10 years follow-up. J Hand Surg Eur Vol. 2020;45:465–9. Denard PJ, Nolte P-C, Millett PJ, Adams CR, Liebler SAH, Rego G, et al. A Tensionable Suture-based Cerclage Is an Alternative to Stainless Steel Cerclage Fixation for Stabilization of a Humeral Osteotomy During Shoulder Arthroplasty. J Am Acad Orthop Surg. 2021;29:e609–17. Gupta AK, Godwin T, Poon P. Is Nice knot suture comparable to wire for cerclage fixation? A biomechanical performance study. JSES Rev Rep Tech. 2022;2:20–5. Grubhofer F, Ernstbrunner L, Bachmann E, Wieser K, Borbas P, Bouaicha S, et al. Cow-hitch fixation in fracture hemiarthroplasty. JSES Int. 2021;5:1027–33. Tables Table 1: Ultimate force and slippage for Dynatape (DT), SutureTape (ST), Dynacord (DC) and FibreWire (FW) presented in terms of mean value and standard deviation, together with the p-values from the statistical comparisons between Cow-hitch and Nice-knot (A), 2 versus 3 securing throws (B), and dynamic versus conventional suture material (C). * Indicates significant differences. A) Ultimate force and slippage for different knot configurations Cluster Group Throw Number Ultimate force (N ± SD) p-value Slippage (mm ± SD) p-value Cow-hitch Nice-knot Cow-hitch Nice-knot Tape DT 2 524.0 ± 169.0 724.5 ± 185.9 0.001 * 10.9 ± 1.6 8.5 ± 3.7 0.080 ST 2 543.9 ± 70.0 654.5 ± 67.7 0.082 6.9 ± 1.1 7.6 ± 2.1 0.560 DT 3 654.5 ± 67.7 823.2 ± 81.4 0.100 7.2 ± 2.7 6.1 ± 1.9 0.362 ST 3 637.4 ± 97.3 696.7 ± 99.3 0.346 6.9 ± 1.3 7.0 ± 1.9 0.883 Cord DC 2 382.1 ± 31.7 389.7 ± 28.3 0.738 3.8 ± 0.4 2.7 ± 0.5 0.019 * FW 2 211.9 ± 48.4 267.2 ± 41.3 0.018 * ∞ ∞ 1.000 DC 3 396.1 ± 38.8 413.0 ± 29.4 0.459 4.3 ± 1.8 3.5 ± 0.8 0.074 FW 3 339.6 ± 60.0 358.1 ± 49.9 0.418 3.9 ± 0.9 3.1 ± 0.7 0.077 B) Ultimate force and slippage for increasing number of securing knots Cluster Group Knot Type Ultimate force (N ± SD) p-value Slippage (mm ± SD) p-value 2 Throws 3 Throws 2 Knots 3 Knots Tape DT Cow-hitch 524.0 ± 169.0 654.5 ± 67.7 0.002* 10.9 ± 1.6 7.2 ± 2.7 0.005* ST Cow-hitch 543.9 ± 70.0 637.4 ± 97.3 0.140 6.9 ± 1.1 6.9 ± 1.3 0.983 DT Nice-knot 724.5 ± 185.9 823.2 ± 81.4 0.120 8.5 ± 3.7 6.1 ± 1.9 0.004* ST Nice-knot 654.5 ± 67.7 696.7 ± 99.3 0.502 7.6 ± 2.1 7.0 ± 1.9 0.646 Cord DC Cow-hitch 382.1 ± 31.7 396.1 ± 38.8 0.540 3.8 ± 0.4 4.3 ± 1.8 0.263 FW Cow-hitch 211.9 ± 48.4 339.6 ± 60.0 <0.001* ∞ 3.9 ± 0.9 <0.001* DC Nice-knot 389.7 ± 28.3 413.0 ± 29.4 0.309 2.7 ± 0.5 3.5 ± 0.8 0.090 FW Nice-knot 267.2 ± 41.3 358.1 ± 49.9 <0.001* ∞ 3.1 ± 0.7 <0.001* C) Ultimate force and slippage for different suture and tape technologies Cluster Throw Number Knot Type Ultimate force (N ± SD) p-value Slippage (mm ± SD) p-value Dynamic Conventional Dynamic Conventional Tape 2 Cow-hitch 524.0 ± 169.0 543.9 ± 70.0 0.619 10.9 ± 1.6 6.9 ± 1.1 0.002* 2 Nice-knot 724.5 ± 185.9 654.5 ± 67.7 0.267 8.5 ± 3.7 7.6 ± 2.1 0.413 3 Cow-hitch 654.5 ± 67.7 637.4 ± 97.3 0.200 7.2 ± 2.7 6.9 ± 1.3 0.775 3 Nice-knot 823.2 ± 81.4 696.7 ± 99.3 0.048* 6.1 ± 1.9 7.0 ± 1.9 0.439 Cord 2 Cow-hitch 382.1 ± 31.7 211.9 ± 48.4 <0.001* 3.8 ± 0.4 ∞ <0.001* 2 Nice-knot 389.7 ± 28.3 267.2 ± 41.3 <0.001* 2.7 ± 0.5 ∞ <0.001* 3 Cow-hitch 396.1 ± 38.8 339.6 ± 60.0 0.016* 3.8 ± 0.4 3.9 ± 0.9 0.406 3 Nice-knot 413.0 ± 29.4 358.1 ± 49.9 0.019* 2.7 ± 0.5 3.1 ± 0.7 0.416 DT = Dynatape, ST = Suturetape, DC = Dynacord, FW = Fibrewire, Dynamic = DT & DC, Conventional = ST & FW Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 20 May, 2024 Reviews received at journal 17 May, 2024 Reviewers agreed at journal 08 May, 2024 Reviewers invited by journal 20 Apr, 2024 Editor assigned by journal 20 Apr, 2024 Submission checks completed at journal 20 Apr, 2024 First submitted to journal 18 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4286165","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":294406725,"identity":"817ea17c-462f-42b1-91c1-4b59e37efd3e","order_by":0,"name":"Mehar Dhillon","email":"","orcid":"","institution":"AO Foundation","correspondingAuthor":false,"prefix":"","firstName":"Mehar","middleName":"","lastName":"Dhillon","suffix":""},{"id":294406727,"identity":"64c41520-3379-4d53-9a8c-139d431ce009","order_by":1,"name":"Tatjana Pastor","email":"","orcid":"","institution":"AO Foundation","correspondingAuthor":false,"prefix":"","firstName":"Tatjana","middleName":"","lastName":"Pastor","suffix":""},{"id":294406729,"identity":"5ba35b26-ab3c-46ac-b3d9-6d4d3960af7b","order_by":2,"name":"Ivan Zderic","email":"","orcid":"","institution":"AO Foundation","correspondingAuthor":false,"prefix":"","firstName":"Ivan","middleName":"","lastName":"Zderic","suffix":""},{"id":294406730,"identity":"4361a016-f53a-4c68-bbc5-d61cac0d85f2","order_by":3,"name":"Sarina Hebsacker","email":"","orcid":"","institution":"Luzerner Kantonsspital","correspondingAuthor":false,"prefix":"","firstName":"Sarina","middleName":"","lastName":"Hebsacker","suffix":""},{"id":294406731,"identity":"342a3a26-96d1-4a65-8527-64ba3960759a","order_by":4,"name":"Björn-Christian Link","email":"","orcid":"","institution":"Luzerner Kantonsspital","correspondingAuthor":false,"prefix":"","firstName":"Björn-Christian","middleName":"","lastName":"Link","suffix":""},{"id":294406732,"identity":"f8eab057-94fd-47d8-973d-62949bdac919","order_by":5,"name":"R Geoff Richards","email":"","orcid":"","institution":"AO Foundation","correspondingAuthor":false,"prefix":"","firstName":"R","middleName":"Geoff","lastName":"Richards","suffix":""},{"id":294406734,"identity":"efcb8ecc-572a-4ddc-b66c-6629abcf15b3","order_by":6,"name":"Boyko Gueorguiev","email":"","orcid":"","institution":"AO Foundation","correspondingAuthor":false,"prefix":"","firstName":"Boyko","middleName":"","lastName":"Gueorguiev","suffix":""},{"id":294406739,"identity":"4fce4674-c12a-4595-8cf3-bb14162bee87","order_by":7,"name":"Torsten Pastor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYAgAGxkGHiDF2IBbCUie4QCEDVKXxkOylsOEtdiz9z7+/KHiDoM5+/HnDz7uOc9jcOb4A4afO/DYwnPcTOLAmWcMlj05ho0znt3mMTjbY8DYewaPFok0NoaDbYcZDA7kMDbzHABqOc/DwMzYhlcL84eD/4Bazj9/CNRyDqiF/QEhLQwSBxuAWm4kGAK1HAA6rMEAv5Yzx9gkzhw7zGM5443hzBkHknkkz5wxONiLRwt7exvzh4qaw3Lm/OkPPnw4YCfHdyb94YOfeLTAbTNA5h0grAEIDAgrGQWjYBSMgpEKAPGhVU6uPBPDAAAAAElFTkSuQmCC","orcid":"","institution":"Luzerner Kantonsspital","correspondingAuthor":true,"prefix":"","firstName":"Torsten","middleName":"","lastName":"Pastor","suffix":""}],"badges":[],"createdAt":"2024-04-18 08:18:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4286165/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4286165/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55241357,"identity":"10596c68-a0bb-4950-8362-0361efc754f0","added_by":"auto","created_at":"2024-04-24 15:05:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":478367,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eKnot tying of the two double-stranded suture configurations Cow-hitch (\u003c/em\u003e\u003cem\u003e\u003cstrong\u003eA-F\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e) and Nice-knot (\u003c/em\u003e\u003cem\u003e\u003cstrong\u003eG-L\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e) for an exemplified fixation of a periprosthetic femur fracture (red line). \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eCow-hitch:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: A doubled-over suture is passed around the bone. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: A loop is created. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: The two free limbs are passed through the loop. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: The knot is slid down by pulling the free limbs. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eE-F\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: The tightened knot is secured with 3 alternating surgeons` throws. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eNice-knot:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eG\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: A doubled-over suture is passed around the bone. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eH\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: A single square knot is thrown. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eI\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: The two free limbs are passed through the loop. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eJ\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: The knot is slid down by pulling the free limbs. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eK-L\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: The tightened knot is secured with 3 alternating surgeons` throws. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eM\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: Outline of a single stranded knot configuration with 7 alternating surgeons` throws. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: Outline of a double stranded Cow-hitch secured with 3 alternating surgeons` throws.\u003c/em\u003e\u003cem\u003e\u003cstrong\u003e O\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e: Outline of a double stranded Nice-knot secured with 3 alternating surgeons` throws.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig11.png","url":"https://assets-eu.researchsquare.com/files/rs-4286165/v1/d15240ce84295c2355983341.png"},{"id":55241355,"identity":"f6b32cdd-5465-42a0-b479-d8d69f32d693","added_by":"auto","created_at":"2024-04-24 15:05:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":629581,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eLeft: Custom made device for force-controlled knot tying using a spring scale. In this configuration all knots were tightened with 50 N force. Right: Enlarged view of the knot holder with a specimen after tying a Cow-hitch secured with 3 surgeons` throws. Subsequently, both suture ends were cut at 5 mm and black markers were made right to next to the knot.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig21.png","url":"https://assets-eu.researchsquare.com/files/rs-4286165/v1/feee484b3c70c19bd5d6601a.png"},{"id":55241356,"identity":"a8504e31-ccf4-41cc-8a74-7eb41fae5fb3","added_by":"auto","created_at":"2024-04-24 15:05:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1131926,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSetup with a specimen mounted for mechanical testing in physiologic (fatty-wet) conditions. 'F' indicates loading direction. Slippage was evaluated post testing using the two markers.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig31.png","url":"https://assets-eu.researchsquare.com/files/rs-4286165/v1/7034921a07cef43606ee48a0.png"},{"id":55241354,"identity":"30924c44-db09-4cf7-a5c4-6e205854575b","added_by":"auto","created_at":"2024-04-24 15:05:02","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":22012,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIllustration of the percentage of secure knots (y-axis) for each securing knot number (x-axis) for DT, ST and DC (blue line) and FW (green line) for both Cow-hitch and Nice-knot suture configurations.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig41.png","url":"https://assets-eu.researchsquare.com/files/rs-4286165/v1/a80f93c7bb45d7be4ff5e361.png"},{"id":55242626,"identity":"7dd3b8ba-f206-47b3-afe9-8f85331c74a1","added_by":"auto","created_at":"2024-04-24 15:21:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2523217,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4286165/v1/f13d3f9b-f101-4806-864b-0108f027f222.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Biomechanical evaluation of double stranded knot configurations in high strengths sutures and tapes","fulltext":[{"header":"Background","content":"\u003cp\u003eSince the introduction of high-strength sutures to orthopaedic surgery, they are successfully used to repair ligaments, tendons and even bones in various procedures. For many years, the surgeons\u0026acute; knot has been the gold standard in traditional open techniques (\u003cem\u003eFigure 1M\u003c/em\u003e). However, in order to enhance reproducibility, knot security, and size, novel suture and knot configurations were required\u0026nbsp;[1]. Compared to the surgeons` knot, double-stranded knots are biomechanically stronger, stiffer, less bulky, and can preserve applied tension during tying better than conventional knots\u0026nbsp;[2]. Therefore, they are suitable in orthopaedic procedures requiring resistance to high tensile forces, e.g., when using cerclage sutures for fracture fixation\u0026nbsp;[3], \u0026nbsp;as well as during tubercle refixation after fracture hemiarthroplasty\u0026nbsp;[4]\u0026nbsp;or lateral clavicle fracture stabilization\u0026nbsp;[5]. Although various double-stranded knot configurations are described in the literature, in a biomechanical study by Meyer et al. reported that Cow-hitch and Nice-knots are the best performing and technically most simple knots, best suited to exploit the enormous mechanical capabilities of modern high-strength suture materials\u0026nbsp;[2]\u0026nbsp;(\u003cem\u003eFigure 1\u003c/em\u003e). However, these double-stranded knots need to be secured with surgeons` knots in order to prevent their unraveling, however, as no data exist on how many surgeons\u0026rsquo; knots are necessary for this prevention in the current literature, Mayer et al. used 5 securing throws without evaluating the security of using fewer\u0026nbsp;[2]. Besides advances in knot configurations, a technical development took place for conventional round high strength sutures, such as e.g. FibreWire (FW;\u0026nbsp;Arthrex, Munich, Germany). In addition, tapes\u0026mdash;such as SutureTape (ST;\u0026nbsp;Arthrex, Munich, Germany)\u0026mdash;have been introduced with higher tensile strength increasing both the pressure area of a sutured tendon to the bone and the pullout forces through a sutured tendon\u0026nbsp;[6]. Furthermore, knots tied with this tape are smaller than those with traditional round sutures, reducing the amount of foreign material in the human body. Recently, a new high-strength suture\u0026mdash;DynaCord (DC;\u0026nbsp;DePuy Synthes, Zuchwil, Switzerland)\u0026mdash;was introduced, also available in tape form\u0026mdash;DynaTape (DT;\u0026nbsp;DePuy Synthes, Zuchwil, Switzerland)\u0026mdash;featuring a salt-infused silicone core attracting water- in a fluid environment. In the human body, this suture expands radially due to swelling of the core, leading to self-tensioning because of braid shortening. This new dynamic suture technology preserves consistent tissue approximation between the repaired structures and needs fewer throws to achieve 100% knot security in surgeons` knots as compared to the conventional suture material (4 instead of 7 throws)\u0026nbsp;[7].\u003cs\u003e\u0026nbsp;\u003c/s\u003eTherefore, the aims of this study were to (1) assess the influence of securing knot number on knot security of two double-stranded knot configurations\u0026mdash;Cow-hitch and Nice-knot\u0026mdash;tied with two different high strength round sutures\u0026mdash;DC and FW\u0026mdash;and two different high strength suture tapes\u0026mdash;DT and ST, (2) to compare the biomechanical competence in terms of ultimate force and knot slippage of the novel dynamic suture and suture tape versus the conventional round suture and suture tape (at their minimal number of needed securing throws), and (3) to compare the biomechanical competence in terms of ultimate force and knot slippage of the two double-stranded knot configurations (Cow-hitch and Nice-knot) at their minimal number of needed securing throws. It was hypothesized that (1) the novel dynamic suture and suture tape require less than the proposed 5 securing throws by Meyers at al. to achieve knot security in double stranded knot configurations, (2) tapes require less securing throws than round sutures, and (3) the biomechanical competence of the two double-stranded knot configurations Cow-hitch and Nice-knot are comparable.