title: Optimization of the racking hitch knot: how many half hitches and which suture material provide the greatest security?
abstract: BACKGROUND
  Reliable methods of fixation of soft tissue and bone are of utmost importance in reconstructive shoulder surgery and in many orthopaedic applications. Current methods of securing lesser tuberosity osteotomies performed during shoulder arthroplasty and tuberosity fixation performed during repair of proximal humeral fractures often rely on alternating half hitches or surgeon's knots regardless of the suture configuration used passing through the tissue (eg, Mason-Allen, Krackow). The racking hitch knot in contrast to half hitches allows sequential tightening, even under tension, with minimal risk of knot slippage or premature locking. These knot characteristics allow the surgeon to stepwise improve their reduction before committing and locking a construct, preventing hanging knots or under-tensioned repairs. However, little data exist to support the use the racking hitch knot to guide decision making regarding how to back up the knot or to explain the effect of suture material on security and strength.
  
  
  OBJECTIVE
  The objectives of our study were (1) to identify the optimal number of half hitches necessary to maintain knot security for a single knot; (2) to evaluate if a difference exists in the relative behavior of racking hitch knots when tied using different suture materials; and (3) to define the biomechanical differences between the racking hitch and two other knot configurations commonly used in shoulder surgery (Weston and square knots).
  
  
  METHODS
  Using an Instron device we tested the effect of adding supplemental half hitches (from one to four) to the racking hitch. Additionally, a selection of commercially available braided nonabsorbable polyethylene sutures and different knot configurations (racking hitch, Weston knot, and square knot) also were tested. Data were compared using ANOVA.
  
  
  RESULTS
  Increasing the number of half hitches improved knot performance in peak load testing and cyclic testing, revealing a significant difference between the racking hitch supplemented with one and four half hitches (199.2 N versus 428.8 N, p < 0.05). Force Fiber™ #2 (359.6 N) and FiberWire(®) #2 (302 N) showed increased loads to failure compared with Ethibond Excel™ #2 or Force Fiber™ #3/4, whereas Ethibond Excel™ had the least amount of slippage during cyclic testing (0.09 mm). The racking hitch knot had considerably higher loads to failure (359.6 N) than the Weston (145.2 N) or square (77 N) knots.
  
  
  CONCLUSIONS
  The racking hitch knot exhibited significantly higher loads to failure and comparable knot slippage (elongation during cyclic testing) when compared with other commonly used knots. According to the biomechanical data, the addition of four half hitches to supplement the racking hitch and the choice of FiberWire(®) #2 or Force Fiber™ #2 suture resulted in increased knot security.
  
  
  CONCLUSIONS
  This knot adds a tool to the arsenal for surgeons best suited for repairs requiring a high degree of knot security and reliable tissue tensioning.
authors: San Francisco Shoulder, Elbow, and Hand Clinic, 2351 Clay Street, Suite 510, San Francisco, CA, 94115, USA.
authors: James D
authors: JD
authors: Kelly
authors: Suketu
authors: S
authors: Vaishnav
authors: Bradley M
authors: BM
authors: Saunders
authors: Mark A
authors: MA
authors: Schrumpf
mesh_terms: D001178:Arthroplasty; D004867:Equipment Design; D004868:Equipment Failure; D019544:Equipment Failure Analysis; D006801:Humans; D008422:Materials Testing; D019637:Orthopedic Procedures / Q000295:instrumentation* / Q000379:methods; D010027:Osteotomy; D019651:Plastic Surgery Procedures; D012782:Shoulder / Q000601:surgery*; D013314:Stress, Mechanical; D013536:Suture Techniques / Q000295:instrumentation*; D013537:Sutures