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关节镜下打结技术•Anincreasingnumberofsurgeonsareperformingarthroscopicsurgeryinthekneetorepairmeniscaltearsa

ndintheshouldertorepairrotatorcufforlabraltears•Manyarealsoperformingcapsularshiftstotreatinstability.•Essentialtotheseproce

duresistheabilitytotiearthroscopicknotstoapproximateintraarticularIntroduction•Thesurgeonmustsequentiallyconstructtheknotoutsidethejointan

dthenpasstheknotintothejointthroughsmallcannulas•Tyingarthroscopicknotsistechnicallydemandingandrequiresconsiderableprac

tice•Withthepopularityofarthroscopicsurgery,thenumberofusedarthroscopicknotsandthenumberofsurgeonsusingtheseknotshasincreasedKnotTyin

gPrinciples•Thegoalofknottyingistoapproximatetissueundertensionandmaintainthetissueinappositionuntilbiologicrepairandhealing

canoccur•Itisimperativeforallsurgeonstolearnanduseknot-tyingtechniquesthatminimizethechanceofknotfailure•Knotsecurity

friction,internalinterference,andslackbetweenthrows•Frictionisinherenttothesuturematerial•Internalint

erferencetheconfigurationoftheknotandincreasedbythelengthofthecontactbetweenthelooplimbandthepostlimb•slackbetweentheindividualthro

wsineachknottomaximizeloopsecurity•slippagecanleadtofailureoftissueappositionKnotTyingPrinciples◆fourdifferentprocessesofknotfailure➢kno

tslippageandloosening➢suturebreakage➢tissuefailure➢sutureanchorpulloutfrombone➢throughsuturebreakageKnotfailureKnotTerminology•postlimb(also

commonlyknownastheaxiallimb)•looplimb(alsocommonlyknownasthewrappinglimb,workingend,runningend,orfreeend)•Knotsareconstructedbytying

thelooplimbaroundthepostlimb(Fig.1)FIGURE1.LoopandpostconfigurationArthroscopicKnotPushers•Anarthroscopicknotpusherisadevi

ceusedtoadvancetheloopdownthepostlimbintothejointtocreatetheknot.Arthrexknotpushers.A.Single-hole,B.Doub

le-hole,C.6thFingerFIGURE3.Mitekknotpushers.A.Single-hole,B.Double-hole,C.Slotteddouble-holeknotpushersanddoublediameterknot•doub

le-holeknotpushersanddoublediameterknotpushersliketheArthrex6thFinger(Arthrex,Naples,FL).Double-diameterknotpush

ersprovidebetterloopsecuritycomparedtostandardsingle-holeknotpushersDouble-holeknotpusherFIGURE4.Double-holeknotpusher.HowtoUsetheDouble-Dia

meterKnotPusherFIGURE5.A-F.TyingknotswiththeArthrex6thfingerSutureProperties•Twotypesofsuturesarecommonlyusedint

yingarthroscopicknots:apermanent,braided,polyester,nonabsorbablesutureandanabsorbable,monofilamentsuture•Exa

mplesofpermanent,braided,polyester,nonabsorbablesuturesareEthibondandTicron•Examplesofabsorbable,monofilamentsuturesarePDSII,poly

diaxononeandMaxon,polyglyconate•Braidedpolyesterhasincreasedpliability,ductility,ahighercoefficientoffrictionandgrea

terstrengththandoesabsorbablemonofilament•Becausethebraidedsutureismorepliable,thevolumeoftheknotisdecreasedandtheseknotscanbe

cinchedtighter.KnotstiedwithEthibondwereshowntobestrongerwhencomparedtoPDSIIinseveralbiomechanicalstudies•However

,braidedpolyestermayfraywithexcessivehandling,whichmayleadtosuturerupture◆Braidedpolyestersuturemaybecoatedto:➢

improvesurgeonhandling➢reducefrictionbetweenthesutureandsurroundingtissue,whichcanleadthetissuedamage➢decre

asefrictionbetweensuturelimbs,whichmayleadtofraying➢However,suturecoatingdecreasesthecoefficientoffrictionoftheknot,whichtheoretic

allyincreasestheriskofknotslippage•Knotstiedwithabsorbable,monofilamentsuturesareeasiertoslidedownapostanddon

otfray•Thereislessfrictionbetweenthesutureandsurroundingtissueleadingtolesspotentialtissuedamagewhen

thesutureispulledthroughthetissue•absorbablesuturesdissolveanddonotleaveknotsthatmaycauseapersistentinflammato

ryreactionaftertissuehealing•Absorbablesuturescanapposetissueunderstressforapproximatelysixweekswithcom

pleteabsorptionoccurringinapproximatelysixmonths•However,absorbablemonofilamentsuturesarehardertohandlethanpolye

stermakingitmoredifficulttokeepknotstightandsecure•Also,aabsorbablemonofilamentsuturewillfailearlierwithcyclicloadingthanpolyeste

rsutureandmayexpandbyplasticdeformationmorethan30%ofitslengthbeforebreaking•Thesizeofthesutureisalsoafactorindetermi

ningaknot'sholdingcapacityandalsothetensilestrengthofthesutureitself•Clinicalfailureofallknotsandsuturetypesimprovedby100%whensuturesizewasincreased

by2gaugesUSP(U.S.Pharmacopeia.•ThesizesuturemostcommonlyusedinarthroscopicsurgeryisNo.1orNo.2.KnotTypes•Thereareavarietyofknotincludenonsliding

knots,slidingknots,andlockingknots.•Nonslidingknotsareknotsthatdonotslidethoughthetissuesbeingapposed.Theyincludethesquareknotandknotsconsis

tingofaseriesofhalfhitchesliketheRevoknot(34)•Althoughthesquareknotfailsathigherloadsthandoseriesofhalfhitchesinhand-tiedknots(38),thesquareknotisno

tcommonlyusedarthroscopically.•Thesquareknotisaflatknotinwhichbothstrandsenterandleavetheknotparalleltoeachother(