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSpecimens and Preparation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe four high-strength sutures and tapes were assigned to eight groups combined in two clusters\u0026mdash;tape and cord. Group DT was\u0026nbsp;paired with Group ST (cluster tape), and Group DC\u0026mdash;with Group FW (cluster cord). Both\u0026nbsp;clusters were further divided in two subgroups considering the two best performing\u0026nbsp;double-stranded knot configurations (Cow-hitch and Nice-knot) as described by Meyer et al.\u0026nbsp;[2].\u0026nbsp;Each group and subgroup were investigated by knotting the base of the double stranded suture (Cow-hitch or Nice-knot) secured by\u0026nbsp;surgeons\u0026rsquo;\u0026nbsp;knots with 1, 2 and 3 alternating throws separately (\u003cem\u003eFigure 1\u003c/em\u003e). Seven specimens in each group, subgroup and throw number of securing surgeons\u0026rsquo; knots were considered. Accordingly,\u0026nbsp;168 samples were tested in the current study. All knots were tied by a single surgeon using a custom-made device including a spring scale (Pesola,\u0026nbsp;Schindellegi, Switzerland) with accuracy of 1 N and capacity of 100 N (\u003cem\u003eFigure 2\u003c/em\u003e) to ensure a reproducible knot tying force of 50 N. This force was chosen as it demonstrated well seated\u0026nbsp;surgeons\u0026rsquo;\u0026nbsp;knots with minimal slippage in a biomechanical investigation\u0026nbsp;[8]. All knots were tied on a custom-made suture holder consisting of 2 roller bearings positioned at 20 mm to minimize friction during biomechanical testing. Propper knot seating was confirmed by visual inspection of every specimen. Subsequently, suture ends were cut at 5 mm to the last throw of the\u0026nbsp;securing surgeons\u0026rsquo; knot and two black markings were made on both sides of the suture directly adjacent to the double stranded knot for knot slippage evaluation after biomechanical testing (\u003cem\u003eFigure 3\u003c/em\u003e). Prior to testing every specimen was soaked for 24 hours in 200 ml physiologic saline solution at 37.5\u0026deg; mixed with 30 g of subcutaneous human fat obtained from the thigh of a 78-year-old male donor to simulate in-vivo conditions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMechanical testing\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMechanical testing was performed using an electromechanical material testing machine (Instron 5866, Norwood, MA, USA) equipped with a 1 kN load cell. The specimen holder was attached to the base of a custom-made medium container, filled with 200 ml physiologic saline solution at 37.5\u0026deg;C mixed with 30 g of subcutaneous human fat and fixed to the machine base (\u003cem\u003eFigure 3\u003c/em\u003e). A third custom-made roller bearing was attached to the machine actuator and hooked under the double stranded suture. All specimens were preloaded at 1 N to allow for settlement of the knots. Subsequently, quasi-static ramped tension was applied by moving the machine actuator at a rate of 0.1 mm/s until failure, the latter defined as either completely unraveling of the knot with total slippage of one suture end or suture rupture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData acquisition and analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMachine data in terms of axial load and axial displacement were acquired at a rate of 32 Hz. The ultimate force was determined from the force-displacement curve of each test. Slippage was defined as travelled distance of both markers relative to the base of the double stranded knot. Suture unraveling was defined as total slippage of one suture end through the knot\u0026mdash;consequently preventing a suture rupture. Knot security was defined as the percentage of suture ruptures for each group, number of securing surgeons` throws and subgroup without unravelling. The minimum number of throws ensuring 100% knot security in each group and subgroup was registered. By using a digital caliper (Futuro, Br\u0026uuml;tsch/R\u0026uuml;egger, Urdorf, Switzerland) with an accuracy of 0.01 mm, the slippage distance was evaluated post testing by measuring the travelled distance of both markers relative to the base of the double stranded knot in all specimens demonstrating suture rupture as failure mode after biomechanical testing. In each cluster and subgroup, the ultimate force and slippage distance were compared.\u0026nbsp;No comparison was made between round sutures and tapes as it is well known that tapes are made to resist higher loads until failure\u0026nbsp;[6,9,10].\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed with SPSS software package (V27, IBM SPSS Statistics, IBM, Armonk, NY, USA). Differences between the suture types in terms of numbers of throws until achieved knot security were screened with Chi-Squared tests for both suture techniques. Shapiro-Wilk test was used to evaluate and prove normality of the data distribution for scale outcome measures. Outcomes regarding the two suture tapes, two suture materials and two used suture techniques were investigated with One-Way Analysis of Variance (ANOVA) with Bonferroni or Games-Howell post-hoc tests for multiple comparisons. Level of significance was set to 0.05 for all statistical tests.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eKnot security\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe minimum number of securing throws required to achieve 100% knot security\u0026mdash;suture rupture in all 7 specimens\u0026mdash;was 2 for DT, ST, and DC for both Cow-hitch and Nice-knots suture configurations. In contrast, 3 securing throws were needed for FW to achieve 100% knot security for both Cow-hitch and Nice-knot suture configurations (\u003cem\u003eFigure 4\u003c/em\u003e). All specimens secured with only one surgeons\u0026rsquo; knot unraveled during mechanical testing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eUltimate force and slippage\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results for ultimate force and slippage of all investigated specimens are summarized in Table 1.\u0026nbsp;Comparing Nice-knot and Cow-hitch suture configurations when using the same material (DT, ST, DC or FW) with equal number of throws (2 or 3), significantly higher ultimate forces were registered for Nice-knots versus Cow-hitch for DT and FW with two throws (p \u0026le; 0.018), and\u0026nbsp;significantly less slippage was observed for Nice-knots versus Cow-hitch for DC with two throws (p = 0.019), with\u0026nbsp;no further detected significant differences in this regard (p\u0026nbsp;\u0026ge; 0.077).\u003c/p\u003e\n\u003cp\u003eComparing the influence of 2 versus 3 throws when using the same material to secure either Nice-knots or Cow-hitch suture configuration, significantly higher ultimate forces were registered for Nice-knots with FW and for Cow-hitch with either DT or FW secured with 3 throws (p \u0026le; 0.002), whereas significantly less slippage was observed for both Nice-knot and Cow-hitch with DT or FW secured with 3 throws (p \u0026le; 0.005), with\u0026nbsp;no further detected significant differences in this regard (p\u0026nbsp;\u0026ge; 0.090).\u003c/p\u003e\n\u003cp\u003eComparing the influence of the dynamic (DT or DC) versus the corresponding conventional (ST or FW, respectively) suture material tied\u0026nbsp;with equal number of throws (2 or 3), significantly higher ultimate forces were registered for Nice-knots with DT secured with 3 throws and DC secured with 2 or 3 throws, as well as for Cow-hitch with DC secured with 2 or 3 throws (p \u0026le; 0.048), whereas significantly less slippage was observed for Cow-hitch with both ST and DC secured with 2 throws, and for Nice-knots with DC secured with 2 throws (p \u0026le; 0.002), with\u0026nbsp;no further detected significant differences in this regard (p\u0026nbsp;\u0026ge; 0.200).