Background:

Previous studies of the cortical suspensory button (CSB) implant have analyzed fixation strength as a function of suture type and surgical technique, but knot configuration remains an area of interest. This study investigates 4-strand knot configurations in CSB suspensory fixation, specifically comparing the use of 2 separate knots with a single knot. We hypothesize that using 2 knots on the distal side of the CSB with #2 suture will yield the strongest and stiffest suspensory fixation.

Methods:

Two types of knot configurations were compared a single knot with all 4 suture strands versus 2 independent knots with 2 suture strands each (1 knot from inner strands and 1 knot from outer strands). They were tested using #2 or 2-0 suture, and at distal (on top of the button) or proximal (underneath the button) knot positions. Mechanical testing on the Instron measured ultimate failure load, elongation at failure, and stiffness. Statistical analyses (Shapiro-Wilk, unpaired Student's t-tests, and Chi-square tests) assessed differences in strength, stiffness, elongation, and failure mode between knot configurations within each CSB construct combination.

Results:

With #2 suture, 2 knots across the CSB resulted in higher load to failure compared to 1 knot in both proximal (467.00 N vs. 554.66 N, P = .026) and distal (395.18 N vs. 526.51 N, P < .001) locations. Furthermore, 2 knots provided higher stiffness than 1 knot in both proximal (53.24 N/mm vs. 67.89 N/mm, P < .001) and distal (47.08 N/mm vs. 56.73 N/mm, P = .041) knot locations. However, using 2-0 suture showed no significant differences in failure load and stiffness regardless of knot location.

Conclusion:

Using #2 suture and tying 2 independent knots across the CSB increased load to failure and stiffness compared to using only 1 knot regardless of knot position. Thus, if using #2 suture, it is recommended to tie 2 knots to enhance construct strength. However, with 2-0 suture, the number of knots did not impact construct strength. Therefore, if using 2-0 suture, 1 knot can be used to save time. Knot position did not significantly affect the strength or stiffness of the CSB construct, emphasizing the importance of considering knot prominence and surgical approach for determining knot location.