title: Reverse Flipping Technique: An Alternate Approach to Tie Reversing Half-Hitches on Alternating Posts.
abstract: Arthroscopic knot tying requires practice and attention to detail, especially tying the 3 reversing half-hitches on alternating posts (RHAPs) in a knot. Mistakes can occur that result in an unintentional tension (>10 N) applied to the wrapping suture limb, and by placing tension in the wrong limb, the previously "flipped" half-hitch is converted from a series of RHAPs into a series of identical half-hitches on the same post, thereby producing insecure knots or suture loops. This was hypothesized to be a source of knot failure by knot slippage. This error can be avoided by using a technique we describe as "reverse flipping," which purposely "flips" the half-hitch down at the main knot while tying the 3 RHAPs in a knot, and then the half-hitch is retightened using either a past-pointing or over-pointing technique. This way the surgeon can be absolutely sure that the half-hitch is tightened in the direction that it was intended to be placed, and can also prevent the unintentional tension applied to the wrapping suture limb that causes the half-hitch to "flip." However, caution should be used when tensioning the half-hitches; overtensioning (>40 N) during past-pointing or over-pointing could also potentially "flip" the previous half-hitch that has already been tightened and cause potential knot failure.
authors.affiliation: Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.
authors.forename: Alexander C M
authors.initials: AC
authors.lastname: Chong
authors.affiliation: Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Advanced Orthopaedics Associates, Wichita, Kansas, U.S.A.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Prohaska
authors.affiliation: Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Robert J. Dole VA Medical Center, Wichita, Kansas, U.S.A.
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Pate