【文档说明】医学关节镜下打结技术培训课件.ppt，共(111)页，45.784 MB，由小橙橙上传

转载请保留链接：https://www.ichengzhen.cn/view-255828.html

以下为本文档部分文字说明：

关节镜下打结技术•Anincreasingnumberofsurgeonsareperformingarthroscopicsurgeryinthekneetorepairmeniscaltearsandintheshouldertorepairrotatorcuf

forlabraltears•Manyarealsoperformingcapsularshiftstotreatinstability.•Essentialtotheseproceduresistheabilitytotiearthroscopicknotstoapproximateintr

aarticularIntroduction•Thesurgeonmustsequentiallyconstructtheknotoutsidethejointandthenpasstheknotintothejointthroughsmallcannulas•Ty

ingarthroscopicknotsistechnicallydemandingandrequiresconsiderablepractice•Withthepopularityofarthroscopicsurgery,

thenumberofusedarthroscopicknotsandthenumberofsurgeonsusingtheseknotshasincreasedKnotTyingPrinciples•Thegoalofknottyi

ngistoapproximatetissueundertensionandmaintainthetissueinappositionuntilbiologicrepairandhealingcanoc

cur•Itisimperativeforallsurgeonstolearnanduseknot-tyingtechniquesthatminimizethechanceofknotfailure•Knotsecurityfriction,internalinterference,an

dslackbetweenthrows•Frictionisinherenttothesuturematerial•Internalinterferencetheconfigurationoftheknotandincreasedbythelengthofth

econtactbetweenthelooplimbandthepostlimb•slackbetweentheindividualthrowsineachknottomaximizeloopsecurity•slippagecan

leadtofailureoftissueappositionKnotTyingPrinciples◆fourdifferentprocessesofknotfailure➢knotslippageandlooseni

ng➢suturebreakage➢tissuefailure➢sutureanchorpulloutfrombone➢throughsuturebreakageKnotfailureKnotTerminology•postlimb(alsocommonlyknownastheaxiall

imb)•looplimb(alsocommonlyknownasthewrappinglimb,workingend,runningend,orfreeend)•Knotsareconstructedbytyingthelooplimbaroundthepostlim

b(Fig.1)FIGURE1.LoopandpostconfigurationArthroscopicKnotPushers•Anarthroscopicknotpusherisadeviceusedtoadvancetheloopdownthepostlimbintothe

jointtocreatetheknot.Arthrexknotpushers.A.Single-hole,B.Double-hole,C.6thFingerFIGURE3.Mitekknotpushers.A.Single-hole,B.Doub

le-hole,C.Slotteddouble-holeknotpushersanddoublediameterknot•double-holeknotpushersanddoublediameterknotpushersliketheArt

hrex6thFinger(Arthrex,Naples,FL).Double-diameterknotpushersprovidebetterloopsecuritycomparedtostandardsingle-holeknotpushersDouble-holeknotpusherFIGU

RE4.Double-holeknotpusher.HowtoUsetheDouble-DiameterKnotPusherFIGURE5.A-F.TyingknotswiththeArthrex6thfingerSutureProperties

•Twotypesofsuturesarecommonlyusedintyingarthroscopicknots:apermanent,braided,polyester,nonabsorbablesutureandanabsorbable,mon

ofilamentsuture•Examplesofpermanent,braided,polyester,nonabsorbablesuturesareEthibondandTicron•Examplesofabsorbable,monofilamentsuture

sarePDSII,polydiaxononeandMaxon,polyglyconate•Braidedpolyesterhasincreasedpliability,ductility,ahighercoefficientoffrictionandgreaterstrength

thandoesabsorbablemonofilament•Becausethebraidedsutureismorepliable,thevolumeoftheknotisdecreasedandtheseknotscanbeci

nchedtighter.KnotstiedwithEthibondwereshowntobestrongerwhencomparedtoPDSIIinseveralbiomechanicalstudies•However,braidedpolye

stermayfraywithexcessivehandling,whichmayleadtosuturerupture◆Braidedpolyestersuturemaybecoatedto:➢improvesu

rgeonhandling➢reducefrictionbetweenthesutureandsurroundingtissue,whichcanleadthetissuedamage➢decreasefrictionbetweensuturelimbs,whichm

ayleadtofraying➢However,suturecoatingdecreasesthecoefficientoffrictionoftheknot,whichtheoreticallyincreasestheriskofkno

tslippage•Knotstiedwithabsorbable,monofilamentsuturesareeasiertoslidedownapostanddonotfray•Thereislessfrictionbetweenthesutureandsu

rroundingtissueleadingtolesspotentialtissuedamagewhenthesutureispulledthroughthetissue•absorbablesuturesdissolv

eanddonotleaveknotsthatmaycauseapersistentinflammatoryreactionaftertissuehealing•Absorbablesuturescanapposetissueunderstressfora

pproximatelysixweekswithcompleteabsorptionoccurringinapproximatelysixmonths•However,absorbablemonofilamentsuturesarehardertohandlethanp

olyestermakingitmoredifficulttokeepknotstightandsecure•Also,aabsorbablemonofilamentsuturewillfailearlierwithcyclicloadingth

anpolyestersutureandmayexpandbyplasticdeformationmorethan30%ofitslengthbeforebreaking•Thesizeofthesutureisalsoafactorin

determiningaknot'sholdingcapacityandalsothetensilestrengthofthesutureitself•Clinicalfailureofallknotsandsuturetypesimprovedby100%whe

nsuturesizewasincreasedby2gaugesUSP(U.S.Pharmacopeia.•ThesizesuturemostcommonlyusedinarthroscopicsurgeryisNo.1orNo.2