Fig.6).•Inordertotieasquareknot,symmetrictensionmustbesimultaneouslyappliedtoeachlimb,whichisdifficulttodoarthroscopically

•Ifasymmetrictensionisappliedtooneofthelimbs,theknotconvertstotwononidenticalhalfhitches•Thus,mostarth

roscopicsurgeonspreferusingaseriesofhalfhitchesFIGURE6.Squareknotconfiguration.•Slidingknots,liketheDuncanloop(27),areusef

ulinopposingtissueundertension.Whiletyingaslidingknot,thepoststrandisheldundertensionwhiletheloopstrandistiedaroundit.Becausethepoststrandisnoti

ncorporatedintothestructureoftheknot,theknot,oncetied,caneasilymovedownthepostresultinginaslidingknotinsteadofaflatknotsuchasthesquareknot.

•Oncetheslidingknotsareseated,theyareoftenlockedwithaseriesofhalfhitches.Someslidingknotspreferentiallyslidein

onlyonedirection•Alockingknotisamodificationofaslidingknot•Asimpleslidingknotcanloosenbeforeaseriesofhalfhitchesarethrownto“lock”theslidingkno

tinplace•lockingknots(alsoknownasflipknots)havebeendevelopedtomaintaininitialloopsecuritythatdoesnotloosenwhentensionisremoved•Thepoststra

nd“flips,”convertingtheloopstrandintothenewpoststrandandlockingtheknotintoplace.AnexampleofalockingknotistheSMCknot.lockingkno

tsdonotneedtobesupplementedwithaseriesofhalfhitches•Theauthorsofthismanualhavefoundlockingknotswithoutreinforci

nghalfhitchestobeinferiorintensilestrengthtoknotsreinforcedwiththreereversedhalfhitchesonalternatingposts(

unpublisheddata)•Lockingandslidingknotscanbeadvancedintothejointjustbypullingonthepost.Thiscancausetensionat

therepairsite,whichcandamagethetissuebeingapposed.Tensionattherepairsitecanbeminimizedbypushingtheknotaheadwiththeknotpusherwhil

esimultaneouslypullingonthepostlimb.Withlockingandslidingknots,itisimportantthatthelooplimbisatleasttwiceaslongasthepostlimb.Ifitisno

t,whenpullingthepostlimbtoadvancetheknotthroughthecannulaandintothejoint,theshortenedlooplimbmaybepulledintothecannulamakingitimpossibletosecurethekn

ot.•Whenusingaslidingorlockingknotconfiguration,itisimportanttoensurethatthesutureslideseasilythroughthetissuebeingopposed.Ifthesuturedoesnotslideeas

ily,thesurgeonshouldconsiderusinganonslidingknot.KnotPushingandPulling•Knotconfigurationscanbeeitherpushedorpu

lledintothejoint.hearthroscopicknot-tyingdeviceispositionedonthelooplimbandisadvancedpastthehalfhitchthuspullingtheloopoverthepostlimb

intothejoint(Fig.7A).•Thearthroscopicknot-tyingdeviceispositionedonthepostlimbbehindtheknotthuspushingtheloopoverthepostlimbint

othejoint(Fig.7B).FIGURE7.A.Knotpulling,B.Knotpushing.TyingHalfHitches•Usingtheonehandknot-tyingtechnique,halfhitchescanbetiedeitherunderhandorover

hand•ThefollowinginstructionsdefineanunderhandloopandanoverhandloopFIGURE8.A-E.Underhandhalfhitch.ConfigurationofHalfHitches•Ha

lfhitchescanbethrowninthesamedirection(twosuccessiveoverhandhitches)orcanbethrowninoppositedirections(an

overhandhitchfollowedbyanunderhandhitch)•Halfhitchescanalsobetiedonoppositeposts.TeraandAberg(37)developedanomenclat

urefordescribingflatknots.PostSwitchingFIGURE13.A.Parallelloopandpostlimbs.B.Parallelloopandpostlimbswi

tha“flat”knot.FIGURE14.A.Twistedloopandpostlimbs.B.Whentyingaknotwithtwistedpostandlooplimbs,theknotdoesnotlie“fl

at.”C.Thefinalknotconfigurationwilllooseniftheknotistiedwhentheloopandpostlimbsaretwisted.•ChanandBurkhartdescribedamayincreasethespeedofthekno

t-tyingprocessandalsohelplimittwistingofthesuturelimbs.Onecan“flip”ahalfhitchbyreleasingtensiononthepostlimbandpullingontheloopl

