Knot Security 101: A Comprehensive Practical Review to Optimal Knot Configuration, Pulling Direction, Throw Count,...

Area of Science:

• Surgical techniques
• Biomaterials science
• Medical device engineering

Background:

• Suture knots represent the weakest point in a suture line, compromising the integrity of surgical closures.
• Understanding factors influencing knot security is crucial for preventing suture failure and improving patient outcomes.
• This review focuses on general surgical knots, excluding those exclusively used in laparoscopic or arthroscopic procedures.

Purpose of the Study:

• To critically evaluate factors affecting suture knot security.
• To identify key variables including suture material properties, gauge, configuration, throw count, and tail length.
• To synthesize existing literature on knot security in general surgery.

Main Methods:

• A comprehensive literature search was conducted on PubMed from 1934 to 2023.
• Studies focusing solely on laparoscopic and arthroscopic surgery knots were excluded.
• Included studies analyzed various knot configurations such as Aberdeen, sliding, square, and surgeon's knots.

Main Results:

• Knot security demonstrates significant variability based on suture material, gauge, and configuration.
• Optimal throw counts differ by knot type; Aberdeen knots require fewer throws (3) than surgeon's or square knots (3-5).
• An optimal tail length of 3mm was identified, and knot security is influenced by stitch type and environmental conditions.

Conclusions:

• Knot security is multifactorial, with substantial differences observed across various parameters.
• Proposing a universally ideal knot is challenging due to limited studies evaluating a wide range of parameters for each knot type.
• Further rigorous research is necessary to establish definitive guidelines for optimal knot selection and technique.