.KnotTypes•Thereareavarietyofknotincludenonslidingknots,slidingknots,andlockingknots.•Nonslidingknotsareknotsthatdonotslidethou

ghthetissuesbeingapposed.TheyincludethesquareknotandknotsconsistingofaseriesofhalfhitchesliketheRevoknot(34)•Althoughthesq

uareknotfailsathigherloadsthandoseriesofhalfhitchesinhand-tiedknots(38),thesquareknotisnotcommonlyusedart

hroscopically.•Thesquareknotisaflatknotinwhichbothstrandsenterandleavetheknotparalleltoeachother(Fig.6).•Inor

dertotieasquareknot,symmetrictensionmustbesimultaneouslyappliedtoeachlimb,whichisdifficulttodoarthroscopically•Ifasymmetrictensionisapplied

tooneofthelimbs,theknotconvertstotwononidenticalhalfhitches•Thus,mostarthroscopicsurgeonspreferusingase

riesofhalfhitchesFIGURE6.Squareknotconfiguration.•Slidingknots,liketheDuncanloop(27),areusefulinopposingtissueundert

ension.Whiletyingaslidingknot,thepoststrandisheldundertensionwhiletheloopstrandistiedaroundit.Becausethepoststrandisnotincorporatedintothes

tructureoftheknot,theknot,oncetied,caneasilymovedownthepostresultinginaslidingknotinsteadofaflatknotsuchasthesquareknot.•Oncethesl

idingknotsareseated,theyareoftenlockedwithaseriesofhalfhitches.Someslidingknotspreferentiallyslideinonlyonedirection•A

lockingknotisamodificationofaslidingknot•Asimpleslidingknotcanloosenbeforeaseriesofhalfhitchesarethrownto“lock”the

slidingknotinplace•lockingknots(alsoknownasflipknots)havebeendevelopedtomaintaininitialloopsecuritythatdoesnotloosenwhentensionisre

moved•Thepoststrand“flips,”convertingtheloopstrandintothenewpoststrandandlockingtheknotintoplace.Anexampleofalocking

knotistheSMCknot.lockingknotsdonotneedtobesupplementedwithaseriesofhalfhitches•Theauthorsofthismanualhavefoundlockingknotswithoutr

einforcinghalfhitchestobeinferiorintensilestrengthtoknotsreinforcedwiththreereversedhalfhitchesonalternatingposts(unpublisheddata)•Lockingandsli

dingknotscanbeadvancedintothejointjustbypullingonthepost.Thiscancausetensionattherepairsite,whichcandamag

ethetissuebeingapposed.Tensionattherepairsitecanbeminimizedbypushingtheknotaheadwiththeknotpusherwhilesimultaneouslypullingont

hepostlimb.Withlockingandslidingknots,itisimportantthatthelooplimbisatleasttwiceaslongasthepostlimb.Ifiti

snot,whenpullingthepostlimbtoadvancetheknotthroughthecannulaandintothejoint,theshortenedlooplimbmaybepulle

dintothecannulamakingitimpossibletosecuretheknot.•Whenusingaslidingorlockingknotconfiguration,itisimportanttoensurethatthesutureslidese

asilythroughthetissuebeingopposed.Ifthesuturedoesnotslideeasily,thesurgeonshouldconsiderusinganonslidingknot.KnotPushing

andPulling•Knotconfigurationscanbeeitherpushedorpulledintothejoint.hearthroscopicknot-tyingdeviceispositionedonthelooplimban

disadvancedpastthehalfhitchthuspullingtheloopoverthepostlimbintothejoint(Fig.7A).•Thearthroscopicknot-ty

ingdeviceispositionedonthepostlimbbehindtheknotthuspushingtheloopoverthepostlimbintothejoint(Fig.7B).FIGURE7.A.Knotp

ulling,B.Knotpushing.TyingHalfHitches•Usingtheonehandknot-tyingtechnique,halfhitchescanbetiedeitherunderhandoroverhand•Thefollowinginstruc

tionsdefineanunderhandloopandanoverhandloopFIGURE8.A-E.Underhandhalfhitch.ConfigurationofHalfHitches•Halfhitchescan

bethrowninthesamedirection(twosuccessiveoverhandhitches)orcanbethrowninoppositedirections(anoverhandhitchfollowedbyanun

derhandhitch)•Halfhitchescanalsobetiedonoppositeposts.TeraandAberg(37)developedanomenclaturefordescribingfl

atknots.PostSwitchingFIGURE13.A.Parallelloopandpostlimbs.B.Parallelloopandpostlimbswitha“flat”knot.FIGURE14.A.Twistedloop

andpostlimbs.B.Whentyingaknotwithtwistedpostandlooplimbs,theknotdoesnotlie“flat.”C.Thefinalknotconfigurationwilllooseniftheknotistiedwhentheloop

andpostlimbsaretwisted.•ChanandBurkhartdescribedamayincreasethespeedoftheknot-tyingprocessandalsohelplimittw