imb.•Whenthepostisswitched,thedirectionofthehalfhitchisalsoreversed.Theauthorsofthistechniquereportthatitiseasie

rtofliphalfhitchesusingmonofilamentbecauseitmorereadilyconvertstoaflatknot,butitcanalsobedonewithbraidedsuture.•H

oldthepostinthenondominanthandandtheloopinthedominanthand(Fig.15A).•Movetheoriginalpostforwardandaheadofthehalfhitch.•Apply

paralleltractiononthepostandloopsimultaneouslyconvertingthehalfhitchtoaflatknot(Fig.15B).•Applyaxialtractiontothelooplimbconvertingitintothenewpos

tlimbandthehalfhitchisreversed(Fig.15C).PostSwitchingTechniqueFIGURE15.A-C.PostswitchingtechniqueArthroscopicKnot-TyingTechniques

•Itisimportanttodetermineifthesutureslidesthroughthetissueandsutureanchorpriortoknottying.Ifthesuturedoesnotreadilyslide,aslidingorlockingknotsh

ouldnotbeusedandanonslidingknotshouldbechosen•Onlyonepairofsuturesshouldbewithintheworkingcannuladuringarthro

scopicknottying.Ifmorethanonepairofsuturesarewithintheworkingcannuladuringtying,thereisahighlikelihoodthatthesutureswillbecometwistedandkno

ttyingwillbecomequitetediousifnotimpossible.Additionalsuturesshouldbeshuttledviaamonofilamentsuture(lesstissueabrasion)orbyanarthroscopicgras

pertoanaccessoryportal•Transparentcannulasarerecommendedforarthroscopicknottying.Thesecannulasallowthesurgeontos

eeifthereisanytwistingofthesuturestrandspriortoknottying•Thearthroscopicsurgeonshouldensurethatthereisnoredundantsof

ttissuearoundthetissuebeingapposedorinthepathofthesuturelimbsbecausethiswillimpedeknottyingandincreasethelikelihoodofknotfa

ilure•Whentyinghalfhitcheswithastandardsingle-holeknotpusher,thefirstthrowcommonlyslipswhentheknotpush

erisremovedinpreparationforthesecondthrow•Whenthesecondthrowisadvanced,thereisachancethatthehitcheswilllockpriortoc

ompleteappositionofthetissue•Topreventthis,thesurgeoncanthrowthefirsttwohitchesinthesamedirectionallowingthehitchestosl

idedowntheposttoapposethetissue•Anothermethodofpreventinginitiallooplooseningistouseadouble-diameterknot-pushingdevice,su

chastheArthrex6thtomaintaintensionontheinitialhitchwhilethrowingthesecondhitchNon-SlidingKnotsFIGURE16.A-F.Squareknot.RevoKnot•

TheRevoknotisaseriesofmultiplehalfhitchesmadebyalternatingthepostanddirectionofthehalfhitches.Therehavebeenseveralmo

dificationstotheRevoknotFIGURE17.A-H.OriginalRevoknot.•TheOriginalRevoknotconsistsoftworeversedhalfhitchesonanidenticalpostfollowedbypost

switchingandtworeversedhalfhitches.•Throwanoverhandlooparoundthepost(Fig.17A).•Pulltheloopintothejoi

ntwiththeknotpusheronthelooplimb(Fig.17B)•Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb.•

Throwanunderhandlooparoundthesamepost(Fig.17C)•Pulltheloopintothejointandseattheknotwiththeknotpusher.Once

thetwohitchesareseated,past-pointtocinchtheknotdown(Fig.17D).•Switchpostsandthrowanunderhandlooparoundthenewpost(Fig.17E).•Pullth

eloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown(Fig.17F).•Next,throwanoverhandlooparoundthe

post(Fig.17G).•Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown.(Fig.17

H)Snyder'sKnotSnyder'sKnot•Snyder'sisanothervariationoftheRevoknot•Throwanoverhandlooparoundthepost(Fig.18A).•Pul

ltheloopintothejointwiththeknotpusheronthelooplimb(Fig.18B)•Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb.•

Throwanunderhandlooparoundthesamepost(Fig.18C)•Pulltheloopintothejointandseattheknotwiththeknotpusher.Oncethetw

ohitchesareseated,past-pointtocinchtheknotdown(Fig.18D).•Switchpostsandthrowanoverhandlooparoundthenew

post(Fig.18E).•Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown(Fig.18F).•Next,throwanunderhandlooparoundthe

post(Fig.18G).•Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown(Fig.18H).•Switchpostsandthrowanoverhan

dlooparoundthenewpost(Fig.18I).•Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpastpointtocinchtheknotdon(Fi

g18J)FIGURE19.A-K.Revoknot.•ThecurrentRevoknotisamodificationoftheOriginalRevoknot•Throwanunderhandlooparoundthepost(Fig.19A).•Advancetheloopwithth

eknotpusheronthelooplimbuntilthefirsthalfhitchisseated(Fig.19B).•Withdrawtheknotpusherwhilemaintainin

gtensiononthepostlimb.•Throwanotherunderhandlooparoundthesamepost(Fig.19C).•Pulltheloopintothejointandseatthek