\u003c/p\u003e\n\u003cp\u003eWhen the minimal number of needed securing throws was considered for a comparison between round sutures tied with the same configuration (Nice-knots or Cow-hitch), no significant differences were registered for both ultimate force and slippage when comparing DC with 2 throws versus FW with 3 throws (p \u0026ge; 0.066).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study evaluated the influence of throws number on knot security of two double-stranded knot configurations\u0026mdash;Cow-hitch and Nice-knot\u0026mdash;tied with two different high strength round sutures\u0026mdash;DC and FW\u0026mdash;and 2 different high strength suture tapes\u0026mdash;DT and ST. Furthermore, the mechanical competence in terms of ultimate force and knot slippage of the novel dynamic suture and suture tape versus the conventional round suture and suture tape was evaluated.\u0026nbsp;The results have clinical relevance as no standard exist in the current literature on how many throws of surgeons` knots are necessary to secure double stranded knot configurations. A minimum number of securing throws should be used to reduce the amount of foreign material in patients\u0026rsquo; bodies, possibly reducing the amount of disturbing hardware in patients\u0026rsquo; bodies.\u003c/p\u003e\n\u003cp\u003eSuture\u0026nbsp;tapes are a further technical development of conventional round high strength sutures designed to maximize the pressure area of the sutured tendon and its insertion. Furthermore, they are designed to reduce the amount of foreign material in the human body, as knots tied with this tape are smaller than knots tied with conventional round high-strength sutures. Another advantage is the greater tendon pullout resistance of tapes compared to conventional round sutures\u0026nbsp;[11,12].\u0026nbsp;Sufficient tissue approximation and footprint pressure are needed for optimal repair and \u0026nbsp;healing capability\u0026nbsp;[13,14]. Another technical evolution took place and led to the development of self-tightening high strength sutures, also available in tape form. However, up to now, there are no existing studies evaluating their biomechanical competence in double-stranded knot configurations. In recent times conventional high strength sutures and suture tapes are also used for fracture treatment as an alternative to metallic cerclage wires. Renner et al. reported comparable load to failure with fracture cerclage by a metallic wire and a non-metallic form in terms of tapes and sutures, however, the tightening force for metal wires was still higher allowing to actively reduce a fracture\u0026nbsp;[3]. To overcome these downsides, new technical instruments were designed to assist with active fracture reduction using conventional high-strength sutures and tapes featuring a disposable tensioning device (e.g. FiberTape Cerclage System; Arthrex, Naples, FL, USA). These suture cerclages use double-stranded knot configurations featuring higher ultimate load to failure and less knot slippage in contrast to conventional sutures (e.g. surgeon`s knot)\u0026nbsp;[2]. In this context Meyer et al. presented the Cow-Hitch and Nice-knot as best suture configuration for double-stranded knots as they are easy to tie and reveal the greatest loads to failure\u0026nbsp;[2].\u0026nbsp;Another study further corroborated these findings and depicted FW as failing at higher load than metallic wire, however the authors concluded that these results depended on the used suture material but not on the used suture configuration\u0026nbsp;[15]. In a systematic review, it was reported that non-metallic cerclage can replace metallic cerclage for treatment of soft tissue and fractures\u0026nbsp;[16]. Furthermore, a cerclage performance analysis study concluded that all cerclage options (wires, cables, sutures and tapes) achieve reliable stability but differ in compression forces and non-metallic options provide more elasticity without losing their stability\u0026nbsp;[17]. Thus, non-metallic cerclage options have become a norm and it is imperative to evaluate the strength in double stranded knot configurations using the novel dynamic suture materials (DC \u0026amp; DT), which already led to a reduced needed knot number in simple surgeons` knots to achieve 100 % knot security in a biomechanical study (4 knots DC vs 7 knots FW)\u0026nbsp;[7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsequently, the primary research question of the current study was to assess the number of securing throws required for 100 % knot security in double-stranded sutures and tapes. In case of both tapes (DT, ST) and DC, 2 securing throws were found to be sufficient to achieve 100% knot security both in Cow-hitch and Nice-knot configurations. In contrast, FW required 3 securing throws with Cow-hitch and Nice-knots.\u0026nbsp;Kelly et al. concluded in a biomechanical study that for Cow-hitch 3 throws of securing surgeons` knots are biomechanically robust and FW was with higher slippage\u0026nbsp;[18]. These results were confirmed in the current study and FW also needed 3 securing throws to achieve 100 % knot security.\u0026nbsp;Since 2 securing throws after double stranded Cow-hitch and Nice-knots are sufficient for both tapes (DT, ST), this may reduce the foreign body irritation due to cerclage fixation in regions lacking soft tissue cover and over prominent bones. Therefore, these findings may hold value in several orthopaedic procedures like during distal end clavicle fracture repair\u0026nbsp;[5,19], acromioclavicular joint repair\u0026nbsp;[20]\u0026nbsp;or cerclage of arpe prosthesis implanted in the thumb\u0026nbsp;[21]. In 2021 Laux et al. reported the stabilization of Neer-type V distal clavicle fractures using a novel Cow-hitch technique with FW secured with 4 surgeon`s throws, depicting promising results\u0026nbsp;[19]. These fractures are comminuted, have limited screw purchase and 29% of them are with local irritation by the standard implant. The study revealed satisfactory results, however, increasing the number of securing throws did lead to foreign body irritation in patients and complains about the stiff knot on top of their clavicle\u0026nbsp;[19]. Even though increasing the number of securing throws undoubtedly increases the knot security, there are certain disadvantages such as the amount of foreign material in the human body, patient discomfort, and the low contact area of the round suture braids in specific repair techniques. Furthermore, knot slippage is unavoidable when these sutures are heavily loaded, leading to a laxity of the suture with gap formation between the repaired structures\u0026nbsp;[8]. Borbas et al. presented acromioclavicular joint stabilization with Cow-hitch knots using FW, reporting comparable results to double tightrope techniques with FW\u0026nbsp;[20]. Another anatomical region with limited soft tissue coverage is the thumb, thus knot number reduction may hold value for patient comfort. A study revealed that out of 80 patients with arpe prosthesis, 21 required revisions due to fracture or dislocation for which traditionally metallic cerclage wires are used. Thus, in such cases the use of suture cerclage may hold great value and the number of securing throws matters for patient discomfort as well as knot security\u0026nbsp;[21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTaking into account the evaluated minimum number of securing throws for all four investigated suture materials in both evaluated double-stranded knot configurations, the following clinical approach might be recommended. Two securing throws for both tape sutures (ST and DT) and the dynamic round suture (DC) and 3 securing throws for the conventional round suture (FW). However, these numbers only focus on knot security leaving slippage and maximum load to failure aside.