Optimization of the Racking Hitch Knot: How Many Half Hitches and Which Suture Material Provide the Greatest Security?

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. Questions/purposes 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