notwiththeknotpusher.Oncethetwohitchesareseated,past-pointtocinchtheknotdown(Figs.19D,E).•Throwanoverhandhalfhitcharoundthepostandadvancewit

htheknotpusher(Fig.19F).•Furthertensionbypastpointingandapplytensiononbothlimbswhileholdingthe(Fig.19G).•Switchpostsandthrowanunderhandloop

aroundthenewpost(Fig.19H).•Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpastpointtocinchthekno

tdown(Fig.19I).•Switchpostsandthrowanoverhandlooparoundthenewpost(Fig.19J).•Pulltheloopintothejoint,seattheknotwiththeknotp

usher,andpastpointtocinchtheknotdown(Fig.19K).SlidingKnots•OverhandThrowDuncanLoop•TheDuncanloopwasoriginallydescrib

edinthefishingliterature(Uni-Knot)andhasbeenmodifiedforuseinarthroscopicsurgery.ThearthroscopicDuncanloopis

alsoknownastheFisherman'sknotortheHangman'sknotThedifferencebetweenthefishingknotandthearthroscopicknot

isthedirectiontheloopstrandtravelsaroundthepost.WhentyingthefishingDuncanloop,onewrapsthelooplimbaroundthepostinad

irectionawayfromthejoint.TotiethemodifiedDuncanlooporHangman'sknot,thesurgeonsequentiallywrapsthelooplimbaroundthepost

inadirectiontowardthejointFIGURE21.A-F.FishingDuncanloop.BerkleyDuncanLoopKnotArthroscopicDuncanLoop(Hangman'sKnot)(Fig.22)FIGURE22.A-F.Arthroscopi

cDuncanloop.Frenchknot.FIGURE23.A-H.FIGURE23.A-H.Frenchknot.•TheFrenchknot(22)isaslidingknotthatisamodificationoftheDunca

nloop.•Makethepostlimbhalfaslongasthelooplimb.•Graspthesuturesbetweenthethumbandindexfingerofyournon-dominanthand(Fig.23A).•Createasmallcirclein

theloopstrandbypassingtheloopoverthecombinedpostandloopstrandsandholditbetweenyourthumbandindexfinger(Fig.23B).•Makeatotaloffour

loopsaroundboththepostandthelooplimbstravelingtowardthejoint(Fig.23C).•Passthetailoftheloopstrandoverandthroughthesmall

circleintheloopstrandthatisheldbetweenthethumbandindexfinger(Fig.23D).•Passthetailoftheloopstrandunde

randthroughtheloopcirclecreatedbythedistalendoftheloopstrandandthecombinedlimbsoftheloopandpoststrands(Fig

.23E).•Pullonboththelooplimbandthepostlimbsymmetricallytotightentheknot(Fig.23F).•Advancetheknotbypullingonthepostlimbwhilepushin

gtheknotdownwiththeknotpusheronthepoststrand(Fig.23G).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.23H).–Throwanunde

rhandloopontheoriginalpost.Tensionwiththeknotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.–Swit

chposts.–Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.•TheFrenchknotwasshowntohaveahigherloadtofailurew

hencomparedtotheDuncanloopandtheRevoknotRoederKnot•TheRoederknotisaslidingknotthatisavariationoftheDuncanloop.Itwasoriginallyusedintonsillec

tomysurgeryanddescribedintheGermanliteraturebyRöderin1918•Therehavebeenseveralmodificationsoftheknotthathavebeendescribeds

incetheinitialdescriptionoftheknot.ModificationsoftheRoederknotarecurrentlyusedinbothlaparoscopicandarthroscopicsurgeryFIGURE24.A-G.Roe

derknot.•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Throwthefirstlooparoundthepostlimbandthenholdtheloopandpost

togetherwiththethumbandindexfingerofthenon-dominanthand(Fig.24A).•Throwasecondlooparoundboththepostandlooplimbs(Fig.24B

).•Throwathirdlooparoundonlythepostlimbandbetweenthepostandloop(Fig.24C).•Passthetailoftheloopbetweenthesecond

andthirdturnsandinbetweenthelooplimbandthepostlimb(Fig.24D).•Tensiontheknotbygentlypullingonboththepo

standthelooplimbssimultaneously(Fig.24E).•Whilepullingonthepostlimb,pushtheknotintothejointwiththeknotpusheronthepoststrand(Fig.24F).•Locktheknotwit

haseriesofthreealternatinghalfhitcheswithpostswitching(Fig.24G).–Throwanunderhandloopontheoriginalpost.Tension

withtheknotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.–Switchposts.–Throwanunderha

ndloopontheoriginalpostagain.Tensionwiththeknotpusher.•TheRoederknotwasshowntobeinferiortotheDuncanloopandtheSny

derknotinloadtoclinicalfailuretrialsbutastatisticalsignificancewasnotfound(26).Savoie-ModifiedRoederKnot(Fig.25)•The