istingofthesuturelimbs.Onecan“flip”ahalfhitchbyreleasingtensiononthepostlimbandpullingonthelooplimb.•Whenthepostissw

itched,thedirectionofthehalfhitchisalsoreversed.Theauthorsofthistechniquereportthatitiseasiertofliphal

fhitchesusingmonofilamentbecauseitmorereadilyconvertstoaflatknot,butitcanalsobedonewithbraidedsuture.•Holdthepostinthenondominanth

andandtheloopinthedominanthand(Fig.15A).•Movetheoriginalpostforwardandaheadofthehalfhitch.•Applyparalleltractiono

nthepostandloopsimultaneouslyconvertingthehalfhitchtoaflatknot(Fig.15B).•Applyaxialtractiontothelooplimbconvertingitintothenewpostlimbandthehalfhitch

isreversed(Fig.15C).PostSwitchingTechniqueFIGURE15.A-C.PostswitchingtechniqueArthroscopicKnot-TyingTechniques•

Itisimportanttodetermineifthesutureslidesthroughthetissueandsutureanchorpriortoknottying.Ifthesuturedoesnotreadilyslide,aslidingorlockingknotsho

uldnotbeusedandanonslidingknotshouldbechosen•Onlyonepairofsuturesshouldbewithintheworkingcannuladuringarthroscopickno

ttying.Ifmorethanonepairofsuturesarewithintheworkingcannuladuringtying,thereisahighlikelihoodthatthesutureswillbecometwistedandknottyingw

illbecomequitetediousifnotimpossible.Additionalsuturesshouldbeshuttledviaamonofilamentsuture(lesstissueabrasion)orbyanarthroscopicgraspertoa

naccessoryportal•Transparentcannulasarerecommendedforarthroscopicknottying.Thesecannulasallowthesurgeontoseeifthereisanytwistingofthesu

turestrandspriortoknottying•Thearthroscopicsurgeonshouldensurethatthereisnoredundantsofttissuearoundthetissuebei

ngapposedorinthepathofthesuturelimbsbecausethiswillimpedeknottyingandincreasethelikelihoodofknotfailure•Whentyinghalfhitcheswithasta

ndardsingle-holeknotpusher,thefirstthrowcommonlyslipswhentheknotpusherisremovedinpreparationfortheseco

ndthrow•Whenthesecondthrowisadvanced,thereisachancethatthehitcheswilllockpriortocompleteappositionofthetissue•To

preventthis,thesurgeoncanthrowthefirsttwohitchesinthesamedirectionallowingthehitchestoslidedowntheposttoapposethetissue•Anothe

rmethodofpreventinginitiallooplooseningistouseadouble-diameterknot-pushingdevice,suchastheArthrex6thtomaintaintensionontheinitialhitchwhi

lethrowingthesecondhitchNon-SlidingKnotsFIGURE16.A-F.Squareknot.RevoKnot•TheRevoknotisaseriesofmultiplehalfhitchesmadebyalternatingthepostandd

irectionofthehalfhitches.TherehavebeenseveralmodificationstotheRevoknotFIGURE17.A-H.OriginalRevoknot.•TheOriginalRevoknotconsistsoft

woreversedhalfhitchesonanidenticalpostfollowedbypostswitchingandtworeversedhalfhitches.•Throwanoverhandlooparound

thepost(Fig.17A).•Pulltheloopintothejointwiththeknotpusheronthelooplimb(Fig.17B)•Withdrawtheknotpusherwhilem

aintainingtensiononthepostlimb.•Throwanunderhandlooparoundthesamepost(Fig.17C)•Pulltheloopintothejointandseatth

eknotwiththeknotpusher.Oncethetwohitchesareseated,past-pointtocinchtheknotdown(Fig.17D).•Switchpostsandthrowanu

nderhandlooparoundthenewpost(Fig.17E).•Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown(Fig.17F).•Next,t

hrowanoverhandlooparoundthepost(Fig.17G).•Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown.(Fig.17H)Snyder'

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

heronthelooplimb(Fig.18B)•Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb.•Throwanunderhandlooparoundthesame

post(Fig.18C)•Pulltheloopintothejointandseattheknotwiththeknotpusher.Oncethetwohitchesareseated,past-pointtocinchtheknotdown(Fi

g.18D).•Switchpostsandthrowanoverhandlooparoundthenewpost(Fig.18E).•Pulltheloopintothejoint,seattheknotwiththeknotpush

er,andpast-pointtocinchtheknotdown(Fig.18F).•Next,throwanunderhandlooparoundthepost(Fig.18G).•Pullthel

oopintothejoint,seattheknotwiththeknotpusher,andpast-pointtocinchtheknotdown(Fig.18H).•Switchpostsandthrowanoverhandlooparoun

dthenewpost(Fig.18I).•Pulltheloopintothejoint,seattheknotwiththeknotpusher,andpastpointtocinchtheknotdon(Fig18J)FIGURE19.A-K.Revoknot.•ThecurrentRe

voknotisamodificationoftheOriginalRevoknot•Throwanunderhandlooparoundthepost(Fig.19A).•Advancetheloopwiththeknotpusheronthel

ooplimbuntilthefirsthalfhitchisseated(Fig.19B).•Withdrawtheknotpusherwhilemaintainingtensiononthepostlimb.•Throwanotherund