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComparing the influence of the dynamic (DT and DC) versus the conventional (ST and FW) suture material, significant findings were established in the current study using the minimal number of securing throws and tapes. Interestingly, in case of Nice-knot and Cow-hitch tied with 2 securing throws, significantly higher slippage was registered for DT compared to ST, however, no differences were found for maximum load. This difference in slippage was no longer detectable, when both tapes were secured with 3 throws for both Nice-knot and Cow-hitch. For round sutures tied with both Cow-hitch and Nice-knots and secured with the minimal number of securing knots (2 for DC and 3 for FW) no significant differences were found neither for slippage nor for maximum load.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith these findings surgeons need to evaluate whether their sutures are positioned in regions of the human body covered with adequate soft tissues, but the sutures are maximally loaded (e.g. periprosthetic hip fracture) or whether the sutures are less loaded but positioned in exposed areas with only limited soft tissue coverage (e.g. thumb or clavicle). This should influence the surgeons` decision whether 2 or 3 securing throws should be used for tapes (DT, ST) and dynamic round sutures (DC) when slippage is expected. In contrast, double-stranded sutures with FW should always be secured with 3 throws. Furthermore, it must be considered that a proper knot tying technique is a\u0026nbsp;basic requirement when surgeons want to use the evaluated minimal number of securing throws and more throws should be used in case the surgeon is uncertain. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDouble-stranded suture configurations are found to have higher load to failure than simpler surgeons\u0026rsquo; knots with lower gap displacement and higher initial tension\u0026nbsp;[22]. Furthermore, they reveal less slippage, have more contact surface to the bone, can therefore hold adequate compression to the repaired structures\u0026nbsp;[19]\u0026nbsp;and are mechanically stronger and stiffer than single stranded knot configurations\u0026nbsp;[2].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current study revealed differences between the evaluated double-stranded knot configurations Nice-knot and Cow-hitch, with a slightly better performance of Nice-knots, especially when DT is used and only 2 securing throws are tied. In the current literature several reports exist investigating these two double-stranded knot configurations.\u0026nbsp;It has been previously reported by Meyer et al. that the Nice-Knot and Cow-hitch\u0026nbsp;have comparable knot security and load resistance, and both were considered as optimal double-stranded knot configuration due to their ease to tie\u0026nbsp;[2].\u0026nbsp;Cow-hitch tied with FW yielded similar mechanical resistance to failure as stainless steel cerclages, however, the authors used 5 surgeons` throws to secure the base of the Cow-hitch\u0026nbsp;[3]. Furthermore, Gupta et al. reported that the Nice-knot tied with FW was comparable to wire cerclage with comparable compression properties\u0026nbsp;[23]. During a comparison of various suture configurations by Peeters et al., Nice-knot was found to be the best one due to its self-gliding and locking principle showing least elongation\u0026nbsp;[16]. However, the Cow-hitch was not evaluated in their biomechanical study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral clinical reports on Nice-knots and Cow-hitch are available, yielding excellent results in cerclage treatment of periprosthetic fractures\u0026nbsp;[3], fracture hemiarthroplasty\u0026nbsp;[24], greater tuberosity repair in reverse total shoulder arthroplasty\u0026nbsp;[4], all-suture distal clavicle fracture repair\u0026nbsp;[5,19], and acromioclavicular joint repair\u0026nbsp;[20]. However, there is a lack of literature evaluating the novel dynamic self-tightening suture materials in clinical scenarios. It was hypothesized that\u0026nbsp;the dynamic self-tightening effect of DC and DT might compensate for inevitable occurring knot slippage, however, future clinical research must confirm this in vivo and demonstrate a benefit for patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral limitations of the current study must be considered. First, only 7 specimens per knot configuration, suture material and number of securing throws were tested, restricting the generalization of the study findings. Second, it was not possible to completely simulate in vivo situations after an arthroscopy or open surgery in a real human with different conditions of the fluid in the joint. However, 37.5\u0026deg;C warm physiologic NaCl solution was used to simulate the conditions in the early postoperative phase and fat was used to represent the contact of the suture with the subcutaneous fat, with full fat coverage simulating the worst-case scenario. Second, slipped distance was measured by a single surgeon using a caliper, which might have biased the results. Finally, only one suture diameter of 4 different materials was investigated using 2 different knot configurations, limiting the transferability of the results to other clinical problems requiring thinner sutures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStrengths of this study include knot tying by a single surgeon. This allowed to exclude potential inter-operator differences since knots tied by different surgeons might behave differently. Moreover, a standardized setup was used to allow reproducibility and a more realistic testing condition using physiologic saline mixed with body fat utilized in contrast to most biomechanical studies on suture materials performed in dry conditions only.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFuture research should focus on the dynamic sutures and suture tapes in a clinical setup to observe their patient acceptability. It has already been established that the double-stranded sutures are comparable to metallic cerclage and further studies should be conducted to report the compression achieved by these sutures so that the disadvantages of metallic implants like implant failure, inadequate implant purchase and implant prominence can be tackled by using non-metallic sutures. Future biomechanical research is needed to evaluate the tested suture configurations (Nice-not and Cow-hitch), suture forms (round suture and tape), number of securing throws and used materials (dynamic and conventional) in a more realistic biomechanical test setup using a cyclic loading protocol. Furthermore, biomechanical research should quantify the amount of shortening when the repaired structures are under tension.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe minimum number of securing throws required to achieve 100% knot security was 2 with DC, DT and ST for both Cow-hitch and Nice-knots configurations, in contrast to FW where 3 securing throws were needed. With these minimum numbers of securing throws, Nice-knots were associated with significantly higher ultimate forces when using DT and lower slippage with DC versus Cow-hitch knots.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study were followed in accordance with relevant guidelines. This study was approved by the institutional internal review board, based on the approval of the specimens\u0026apos; delivery by Science Care Ethics Committee. The donor gave their informed consent inherent within the donation of the anatomical gift statement during their lifetime, as registered by Science Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConflict of interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are not compensated and there are no other institutional subsidies, corporate affiliations, or funding sources supporting this work. This study was performed with the assistance of the AO Foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMD, TaP, BG, IZ and ToP: designed the study. MD, SH and TaP prepared the specimens. TaP, IZ and MD performed biomechanical testing. IZ obtained data from the machine. BG and IZ performed statistical analysis. TaP, BG, IZ, SH and ToP interpreted results. GR supervised the study. TaP, SH and MD wrote the original draft of the manuscript, which was next revised in detail first by IZ and BG, BL and ToP. Subsequent drafts were prepared by all authors. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis investigation was performed with the assistance of the AO Foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMeetings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study will be presented at the EFORT and EORS congresses 2024.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLo IKY, Burkhart SS, Chan KC, Athanasiou K. Arthroscopic knots: determining the optimal balance of loop security and knot security. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2004;20:489\u0026ndash;502. \u003c/li\u003e\n\u003cli\u003eMeyer DC, Bachmann E, L\u0026auml;dermann A, Lajtai G, Jentzsch T. The best knot and suture configurations for high-strength suture material. An in vitro biomechanical study. Orthop Traumatol Surg Res OTSR. 2018;104:1277\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003eRenner N, Wieser K, Lajtai G, Morrey ME, Meyer DC. Stainless steel wire versus FiberWire suture cerclage fixation to stabilize the humerus in total shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23:1568\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eGrubhofer F, Bachmann E, Gerber C, Wieser K, Ernstbrunner L, Warner JJ, et al. Cow-hitch-suture cerclage for fixation of the greater tuberosity in fracture RTSA. JSES Int. 2021;5:270\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eLaux CJ, Borbas P, Villefort C, Hofstede S, Ernstbrunner L, Wieser K. Fixation of distal clavicle fractures with coracoclavicular instability: a comparative biomechanical study in human cadavers. JSES Int. 2022;6:144\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eBorbas P, Fischer L, Ernstbrunner L, Hoch A, Bachmann E, Bouaicha S, et al. High-Strength Suture Tapes Are Biomechanically Stronger Than High-Strength Sutures Used in Rotator Cuff Repair. Arthrosc Sports Med Rehabil. 2021;3:e873\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003evan Knegsel KP, Zderic I, Kastner P, Varga P, Knobe M, Berk T, et al. Knot holding capacity of two different high-strength sutures-a biomechanical analysis. Int Orthop. 2023; \u003c/li\u003e\n\u003cli\u003eNeuhofer S, Wieser K, Lajtai G, M\u0026uuml;ller D, Gerber C, Meyer DC. Surgical knot tightening: how much pull is necessary? Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2014;22:2849\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eEnsminger 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\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eRapp CM, Koueiter DM, Bojnowski J, Kalma J, Wiater B, Kurdziel MD, et al. Are Suture Tape Knots as Secure as Standard Suture? A Biomechanical Study. Orthop J Sports Med. 2021;9:23259671211045411. \u003c/li\u003e\n\u003cli\u003eOno Y, Joly DA, Thornton GM, Lo IKY. Mechanical and imaging evaluation of the effect of sutures on tendons: tape sutures are protective to suture pulling through tendon. J Shoulder Elbow Surg. 2018;27:1705\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eOwens BD, Algeri J, Liang V, DeFroda S. Rotator cuff tendon tissue cut-through comparison between 2 high-tensile strength sutures. J Shoulder Elbow Surg. 2019;28:1897\u0026ndash;902. \u003c/li\u003e\n\u003cli\u003eHohmann E, K\u0026ouml;nig A, Kat C-J, Glatt V, Tetsworth K, Keough N. Single- versus double-row repair for full-thickness rotator cuff tears using suture anchors. A systematic review and meta-analysis of basic biomechanical studies. Eur J Orthop Surg Traumatol Orthop Traumatol. 2018;28:859\u0026ndash;68. \u003c/li\u003e\n\u003cli\u003eGelberman RH, Boyer MI, Brodt MD, Winters SC, Silva MJ. The effect of gap formation at the repair site on the strength and excursion of intrasynovial flexor tendons. An experimental study on the early stages of tendon-healing in dogs. J Bone Joint Surg Am. 1999;81:975\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003eWestberg SE, Acklin YP, Hoxha S, Ayranci C, Adeeb S, Bouliane M. Is suture comparable to wire for cerclage fixation? A biomechanical analysis. Shoulder Elb. 2019;11:225\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003ePeeters I, Depover A, Van Tongel A, De Wilde L. A review of metallic and non-metallic cerclage in orthopaedic surgery: Is there still a place for metallic cerclage? Injury. 2019;50:1627\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eH\u0026auml;gerich LM, Dyrna FGE, Katthagen JC, Michel PA, Heilmann LF, Frank A, et al. Cerclage performance analysis - a biomechanical comparison of different techniques and materials. BMC Musculoskelet Disord. 2022;23:1037. \u003c/li\u003e\n\u003cli\u003eKelly JD, Vaishnav S, Saunders BM, Schrumpf MA. Optimization of the Racking Hitch Knot: How Many Half Hitches and Which Suture Material Provide the Greatest Security? Clin Orthop. 2014;472:1930\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eLaux CJ, Villefort C, El Nashar R, Farei-Campagna JM, Grubhofer F, Bouaicha S, et al. Stand-alone coracoclavicular suture repair achieves very good results in unstable distal clavicle fractures at a minimum follow-up of 1 year. J Shoulder Elbow Surg. 2021;30:2090\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eBorbas P, Angelella D, Laux CJ, Bachmann E, Ernstbrunner L, Bouaicha S, et al. Acromioclavicular joint stabilization with a double cow-hitch technique compared to a double tight-rope: a biomechanical study. Arch Orthop Trauma Surg. 2022;142:1309\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eDumartinet-Gibaud R, Bigorre N, Raimbeau G, Jeudy J, Saint Cast Y. Arpe total joint arthroplasty for trapeziometacarpal osteoarthritis: 80 thumbs in 63 patients with a minimum of 10 years follow-up. J Hand Surg Eur Vol. 2020;45:465\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eDenard PJ, Nolte P-C, Millett PJ, Adams CR, Liebler SAH, Rego G, et al. A Tensionable Suture-based Cerclage Is an Alternative to Stainless Steel Cerclage Fixation for Stabilization of a Humeral Osteotomy During Shoulder Arthroplasty. J Am Acad Orthop Surg. 2021;29:e609\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eGupta AK, Godwin T, Poon P. Is Nice knot suture comparable to wire for cerclage fixation? A biomechanical performance study. JSES Rev Rep Tech. 2022;2:20\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eGrubhofer F, Ernstbrunner L, Bachmann E, Wieser K, Borbas P, Bouaicha S, et al. Cow-hitch fixation in fracture hemiarthroplasty. JSES Int. 2021;5:1027\u0026ndash;33. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eUltimate force and slippage for Dynatape (DT), SutureTape\u003csup\u003e\u0026nbsp;\u003c/sup\u003e(ST), Dynacord (DC) and FibreWire (FW) presented in terms of mean value and standard deviation, together with the p-values from the statistical comparisons between Cow-hitch and Nice-knot (A), 2 versus 3 securing throws (B), and dynamic versus conventional suture material (C).\u003c/em\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e* Indicates significant differences.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eA) Ultimate force and slippage for different knot configurations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.874801901743265%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCluster\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.508716323296355%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.568938193343898%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eThrow\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.148969889064976%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eUltimate force (N \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.19175911251981%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.722662440570524%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSlippage (mm \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.984152139461173%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.884012539184955%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.90302066772655%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eTape\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.538950715421304%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e524.0 \u0026plusmn; 169.