Savoie-ModifiedRoederknotisalockingknotinsteadofaslipknot•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Throw

anunderhandlooparoundthepoststrand(Fig.25A).•Throwasecondlooparoundboththepostandlooplimbs.Besuretoleaveasmall“hole”intheloopprio

rtothrowingthesecondloop(Fig.25B).•Throwathirdlooparoundboththepostandlooplimbs(Fig.25C).•Throwafourthlo

oparoundboththepostandlooplimbs(Fig.25D).•Wrapthelooplimbaroundonlythepostandbringitawayfromthejoint(Fig.25E).•Passthetailofthelooplimbbetweenthe“h

ole”madeinstepC(Fig.25F).•Looselytensiontheknotbutdonotpullontheloopstrandorthiswillprematurelylocktheknot(Fig.25G).•Whilepullingonthepostlimb,p

ushtheknotintothejointwiththeknotpusheronthepoststrand.•Whentheknotisseated,pushdownontheknotpushertoholdtheknotinplaceandwhilemaintainingten

siononthepoststrand,pullontheloopstrandtolocktheknot.Thiswillpreventtheknotfromlooseningoncetensionisreleasedfromthest

rands(Fig.25H).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.25I）Lieurance-ModifiedRoederKnot(Fig.26)FIGURE26.A-H.Lieur

ance-ModifiedRoederknot.•TheLieurance-ModifiedRoederknotisalockingknotinsteadofaslipknot•Thepostlimbshouldbeone

halfthelengthofthelooplimb.•Throwanoverhandlooparoundonlythepoststrand(Fig.26A).•Throwasecondloopacrossboththepostandlooplimbs(Fig.26

B).•Throwathirdloopacrossboththepostandlooplimbs(Fig.26C).•Wrapthelooplimbaroundthepostonlyandbringitbetweenthepostandloop

limbs(Fig.26D).•Passthetailofthelooplimboverandthroughtheinitialloopmadebythepostandlooplimbs(Fig.26E).•Looselyt

ensiontheknotbutdonotpullontheloopstrandorthiswillprematurelylocktheknot(Fig.26F).•Whilepullingonthepostlimb,pushtheknotintoth

ejointwiththeknotpusheronthepoststrand.•Whentheknotisseated,pushdownontheknotpushertoholdtheknotinplaceandwhilemaintainingtensiononthepoststrand,pu

llontheloopstrandtolocktheknot.Thiswillpreventtheknotfromlooseningoncetensionisreleasedfromthestrands(Fig.26G).•Locktheknotwith

aseriesofthreealternatinghalfhitcheswithpostswitching(Fig.26H）LaparoscopicRoederKnot(Fig.27)TennesseeS

lider(Fig.28)FIGURE28.A-F.TennesseeSlider.•TheTennesseeslider(27)isabunt-linehitch,aknotinitiallyusedinsailing,withhalfhitchesthrowninalternatedire

ctionsonoppositeposts.•Thepostlimbshouldbeapproximatelyhalfthelengthofthelooplimb.•Throwtheloopoverandaroundthepostlimb(Fig.28A).•throwtheloopstra

ndaroundthepostlimbclosertothejointthantheprecedingloop(Fig.28B).•Passthetailoftheloopstrandthroughtheinitialloop(Fig.28C

).•Tensiontheknotbygentlypullingbothsuturelimbssimultaneously(Fig.28D).•Pushtheknotintothejointwiththeknotpusherwi

ththeknotpusheronthepoststrandwhilesimultaneouslypullingonthepoststrand(Fig.28E).•Locktheknotwiththreealterna

tinghalfhitcheswithpostswitching(Fig.28F).EasyKnot(Fig.29)FIGURE29.A-E.Easyknot•TheEasyknotisaslidingknotthatconsistsofaseriesoffiveoverhandhalfhit

chesthatislockedwithanoverhandhitchontheoppositepost(2).•Thepostlimbshouldbeapproximatelyhalftheleng

thofthelooplimb.•Throwanoverhandhalfhitcharoundthepost(Fig.29A).•Throwfouridenticaloverhandhalfhitches.Eachhalfhitchshouldbethr

owndistal(fartherfromthejointandarthroscopiccannula)thanthepreviousthrow(Fig.29B).•Tensiontheknotbyg

entlypullingsimultaneouslyonboththepoststrandandloopstrandsimultaneously.•Pushtheknotintothejointwiththeknotpusheronthepos

tstrandwhilesimultaneouslypullingonthepost(Fig.29C).•Switchposts.•Throwanoverhandhalfhitcharoundthenewpost(Fig

.29D).•Advancethelockinghalfhitchbypullingthehitchintothejointwiththeknotpusherontheloopstrandandpastpointt

ocinchtheknotdown(Fig.29E).LafosseKnot(Fig.30)FIGURE30.A-J.Lafosseknot•TheLafosseknotissimilarinstructuretotheEasyknotbuti

ncorporatesthepostswitchingtechnique.•Thepostlimbshouldbeapproximatelyhalfthelengthofthelooplimb.•Throwanoverhandhalfhit

charoundthepostwhilemaintainingtensiononthepoststrand(Fig.30A).•Throwfouridenticaloverhandhalfhitches.Ea

chhalfhitchshouldbethrowndistalthanthepreviousthrow.Ensuretomaintaintensiononthepoststrand(Fig.30B).•Pushtheknotintothejointw

iththeknotpusheronthepoststrandandwhilesimultaneouslypullingonthepost(Fig.30C).•Crosstheknotpusherovertheloopstrandattheleveloftheknot,p

