Understanding surgical knot security: A proposal to standardize the literature

BACKGROUND: There is very little published data concerning the knot handling properties of suture materials. The few studies that are available on this subject contain discrepancies in nomenclature, testing methods, and in the type of data reported. To date, there has been no effort to present what is currently known concerning knot security in a unified format. STUDY DESIGN: A review of the literature was conducted to determine what is currently known concerning surgical knots, the efficiency of these knots, testing techniques, and nomenclature. The structures of common surgical knots were analyzed and their relationships determined. The results of the various studies were analyzed and a summary of existing data was prepared. RESULTS: Based on current literature and a thorough analysis of surgical knots, a standard method for testing knot efficiency and a standard nomenclature were proposed. Suture security has been shown to be strongly influenced by the type of knot used. Knots in which the second throw contains two turns are most efficient. CONCLUSIONS: Existing studies have demonstrated a strong variation in the efficiency of different surgical knots. Standards for testing and nomenclature have been presented. Effort now needs to be directed in three areas: simulating in vivo conditions, testing knots under these conditions, and determining the factors that make some suture materials more efficient in knot holding than others.