erhandlooparoundthesamepost(Fig.19C).•Pulltheloopintothejointandseattheknotwiththeknotpusher.Oncethetwohitchesareseated,past-pointtocincht

heknotdown(Figs.19D,E).•Throwanoverhandhalfhitcharoundthepostandadvancewiththeknotpusher(Fig.19F).•Furthertensionbypastpointingandappl

ytensiononbothlimbswhileholdingthe(Fig.19G).•Switchpostsandthrowanunderhandlooparoundthenewpost(Fig.19H).•Pulltheloopintothejoint,seattheknotwith

theknotpusher,andpastpointtocinchtheknotdown(Fig.19I).•Switchpostsandthrowanoverhandlooparoundthenewpost(Fig.19J).•Pu

lltheloopintothejoint,seattheknotwiththeknotpusher,andpastpointtocinchtheknotdown(Fig.19K).SlidingKnots•OverhandThrowDuncanLoop•TheDuncanloopwaso

riginallydescribedinthefishingliterature(Uni-Knot)andhasbeenmodifiedforuseinarthroscopicsurgery.ThearthroscopicDu

ncanloopisalsoknownastheFisherman'sknotortheHangman'sknotThedifferencebetweenthefishingknotandthearthr

oscopicknotisthedirectiontheloopstrandtravelsaroundthepost.WhentyingthefishingDuncanloop,onewrapsthelooplimbaroundthepostinadirectionawa

yfromthejoint.TotiethemodifiedDuncanlooporHangman'sknot,thesurgeonsequentiallywrapsthelooplimbaroundthepostinadi

rectiontowardthejointFIGURE21.A-F.FishingDuncanloop.BerkleyDuncanLoopKnotArthroscopicDuncanLoop(Hangman'sKnot)(Fig.22)FIGURE22.A-

F.ArthroscopicDuncanloop.Frenchknot.FIGURE23.A-H.FIGURE23.A-H.Frenchknot.•TheFrenchknot(22)isaslidingknotthatisamodificationoftheDuncanl

oop.•Makethepostlimbhalfaslongasthelooplimb.•Graspthesuturesbetweenthethumbandindexfingerofyournon-dominanthand(Fig.23A).•Createasmallcircleintheloop

strandbypassingtheloopoverthecombinedpostandloopstrandsandholditbetweenyourthumbandindexfinger(Fig.23B).•Makeatotaloffour

loopsaroundboththepostandthelooplimbstravelingtowardthejoint(Fig.23C).•Passthetailoftheloopstrandoverandthroughthesmallcirc

leintheloopstrandthatisheldbetweenthethumbandindexfinger(Fig.23D).•Passthetailoftheloopstrandunderandthroughtheloopcirclecreatedbythedistalendofthelo

opstrandandthecombinedlimbsoftheloopandpoststrands(Fig.23E).•Pullonboththelooplimbandthepostlimbsymmetricallytotightentheknot(Fig.

23F).•Advancetheknotbypullingonthepostlimbwhilepushingtheknotdownwiththeknotpusheronthepoststrand(Fig.23G).•

Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.23H).–Throwanunderhandloopontheoriginalpost.Tensionwiththe

knotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.–Switchposts.–Throwanunderhandloo

pontheoriginalpostagain.Tensionwiththeknotpusher.•TheFrenchknotwasshowntohaveahigherloadtofailurewhen

comparedtotheDuncanloopandtheRevoknotRoederKnot•TheRoederknotisaslidingknotthatisavariationoftheDuncanloop.Itwasoriginally

usedintonsillectomysurgeryanddescribedintheGermanliteraturebyRöderin1918•Therehavebeenseveralmodificationsoftheknotthathavebeendescribe

dsincetheinitialdescriptionoftheknot.ModificationsoftheRoederknotarecurrentlyusedinbothlaparoscopicandarthrosco

picsurgeryFIGURE24.A-G.Roederknot.•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Throwthefirstlooparo

undthepostlimbandthenholdtheloopandposttogetherwiththethumbandindexfingerofthenon-dominanthand(Fig.24A).•Throwasecondlooparoundboththepostandlooplim

bs(Fig.24B).•Throwathirdlooparoundonlythepostlimbandbetweenthepostandloop(Fig.24C).•Passthetailoftheloopbetweenthesecondandthirdturn

sandinbetweenthelooplimbandthepostlimb(Fig.24D).•Tensiontheknotbygentlypullingonboththepostandthelooplimbssimultaneously(Fig.24E).•Wh

ilepullingonthepostlimb,pushtheknotintothejointwiththeknotpusheronthepoststrand(Fig.24F).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpos

tswitching(Fig.24G).–Throwanunderhandloopontheoriginalpost.Tensionwiththeknotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Tensio

nwiththeknotpusher.–Switchposts.–Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.•TheRoederknotwasshowntobei

nferiortotheDuncanloopandtheSnyderknotinloadtoclinicalfailuretrialsbutastatisticalsignificancewasnotfound(26).Savoie-Modif

iedRoederKnot(Fig.25)•TheSavoie-ModifiedRoederknotisalockingknotinsteadofaslipknot•Thepostlimbshouldbeonehalfthelengthoftheloop

limb.•Throwanunderhandlooparoundthepoststrand(Fig.25A).•Throwasecondlooparoundboththepostandlooplimbs.Besureto