ulltensionontheloopstrand,andpast-point.Thiscausestheposttoswitchandthelasthitchreversestolocktheslidingknot(Fig.30D).•Atthispoint,iftheknotisnottigh

tenough,pullontheinitialpostandthehalfhitchreversestherebyunlockingtheknot.Theknotcanbefurthertightenedbypullingonthepostan

dpushingtheknotdownwiththepusher.TheknotcanberelockedinthemannerdescribedinstepE.•Throwanoverhandhalfhitcharoundthesa

mepost(Fig.30E).•Withtheknotpusheronthepoststrand,advancethelockinghalfhitchbypushingthehitchintothejo

intwiththeknotpusher(Fig.30F).•Crosstheknotpusherovertheloopstrandattheleveloftheknot,pulltensionontheloopstrand,andpast-

point.Thiscausestheposttoswitchandthehitchtoreversedirections(Fig.30G).•Throwasecondoverhandhalfhitcharoundthesamepost(Fig.30H).•Withtheknotpusher

onthepoststrand,advancethelockinghalfhitchbypushingthehitchintothejointwiththeknotpusher(Fig.30I).Double-TwistKnot(Fig.31,32)FIGURE31.A-C.Double-

twistknot.•Thedouble-twistknot(31)isaknotthatemploysadoublesuturestitch.Itcanbeusedwithasutureanchororwhe

ndoingaside-to-siderotatorcuffrepair(Fig.31).•Asutureisdoubledoverandthelimbsarepassedthruthesofttissuesandboththeloo

pandtwostrandsareretrievedfromthecannula(Figs.32A,B).•Eachstrandistwistedclockwisearoundthelooptwice(Fig.32C).•Pullonbothlimb

ssimultaneouslytoadvancetheknot(Figs.32D,E,F).•Usetheknotpusheroneachlimbtoadvancetheloopdownwhileeachstrandisalternatelypul

led(Figs.32G,H,I)•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.32J).–Throwanunder

handloopontheoriginalpost.Tensionwiththeknotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.–Switchposts.–

Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.FIGURE32.A-J.Double-twistknot.•Th

eDouble-twistknotwasshowntohaveasignificantlyhighermeanpeaktofailurecomparedtotheTennesseeSliderandSnyder'sknot(31).Nicky'sKnot(Fig.3

3)FIGURE33.A-F.Nicky'sknot.•Nicky'sknot(9)isaone-wayslipknot.ItisamodificationoftheTautlinehitch(16,41).•Thepostlimbshouldbeapproximatelyhalfth

elengthofthelooplimb.•Throwanoverhandhalfhitcharoundthepost(Fig.33A).•Makeasecondoverhandhalfhitchproximal(

closertothearthroscopiccannula)tothefirstthrow(Fig.33B).•Bringtheloopstranddistal(closertotheendsofthesuture)tothetwol

oopsandmakeathirdoverhandhalfhitch(Fig.33C).•Tensiontheknotbygentlypullingonbothlimbssimultaneously(Fig.33D).•Pu

llonthepoststrandwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.33E).•Locktheknotwithaseriesoft

hreealternatinghalfhitcheswithpostswitching(Fig.33F).–Throwanunderhandloopontheoriginalpost.Tensionwiththeknotpusher.–Switchposts.–Throwanoverh

andloopoverthenewpost.Tensionwiththeknotpusher.–Switchposts.–Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.ModifiedTaut

LineHitch(Fig.34)•Thepostlimbshouldbeapproximatelyhalfthelengthofthelooplimb.•Makeanoverhandhalfhitcharoundthepost(Fig.34A).•Makeasecondov

erhandhalfhitchproximal(closertothejoint)tothefirstthrow(Fig.34B).•Bringtheloopstranddistal(fartherfromthe

joint)tothetwoloopsandmakeathirdoverhandhalfhitch(Fig.34C).•Makeanotheroverhandhalfhitchproximaltothethirdoverhandthrowb

utdistaltothefirstoverhandthrow(Fig.34D).•Tensiontheknotbygentlypullingonbothlimbssimultaneously.•Pullonthepoststrandwhilepushi

ngtheknotwiththeknotpusheronthepoststrand(Fig.34E).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.34F).•Throwan

underhandloopontheoriginalpost.Tensionwiththeknotpusher.•Switchposts.•Throwanoverhandloopoverthenewpost.Tensionwithth

eknotpusher.•Switchposts.•Throwanunderhandloopontheoriginalpostagain.TensionwiththeknotpusherLockingKnots•FieldKnot(Fig.35)•TheFieldknot(1

1)isalockingknotthatisamodificationoftheSavoie-ModifiedRoeder.Althoughalockingknot,theoriginatorsofthisknotrecomme

ndfurtherreinforcingitwithaseriesofthreehalfhitches.•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Throwanoverhandloopoverthepoststrand(Fig