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e724.5 \u0026plusmn; 185.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.220985691573928%\"\u003e\n \u003cp\u003e0.001 *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e10.9 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e8.5 \u0026plusmn; 3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.015898251192368%\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eST\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e543.9 \u0026plusmn; 70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e654.5 \u0026plusmn; 67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e6.9 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e7.6 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.560\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e654.5 \u0026plusmn; 67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e823.2 \u0026plusmn; 81.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e7.2 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e6.1 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.362\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eST\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e637.4 \u0026plusmn; 97.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e696.7 \u0026plusmn; 99.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e6.9 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e7.0 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.883\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.90302066772655%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eCord\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.538950715421304%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e382.1 \u0026plusmn; 31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e389.7 \u0026plusmn; 28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.220985691573928%\"\u003e\n \u003cp\u003e0.738\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.015898251192368%\"\u003e\n \u003cp\u003e0.019 *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e211.9 \u0026plusmn; 48.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e267.2 \u0026plusmn; 41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.018 *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u0026infin;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e\u0026infin;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e396.1 \u0026plusmn; 38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e413.0 \u0026plusmn; 29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.459\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e4.3 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e339.6 \u0026plusmn; 60.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e358.1 \u0026plusmn; 49.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e3.9 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eB) Ultimate force and slippage for increasing number of securing knots\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.874801901743265%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCluster\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.508716323296355%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.568938193343898%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnot\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eType\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.148969889064976%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eUltimate force (N \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.19175911251981%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.722662440570524%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSlippage (mm \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.984152139461173%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 Throws\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Throws\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.884012539184955%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 Knots\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 Knots\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.90302066772655%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eTape\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.538950715421304%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e524.0 \u0026plusmn; 169.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e654.5 \u0026plusmn; 67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.220985691573928%\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e10.9 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e7.2 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.015898251192368%\"\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eST\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e543.9 \u0026plusmn; 70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e637.4 \u0026plusmn; 97.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e6.9 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e6.9 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.983\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e724.5 \u0026plusmn; 185.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e823.2 \u0026plusmn; 81.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e8.5 \u0026plusmn; 3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e6.1 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eST\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e654.5 \u0026plusmn; 67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e696.7 \u0026plusmn; 99.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.502\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e7.6 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e7.0 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.646\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.90302066772655%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eCord\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.538950715421304%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e382.1 \u0026plusmn; 31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e396.1 \u0026plusmn; 38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.220985691573928%\"\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e4.3 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.015898251192368%\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e211.9 \u0026plusmn; 48.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e339.6 \u0026plusmn; 60.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u0026infin;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e3.9 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e389.7 \u0026plusmn; 28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e413.0 \u0026plusmn; 29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.309\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e267.2 \u0026plusmn; 41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e358.1 \u0026plusmn; 49.