leaveasmall“hole”inthelooppriortothrowingthesecondloop(Fig.25B).•Throwathirdlooparoundboththepostandl

ooplimbs(Fig.25C).•Throwafourthlooparoundboththepostandlooplimbs(Fig.25D).•Wrapthelooplimbaroundonlythepostandb

ringitawayfromthejoint(Fig.25E).•Passthetailofthelooplimbbetweenthe“hole”madeinstepC(Fig.25F).•Looselytensiontheknotbutdonotpullontheloopstr

andorthiswillprematurelylocktheknot(Fig.25G).•Whilepullingonthepostlimb,pushtheknotintothejointwiththeknotpusheronthepoststrand.•Whe

ntheknotisseated,pushdownontheknotpushertoholdtheknotinplaceandwhilemaintainingtensiononthepoststrand,pullontheloopstra

ndtolocktheknot.Thiswillpreventtheknotfromlooseningoncetensionisreleasedfromthestrands(Fig.25H).•Locktheknotwithaseriesofthreea

lternatinghalfhitcheswithpostswitching(Fig.25I）Lieurance-ModifiedRoederKnot(Fig.26)FIGURE26.A-H.Lieurance-ModifiedRoederknot.•T

heLieurance-ModifiedRoederknotisalockingknotinsteadofaslipknot•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Throwanoverhandlooparoundon

lythepoststrand(Fig.26A).•Throwasecondloopacrossboththepostandlooplimbs(Fig.26B).•Throwathirdloopacrossboththepostandlooplimbs(Fig.26C).•Wrap

thelooplimbaroundthepostonlyandbringitbetweenthepostandlooplimbs(Fig.26D).•Passthetailofthelooplimboverandthroughtheinitialloopmadebythepostandlo

oplimbs(Fig.26E).•Looselytensiontheknotbutdonotpullontheloopstrandorthiswillprematurelylocktheknot(Fig.26F).•Whilepull

ingonthepostlimb,pushtheknotintothejointwiththeknotpusheronthepoststrand.•Whentheknotisseated,pushdownontheknotpushertoholdtheknotinplaceandwhilemain

tainingtensiononthepoststrand,pullontheloopstrandtolocktheknot.Thiswillpreventtheknotfromlooseningoncetensionisreleasedfromthes

trands(Fig.26G).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.26H）LaparoscopicRoederKnot(Fig.27)Tennes

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

hhalfhitchesthrowninalternatedirectionsonoppositeposts.•Thepostlimbshouldbeapproximatelyhalfthelengthofthelooplimb.•Throwtheloopoveranda

roundthepostlimb(Fig.28A).•throwtheloopstrandaroundthepostlimbclosertothejointthantheprecedingloop(Fig.28B).•Passthetailo

ftheloopstrandthroughtheinitialloop(Fig.28C).•Tensiontheknotbygentlypullingbothsuturelimbssimultaneously(Fig.

28D).•Pushtheknotintothejointwiththeknotpusherwiththeknotpusheronthepoststrandwhilesimultaneouslypullingonthepoststrand(Fig.28E).•Locktheknotw

iththreealternatinghalfhitcheswithpostswitching(Fig.28F).EasyKnot(Fig.29)FIGURE29.A-E.Easyknot•TheEasyknotisaslidingknotthatconsistsofa

seriesoffiveoverhandhalfhitchesthatislockedwithanoverhandhitchontheoppositepost(2).•Thepostlimbshouldbeapproximatelyhalfthelengthoftheloopl

imb.•Throwanoverhandhalfhitcharoundthepost(Fig.29A).•Throwfouridenticaloverhandhalfhitches.Eachhalfhitchshouldbethrowndistal(fartherfromthejoin

tandarthroscopiccannula)thanthepreviousthrow(Fig.29B).•Tensiontheknotbygentlypullingsimultaneouslyonboththepoststrandandloopstrandsimultaneously

.•Pushtheknotintothejointwiththeknotpusheronthepoststrandwhilesimultaneouslypullingonthepost(Fig.29C).•Switchposts.•Throwanoverhand

halfhitcharoundthenewpost(Fig.29D).•Advancethelockinghalfhitchbypullingthehitchintothejointwiththekn

otpusherontheloopstrandandpastpointtocinchtheknotdown(Fig.29E).LafosseKnot(Fig.30)FIGURE30.A-J.Lafosseknot•TheLafosseknotissimilar

instructuretotheEasyknotbutincorporatesthepostswitchingtechnique.•Thepostlimbshouldbeapproximatelyhal

fthelengthofthelooplimb.•Throwanoverhandhalfhitcharoundthepostwhilemaintainingtensiononthepoststrand(Fig.30A).•Throwfouridenticaloverhandhalfhi

tches.Eachhalfhitchshouldbethrowndistalthanthepreviousthrow.Ensuretomaintaintensiononthepoststrand(Fig.30B).•Pushtheknotin

tothejointwiththeknotpusheronthepoststrandandwhilesimultaneouslypullingonthepost(Fig.30C).•Crosstheknot

pusherovertheloopstrandattheleveloftheknot,pulltensionontheloopstrand,andpast-point.Thiscausestheposttoswitchandthelasthitchreversestolockthe

