Comparing the Influence of Different Overhand/Underhand Stacking Combinations of Reversing Half-Hitches on Alternating Posts on Arthroscopic Knot Security

  • Tyler T. Bilden
  • Heather A. Evin
  • Benjamin C. Noonan
  • Alexander C.M. Chong
Keywords: arthroscopy, suture techniques, orthopedic surgery, operative procedures



Previous literature demonstrated the importance
of stacking at least three reversing half-hitches on alternating posts
(RHAPs) following arthroscopic knot placement. However, RHAPs
construction involves looping the suture in either an “overhand” or an
“underhand” manner as it relates to the post, which may affect knot
security. This study investigated the presently unidentified influence
of different stacking combinations of three RHAPs and suture material
on arthroscopic knot security.


Four different RHAPs stacking combinations were tied
with three different suture materials. Ten knots of each configuration
were tied using each suture material, resulting in 120 evaluated knots.
A single load-to-failure test was performed. The mode of failure and
mean ultimate clinical failure load were recorded.


Different overhand/underhand stacking combinations of
three RHAPs had a statistically significant effect on arthroscopic
knot strength and security; however, all combinations surpassed the
minimum ultimate clinical failure threshold. Knots constructed with
either Force Fiber® or braided fishing line had mean ultimate clinical
failure loads of greater than 200 N and most commonly failed due to
suture material breakage (100%, 60 - 80% respectively). Conversely,
FiberWire® demonstrated lower mean ultimate clinical failure loads
and had a higher incidence of elongated but intact failure (60 - 90%).


Different overhand/underhand stacking combinations
of three RHAPs yielded an arthroscopic knot capable of secure tissue
fixation. A significant effect was observed for suture materials on the
knot strength. This study increases our understanding of suitable
RHAPs construction following arthroscopic knot placement that can
lead to improving the ultimate clinical failure loads of constructed
arthroscopic knots observed between orthopedic surgeons.

Original Research