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u0026infin;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eC) Ultimate force and slippage for different suture and tape technologies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.874801901743265%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCluster\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.508716323296355%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eThrow\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.568938193343898%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnot\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eType\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.148969889064976%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eUltimate force (N \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.19175911251981%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.722662440570524%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSlippage (mm \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.984152139461173%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDynamic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003eConventional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.884012539184955%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDynamic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.705329153605014%\"\u003e\n \u003cp\u003e\u003cstrong\u003eConventional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.90302066772655%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eTape\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.538950715421304%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e524.0 \u0026plusmn; 169.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e543.9 \u0026plusmn; 70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.220985691573928%\"\u003e\n \u003cp\u003e0.619\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e10.9 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e6.9 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.015898251192368%\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e724.5 \u0026plusmn; 185.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e654.5 \u0026plusmn; 67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e8.5 \u0026plusmn; 3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e7.6 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.413\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e654.5 \u0026plusmn; 67.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e637.4 \u0026plusmn; 97.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e7.2 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e6.9 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e823.2 \u0026plusmn; 81.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e696.7 \u0026plusmn; 99.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.048*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e6.1 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e7.0 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.439\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.90302066772655%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eCord\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.538950715421304%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e382.1 \u0026plusmn; 31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e211.9 \u0026plusmn; 48.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.220985691573928%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.605723370429253%\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.036565977742448%\"\u003e\n \u003cp\u003e\u0026infin;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.015898251192368%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e389.7 \u0026plusmn; 28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e267.2 \u0026plusmn; 41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e\u0026infin;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCow-hitch\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e396.1 \u0026plusmn; 38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e339.6 \u0026plusmn; 60.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.016*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e3.9 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.406\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.471204188481675%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNice-knot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e413.0 \u0026plusmn; 29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e358.1 \u0026plusmn; 49.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.122164048865619%\"\u003e\n \u003cp\u003e0.019*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.739965095986038%\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.31064572425829%\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.99476439790576%\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDT = Dynatape, ST = Suturetape, DC = Dynacord, FW = Fibrewire, Dynamic = DT \u0026amp; DC, Conventional = ST \u0026amp; FW\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4286165/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4286165/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: \u0026nbsp;Recently, a new dynamic high-strength round suture (DC) was introduced featuring a salt-infused silicone core attracting water in a fluid environment to preserve tissue approximation which is also available in tape form (DT). The aims of this study were to (1) assess the influence of securing throw number on knot security of two double-stranded knot configurations (Cow-hitch and Nice-knot) tied with either dynamic (DC and DT) or conventional round sutures (FW) and conventional suture tapes (ST), and (2) compare the ultimate force and knot slippage of (a) Cow-hitch and Nice-knot and (b) DC and DT versus FW and ST when used with their minimal number of needed securing throws.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Seven specimens of each FW, ST, DC and DT were considered for tying with Cow-hitch or Nice-knots. The base of these Cow-hitch and Nice-knots were secured with surgeons’ knots using 1–3 alternating throws. Tensile tests were conducted under physiologic conditions to evaluate knot slippage, ultimate force at rupture, and minimum number of throws ensuring 100% knot security.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: For both Cow-hitch and Nice-knots, 100 % security was achieved with 2 securing throws for DC, DT, ST, and with 3 securing throws for FW. With these minimum numbers of securing throws, ultimate force was significantly higher for Nice-knots versus Cow-hitch tied with DT (p=0.001) and slippage was significantly less with Nice-knots versus Cow-hitch tied with DC (p=0.019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The minimum number of securing throws required to achieve 100% security was 2 with DC, DT and ST for both with Cow-hitch and Nice-knots configurations, in contrast to FW where 3 securing throws were needed. With these minimum numbers of securing throws, Nice-knots were associated with significantly higher ultimate forces when using DT and lower slippage with DC versus Cow-hitch knots.\u003c/p\u003e","manuscriptTitle":"Biomechanical evaluation of double stranded knot configurations in high strengths sutures and tapes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-24 15:04:58","doi":"10.21203/rs.3.rs-4286165/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-20T15:50:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-17T09:44:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332585841711404368584493461039952857928","date":"2024-05-08T07:47:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-20T16:26:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-20T16:24:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-20T07:11:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2024-04-18T08:17:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"aa73911d-468c-4917-b710-225b48dafc6f","owner":[],"postedDate":"April 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-27T20:37:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-24 15:04:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4286165","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4286165","identity":"rs-4286165","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}