slidingknot(Fig.30D).•Atthispoint,iftheknotisnottightenough,pullontheinitialpostandthehalfhitchreversesthe

rebyunlockingtheknot.Theknotcanbefurthertightenedbypullingonthepostandpushingtheknotdownwiththepusher.Theknotcanberelock

edinthemannerdescribedinstepE.•Throwanoverhandhalfhitcharoundthesamepost(Fig.30E).•Withtheknotpusheronthepoststrand,advancethelo

ckinghalfhitchbypushingthehitchintothejointwiththeknotpusher(Fig.30F).•Crosstheknotpusherovertheloopstran

dattheleveloftheknot,pulltensionontheloopstrand,andpast-point.Thiscausestheposttoswitchandthehitchtoreversedirections(Fig.30G).•Thr

owasecondoverhandhalfhitcharoundthesamepost(Fig.30H).•Withtheknotpusheronthepoststrand,advancethelockinghalfhitchbypushingthehitchintothejointwit

htheknotpusher(Fig.30I).Double-TwistKnot(Fig.31,32)FIGURE31.A-C.Double-twistknot.•Thedouble-twistknot(31)isaknotthatemploysadoublesuturestit

ch.Itcanbeusedwithasutureanchororwhendoingaside-to-siderotatorcuffrepair(Fig.31).•Asutureisdoubledoverandthelimbs

arepassedthruthesofttissuesandboththeloopandtwostrandsareretrievedfromthecannula(Figs.32A,B).•Eachstr

andistwistedclockwisearoundthelooptwice(Fig.32C).•Pullonbothlimbssimultaneouslytoadvancetheknot(Figs.32D,E,F).•Usetheknotpusheroneachlimbtoadvancet

heloopdownwhileeachstrandisalternatelypulled(Figs.32G,H,I)•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.32J

).–Throwanunderhandloopontheoriginalpost.Tensionwiththeknotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.–Switchpos

ts.–Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.FIGURE32.A-J.Double-twistknot.•TheDouble-twistknotwasshowntohaveasign

ificantlyhighermeanpeaktofailurecomparedtotheTennesseeSliderandSnyder'sknot(31).Nicky'sKnot(Fig.33)FIGURE33.A-F.Nicky'sk

not.•Nicky'sknot(9)isaone-wayslipknot.ItisamodificationoftheTautlinehitch(16,41).•Thepostlimbshouldbeapproximatelyhalfthelen

gthofthelooplimb.•Throwanoverhandhalfhitcharoundthepost(Fig.33A).•Makeasecondoverhandhalfhitchproximal(closertothearthrosco

piccannula)tothefirstthrow(Fig.33B).•Bringtheloopstranddistal(closertotheendsofthesuture)tothetwoloopsandmakeathirdoverhandh

alfhitch(Fig.33C).•Tensiontheknotbygentlypullingonbothlimbssimultaneously(Fig.33D).•Pullonthepoststrandwhilepushingtheknotwiththeknotpusheron

thepoststrand(Fig.33E).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.33F).–Thr

owanunderhandloopontheoriginalpost.Tensionwiththeknotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Tensionwith

theknotpusher.–Switchposts.–Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.ModifiedTautLineHitch(Fig.34)•Thepostlimbshouldbe

approximatelyhalfthelengthofthelooplimb.•Makeanoverhandhalfhitcharoundthepost(Fig.34A).•Makeasecondoverhan

dhalfhitchproximal(closertothejoint)tothefirstthrow(Fig.34B).•Bringtheloopstranddistal(fartherfromthejoint)tothetwoloopsandmakeathirdoverhan

dhalfhitch(Fig.34C).•Makeanotheroverhandhalfhitchproximaltothethirdoverhandthrowbutdistaltothefirstoverhandthrow(Fig.34D)

.•Tensiontheknotbygentlypullingonbothlimbssimultaneously.•Pullonthepoststrandwhilepushingtheknotwiththeknotpush

eronthepoststrand(Fig.34E).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.34F).•Throwanunderhandloopontheoriginalp

ost.Tensionwiththeknotpusher.•Switchposts.•Throwanoverhandloopoverthenewpost.Tensionwiththeknotpusher.•Switchposts.•Throwanunderhandloop

ontheoriginalpostagain.TensionwiththeknotpusherLockingKnots•FieldKnot(Fig.35)•TheFieldknot(11)isaloc

kingknotthatisamodificationoftheSavoie-ModifiedRoeder.Althoughalockingknot,theoriginatorsofthisknotrecommendfurtherreinforcingitwithaseriesofthre

ehalfhitches.•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Throwanoverhandloopoverthepoststrand(Fig.35A).•Throwasecondlooparoundbothth

epostandlooplimbs.Besuretoleaveasmall“hole”inthelooppriortothrowingthesecondloop(Fig.35B).•Throwathirdlooparoundboththepostandlooplimbs(Fig.35

C).•Wrapthelooplimbaroundonlythepostandbringitawayfromthejoint(Fig.35D).•Passthetailofthelooplimbbetweenthepoststrandandthroughtheholecreatedinstep

3(Fig.35E).•Looselytensiontheknotbutdonotpullonthelooplimbortheknotwilllockprematurely(Fig.35F).•Whilepullingonthepostlimb,pushthekn

otintothejointwiththeknotpusheronthepoststrand(Fig.35G).Oncetheknotisseatedwiththeknotpusher,maintainpressureontheknotpusherandpullontheloopstr

andwhilekeepingtensiononthepost(Fig.35H).•Locktheknotwithaseriesofthreealternatinghalfhitcheswithpostswitching(Fig.35I)