.35A).•Throwasecondlooparoundboththepostandlooplimbs.Besuretoleaveasmall“hole”inthelooppriortothrowingthesecondloop(Fig.35B).•Throwathirdloopa

roundboththepostandlooplimbs(Fig.35C).•Wrapthelooplimbaroundonlythepostandbringitawayfromthejoint(Fig.35D).•Passt

hetailofthelooplimbbetweenthepoststrandandthroughtheholecreatedinstep3(Fig.35E).•Looselytensiontheknotbutdonotpullonthelooplimbortheknotwilllockprem

aturely(Fig.35F).•Whilepullingonthepostlimb,pushtheknotintothejointwiththeknotpusheronthepoststrand(Fig.35G).O

ncetheknotisseatedwiththeknotpusher,maintainpressureontheknotpusherandpullontheloopstrandwhilekeepingten

siononthepost(Fig.35H).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.35I).–Throwanunderhandloopon

theoriginalpost.Tensionwiththeknotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.–Switchposts.–

Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.SMCKnot(Fig.36)•TheSMCknot(19)isaslidingknotwithalockingmechanism.•Thepostli

mbshouldbeonehalfthelengthofthelooplimb.•Holdboththelooplimbandthepostlimbbetweenthethumbandtheindexfinger.•Passtheloopstrandoverthepostli

mbandbehindboththeloopandpostlimbs(Fig.36A).•Passtheloopstrandoverbothlimbsbutaroundonlythepostlimb(Figs.36B,C)•Pas

sthetailoftheloopunderthepostlimbandinbetweenthepostlimbandthelooplimbinbetweenthefirstandsecondloops(Fig.36D).•Tensiontheknotbyge

ntlypullingonboththeloopandthepoststrandssimultaneously.Donotpulltoohardontheloopstrandortheknotwilllockprematurely(Fig.36E).•Pullthep

oststrandtoadvancetheknotwhilepushingtheknotdownwiththeknotpusheronthepostlimb(Fig.36F).•Whilemaintainingthetensionofthepoststrandandtheknotpush

er,pulltheloopstrandtolocktheknotinplace(Fig.36G).GiantKnot(Fig.37)•TheGiantknot(12)isaone-wayself-lockingratchetknot•Thepo

stlimbshouldbeonehalfthelengthofthelooplimb.•Makeanoverhandthrowwiththeloopstrandoverthepost(Fig.37A).•Makeasecondoverhandthrowprox

imal(closertothejoint)tothefirstthrow(Fig.37B).•Makeathirdoverhandthrowdistal(furtherfromthejoint)tothepre

vioustwothrows(Fig.37C).•Makeafourthoverhandthrowdistaltothepreviousthreethrows(Fig.37D).•Pullthepostlimbwhileusingtheknotpusheronthepostlimbtoplacet

heknot(Fig.37E).•Whileholdingtheknotseatedwiththeknotpusherandmaintainingtensionontheloopstrand,pullth

elooplimbforciblytolocktheknot(Fig.37F）WestonKnot(Fig.38)•TheWestonknotwasoriginallyusedinobstetricsandgyne

cologyandlaterreportedintheorthopaedicliterature•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Throwan

underhandhalfhitcharoundthepost(Fig.38A).•Holdthishalfhitchbetweenthethumbandindexfingerofthenondominanthand.•Passthetailoftheloopst

randbetweentheloopandpostwiththeloopstrandpassingbehindthepost(Fig.38B).•Wrapthelooparoundthepostandpassitbehindandthroughthefirstloopthrown(

Figs.38C,D).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously.Donotpulltoohardontheloopstrandortheknotwilllockp

rematurely(Fig.38E).•Advancetheknotbypullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.38F).•Whilemaintaining

tensiononthepoststrandandusingtheknotpushertokeeptheknotinplace,pulltheloopstrandtolocktheknot(Fig.38GSnyderSlider(Fig.39

)•TheSnyderknothasbeentermeda•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Wraptheloopstrandbehindandoverthe

poststrand(Fig.39A).•Holdtheintersectionoftheloopstrandandthepostbetweenthethumbandindexfingerofthenon-dominanthand.•Wrapthetail

endoftheloopstrandbehindandaroundthecombinedpostandloopstrandsclosertothejointthantheinitialloop(Fig.39B).•Bringthetailendoftheloopstrandbe

hindthelooplimbandthoughtheparallelpostandlooplimbs(Fig.39C).•Tensiontheknotbygentlypullingonboththeloopandthepostst

randssimultaneously.Donotpulltoohardontheloopstrandortheknotwilllockprematurely.•Advancetheknotbypul

lingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.39D).•Whilemaintainingtensiononthepoststr

andandusingtheknotpushertokeeptheknotinplace,pulltheloopstrandtolocktheknot(Fig.39E）DinesSlider(Fig.40)•theDinesSliderh

asbeenreferredtoasaflip-knotbecausetensionappliedtothelooponcetheknothasbeenpushedintoplacecausestheknotto“flip”configurationtoalockedf

orm•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Startwiththeloopstrandtotherightofthepost.Whilestayingabove

thepost,crosstheloopovertotheleftsideandthenbacktotherightsideofthepost.Atthispointtheconfigurationoftheloopandpostsresemble

thenumeraleight(Fig.40A).•Wraptheloopstrandunderandaroundthepostheadingtowardthejoint(Fig.40B).•Passthetailendoftheloopb

ehindthepostthroughtheloopclosesttothejoint(Fig.40C).•Nextpassthetailoftheloopbehindthepostbutinfrontoftheinitialloop(Fig.40D).•Ten

siontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously.Donotpulltoohardontheloopstrandortheknotwilllockprematurely.•Advan

cetheknotbypullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.40E).•Whilemaintainingtensiononthepoststrandandusingtheknotpus

hertokeeptheknotinplace,pulltheloopstrandtolocktheknot(Fig.40FLaparoscopicKnots•Slidingknotsarenotuniquetoarthroscopicsurgery.Thereareanumber

ofslidingknotsthathavebeenusedinlaparoscopy.Manyoftheseknotshavenotbeendescribedinthearthroscopicliterature.However,i

tisconceivablethatoneormoreoftheseknotscouldbeeffectiveinarthroscopicsurgery.Althoughtheselaparoscopicknot

shavebeenstudiedbiomechanically,theyhavenotbeentestedwhenusingarthroscopictechniques.Thus,oneshouldusecautionifalaparos

copicknotischosentoapproximatetissueinarthroscopicsurgery.Thepurposeofincludingseveralarthroscopicknotsinthismanualistoexposethearthrosco

picsurgeontotheslipknotsbeingusedinotherareasofsurgery(33).BloodSlipknot(Fig.41)•Thebloodknotisapopularfishingknottha

thasbeenadaptedtobeusedinlaparoscopicsurgery.•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Crosstheloopover

thepoststrand(Fig.41A).•Wraptheloopbehindandaroundtheparallelpostandloopstrandsproximal(closertothejoint)totheinitialint

ersectionofpostandloopstrands(Fig.41B).•Againwrapthetailoftheloopstrandaroundtheparallelpostandloopstrandsdi

stal(furtherfromthejoint)totheprecedingthrowforatotaloffiveturns.Afterthefifthturn,thetailoftheloopstrand

shouldpassthroughthelargeinitialloopcreatedinstep2(Figs.41C-E).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously(Fi

g.41F).•Advancetheknotbypullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.41G

).•Inonebiomechanicalstudy,thebloodknotwasdeterminedtobeanunreliableknotwithallligaturestested(33).CrossSqu

areKnot(Fig.42)MelzerKnot(Fig.43)•TheMelzerknotisyetanothermodificationoftheRoederknot.•Thepostlimbshouldbeonehalfthelengthofth

elooplimb.•Throwtwoconsecutiveoverhandthrowsaroundthepost(Fig.43A).•Wrapthetailendoftheloopbehindandaroundthepara

llelpostandloopstrand(Fig.43B).•Againwrapthetailendoftheloopbehindandaroundtheparallelpostandloopstrandsclosertothejointthanthepreviousthrow(Fig.43

C).•Wrapathirdlooparoundtheparallelpostandloopstrandclosertothejointthanthepreviousthrowandpassthetailen

doftheloopbetweentheparallelpostandloopstrandsbetweenthesecondandthirdloops(Fig.43D).•Throwalooparoundonlythepoststrandclose

rtothejointthananyofthepreviousthrows(Fig.43E).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssi

multaneously.•Advancetheknotbypullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststran

d.Cinchtheknotdownwiththeknotpusherwhilesimultaneouslyplacingtensiononbothstrands(Fig.43F)TaysideSlipknot(Fig.44)FIGURE44.A-H.Ta

ysideslipknot.FIGURE44.(Continued)•TheTaysideknotwasinitiallyusedasafishingknotinScotland.•Thepostlimbshouldbeo

nehalfthelengthofthelooplimb.•Makeanoverhandthrowaroundthepost(Fig.44A).•Passthetailoftheloopoverandaroundthepostdistal(furtherfromthejoi

nt)thantheinitialthrow.Makesuretoleavea“hole”betweenthetwoloops(Fig.44B).•Wrapthelooparoundthepostagaindistaltotheprevioust

hrow(Fig.44C).•Forthethirdtime,wrapthelooparoundthepostdistaltothepreviousthrow(Fig.44D).•Passthetailoftheloopbehi

ndandthroughthe“hole”createdinstep3.Thiswillcreatealargeloop(Fig.44E).•Thanpassthetailoverandthroughthelargeloop

createdinstep6(Fig.44F).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously.•Advancetheknotbypul

lingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.44G).•Switchtheknotpushertotheloopstrandandcinchthe

knotdownbypastpointingwhilepullingtensiononthepoststrand(Fig.44H）KhatriKnot(Fig.45)•TheKhatriknothasbeenusedastheanchoringknotwhenrunningsuture

toclosealaparotomywound(18).Itisanotherexampleofafishingknot,theImprovedClinchknot,whichwasadoptedforuseinsurgery(36).•Thepostlimbshouldbeoneh

alfthelengthofthelooplimb.•Wrapthelooplimboverandaroundthepoststrandproximal(closertothejoint)todistal(fartherfromthejoint)threeconse

cutivetimes(Fig.45A).•Passthetailendoftheloopunderandthroughthelargeloopproximaltothefirstthrow(Fig.4

5B).•Passthetailendoftheloopstrandoverandthroughthelargeloopcreatedinstep3(Fig.45C).•Tensiontheknotbygentlypullingonthepost

andtheloopstrandssimultaneously(Fig.45D).•Advancetheknotbypullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand

.Cinchtheknotdownwiththeknotpusherwhilesimultaneouslyplacingtensiononbothstrands(Fig.45E).