Knot Security 101: A Comprehensive Practical Review to Optimal Knot Configuration, Pulling Direction, Throw Count, and Tail Length

Abstract

Background: Knots are the weakest structural point in a suture line and inevitably weaken almost all suture materials. This practical review critically evaluates the factors, such as suture material properties, gauge, configuration, throw count, and tail length, that affect knot security. Methods: A PubMed search between the years 1934 and 2023 identified relevant studies that addressed factors relating to knot security. Studies that investigated knots and sutures solely used in laparoscopic and arthroscopic surgery were excluded. Knot configurations assessed were the Aberdeen, sliding, square, and surgeon’s. Results: Eighty-six articles were included in this review article and demonstrated that knot security varies greatly between suture materials and gauge. Knot security also varies by configuration, throw count, conditions, tail length, and stitch type. Throw count differs by knot configuration, with the Aberdeen knot being most secure with three throws and one to two turns compared with three to five throws for surgeon’s and square knots. The optimal tail length was 3 mm. Conclusions: This practical review demonstrates that there are significant differences in knot security based on a variety of factors. It is challenging to propose an ideal knot because most studies did not evaluate knot security using a broad variety of suture materials, gauges, and throws for each of the most common knots. Although this review article demonstrated several applicable findings, additional robust studies are needed to simplify proposals.