.–Throwanunderhandloopontheoriginalpost.Tensionwiththeknotpusher.–Switchposts.–Throwanoverhandloopoverthenewpost.Te

nsionwiththeknotpusher.–Switchposts.–Throwanunderhandloopontheoriginalpostagain.Tensionwiththeknotpusher.SMCKnot(Fig.36)•Th

eSMCknot(19)isaslidingknotwithalockingmechanism.•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Holdboththelooplimbandthepos

tlimbbetweenthethumbandtheindexfinger.•Passtheloopstrandoverthepostlimbandbehindboththeloopandpostlimbs(Fig.36A).•Passtheloopstrandoverbothl

imbsbutaroundonlythepostlimb(Figs.36B,C)•Passthetailoftheloopunderthepostlimbandinbetweenthepostlimbandthelooplimbinbetweenthefirstandsec

ondloops(Fig.36D).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously.Donotpulltoohardontheloopstrandortheknotwilllock

prematurely(Fig.36E).•Pullthepoststrandtoadvancetheknotwhilepushingtheknotdownwiththeknotpusheronthepostlimb(Fig.36F).•Whilemaintaining

thetensionofthepoststrandandtheknotpusher,pulltheloopstrandtolocktheknotinplace(Fig.36G).GiantKnot(Fig.37)•TheGiantknot(12)isaone-w

ayself-lockingratchetknot•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Makeanoverhandthrowwiththel

oopstrandoverthepost(Fig.37A).•Makeasecondoverhandthrowproximal(closertothejoint)tothefirstthrow(Fig.37B).•Makeathirdoverhandthrowdistal(furtherf

romthejoint)totheprevioustwothrows(Fig.37C).•Makeafourthoverhandthrowdistaltothepreviousthreethrows(Fi

g.37D).•Pullthepostlimbwhileusingtheknotpusheronthepostlimbtoplacetheknot(Fig.37E).•Whileholdingtheknotsea

tedwiththeknotpusherandmaintainingtensionontheloopstrand,pullthelooplimbforciblytolocktheknot(Fig.37F）WestonKnot(Fig.38)•TheWestonknotwasoriginallyus

edinobstetricsandgynecologyandlaterreportedintheorthopaedicliterature•Thepostlimbshouldbeonehalfthelengthofthelooplimb

.•Throwanunderhandhalfhitcharoundthepost(Fig.38A).•Holdthishalfhitchbetweenthethumbandindexfingerofth

enondominanthand.•Passthetailoftheloopstrandbetweentheloopandpostwiththeloopstrandpassingbehindthepost(Fig.38B).

•Wrapthelooparoundthepostandpassitbehindandthroughthefirstloopthrown(Figs.38C,D).•Tensiontheknotbygentlypullingonboththeloopan

dthepoststrandssimultaneously.Donotpulltoohardontheloopstrandortheknotwilllockprematurely(Fig.38E).•Advancetheknotbypu

llingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.38F).•Whilemaintainingtens

iononthepoststrandandusingtheknotpushertokeeptheknotinplace,pulltheloopstrandtolocktheknot(Fig.38GSnyderSli

der(Fig.39)•TheSnyderknothasbeentermeda•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Wraptheloopstrandbehindandoverthepoststrand(Fig.39A).•Ho

ldtheintersectionoftheloopstrandandthepostbetweenthethumbandindexfingerofthenon-dominanthand.•Wrapthetailendoftheloopstrandbehindandaround

thecombinedpostandloopstrandsclosertothejointthantheinitialloop(Fig.39B).•Bringthetailendoftheloopstrandbehindthelooplimbandthoug

htheparallelpostandlooplimbs(Fig.39C).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously.Donotpulltoohardonthe

loopstrandortheknotwilllockprematurely.•Advancetheknotbypullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(F

ig.39D).•Whilemaintainingtensiononthepoststrandandusingtheknotpushertokeeptheknotinplace,pulltheloopstrandtolocktheknot(Fig.39E）DinesSlider(Fig.

40)•theDinesSliderhasbeenreferredtoasaflip-knotbecausetensionappliedtothelooponcetheknothasbeenpushedintoplacecausestheknotto“flip”config

urationtoalockedform•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Startwiththeloopstrandtotherig

htofthepost.Whilestayingabovethepost,crosstheloopovertotheleftsideandthenbacktotherightsideofthepost.Atthispointth

econfigurationoftheloopandpostsresemblethenumeraleight(Fig.40A).•Wraptheloopstrandunderandaroundthepost

headingtowardthejoint(Fig.40B).•Passthetailendoftheloopbehindthepostthroughtheloopclosesttothejoint(Fig.40C).•Nextpassthetailofth

eloopbehindthepostbutinfrontoftheinitialloop(Fig.40D).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously.Donotpul

ltoohardontheloopstrandortheknotwilllockprematurely.•Advancetheknotbypullingonthepostlimbwhilepushingt

heknotwiththeknotpusheronthepoststrand(Fig.40E).•Whilemaintainingtensiononthepoststrandandusingtheknotpus

hertokeeptheknotinplace,pulltheloopstrandtolocktheknot(Fig.40FLaparoscopicKnots•Slidingknotsarenotuni

quetoarthroscopicsurgery.Thereareanumberofslidingknotsthathavebeenusedinlaparoscopy.Manyoftheseknotshavenotbee

ndescribedinthearthroscopicliterature.However,itisconceivablethatoneormoreoftheseknotscouldbeeffectiveinarthroscopi

csurgery.Althoughtheselaparoscopicknotshavebeenstudiedbiomechanically,theyhavenotbeentestedwhenusingarthroscopictechniques.Thus,oneshould

usecautionifalaparoscopicknotischosentoapproximatetissueinarthroscopicsurgery.Thepurposeofincludingseveralart

hroscopicknotsinthismanualistoexposethearthroscopicsurgeontotheslipknotsbeingusedinotherareasofsurgery(33).Bl

oodSlipknot(Fig.41)•Thebloodknotisapopularfishingknotthathasbeenadaptedtobeusedinlaparoscopicsurgery.•Thepostlim

bshouldbeonehalfthelengthofthelooplimb.•Crosstheloopoverthepoststrand(Fig.41A).•Wraptheloopbehindandaroundtheparallelpost

andloopstrandsproximal(closertothejoint)totheinitialintersectionofpostandloopstrands(Fig.41B).•Againwrapthetailoftheloopstran

daroundtheparallelpostandloopstrandsdistal(furtherfromthejoint)totheprecedingthrowforatotaloffiveturns.Afterthefifthturn,thetailoftheloopstrandshoul

dpassthroughthelargeinitialloopcreatedinstep2(Figs.41C-E).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandss

imultaneously(Fig.41F).•Advancetheknotbypullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.41G).•Inon

ebiomechanicalstudy,thebloodknotwasdeterminedtobeanunreliableknotwithallligaturestested(33).CrossSquareKn

ot(Fig.42)MelzerKnot(Fig.43)•TheMelzerknotisyetanothermodificationoftheRoederknot.•Thepostlimbshouldbeonehalfthelengthofthe

looplimb.•Throwtwoconsecutiveoverhandthrowsaroundthepost(Fig.43A).•Wrapthetailendoftheloopbehindandaroundtheparallelpostandloopstrand(Fig.43B).

•Againwrapthetailendoftheloopbehindandaroundtheparallelpostandloopstrandsclosertothejointthanthepreviousthrow(Fig.43C).•Wr

apathirdlooparoundtheparallelpostandloopstrandclosertothejointthanthepreviousthrowandpassthetailendoftheloopbetweentheparal

lelpostandloopstrandsbetweenthesecondandthirdloops(Fig.43D).•Throwalooparoundonlythepoststrandclosertothejointthananyofthepreviousthrows(Fi

g.43E).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously.•Advancetheknotbypullingonthepostlimbwhilepushingtheknotwiththeknot

pusheronthepoststrand.Cinchtheknotdownwiththeknotpusherwhilesimultaneouslyplacingtensiononbothstrands(Fig.43

F)TaysideSlipknot(Fig.44)FIGURE44.A-H.Taysideslipknot.FIGURE44.(Continued)•TheTaysideknotwasinitiallyusedas

afishingknotinScotland.•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Makeanoverhandthrowaroundthepost(Fig.44A)

.•Passthetailoftheloopoverandaroundthepostdistal(furtherfromthejoint)thantheinitialthrow.Makesuretoleavea“hole”betweenthetwoloops(Fig.44B).•Wrapthelo

oparoundthepostagaindistaltothepreviousthrow(Fig.44C).•Forthethirdtime,wrapthelooparoundthepostdistaltothepreviousthrow(Fig.44D).•Passthet

ailoftheloopbehindandthroughthe“hole”createdinstep3.Thiswillcreatealargeloop(Fig.44E).•Thanpassthetailoverandthroughthel

argeloopcreatedinstep6(Fig.44F).•Tensiontheknotbygentlypullingonboththeloopandthepoststrandssimultaneously.•Advancethekn

otbypullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand(Fig.44G).•Switchtheknotpushertothe

loopstrandandcinchtheknotdownbypastpointingwhilepullingtensiononthepoststrand(Fig.44H）KhatriKnot(Fig.

45)•TheKhatriknothasbeenusedastheanchoringknotwhenrunningsuturetoclosealaparotomywound(18).Itisanotherexampleofafishingknot,theImprovedCli

nchknot,whichwasadoptedforuseinsurgery(36).•Thepostlimbshouldbeonehalfthelengthofthelooplimb.•Wrapthelooplimboverandaroundthepoststran

dproximal(closertothejoint)todistal(fartherfromthejoint)threeconsecutivetimes(Fig.45A).•Passthetailendofthel

oopunderandthroughthelargeloopproximaltothefirstthrow(Fig.45B).•Passthetailendoftheloopstrandoverandthroughthelargeloopcreatedi

nstep3(Fig.45C).•Tensiontheknotbygentlypullingonthepostandtheloopstrandssimultaneously(Fig.45D).•Advancetheknotbyp

ullingonthepostlimbwhilepushingtheknotwiththeknotpusheronthepoststrand.Cinchtheknotdownwiththeknotpusherwhilesimultaneouslyp

lacingtensiononbothstrands(Fig.45E).