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Editorial Commentary: Good Start But More Testing Needs to Be Done: Load to Failure and Knot Security Comparing Suture Tape Versus High-Strength Suture
Editorial Commentary: Good Start But More Testing Needs to Be Done: Load to Failure and Knot Security Comparing Suture Tape Versus High-Strength Suture Merrick Wetzler, M.D., Editorial Board
Abstract: Two-millimeter high tensile strength tape (HTST) ultimate load to failure and knot security is greater than No. 2 high tensile strength suture. However, not many surgeons tie knots with 2-mm HTST. More testing needs to be done with 1.3- and 1.7-mm HTST.
See related article on page 2461
I
believe that the development of high tensile strength suture (HTSS) was one of the biggest developments to improve the repair of soft-tissue injuries, especially the rotator cuff. Before, we had all experienced, after inserting a suture, anchor failure of No. 2 nonabsorbable suture either during passing the suture through the soft tissue or during knot tying.1 With HTSS, this type of failure has all but been eliminated. High tensile strength suture tape (HTST) uses the same material as HTSS but has a flat core instead of a rounded core.2 This has led to the evolution and development of new orthopaedic surgical techniques that take advantage of the high tensile strength of both the suture and the tape and has improved outcomes in many of these different procedures.3,4 In the study by Leishman and Chudik in this issue, “Suture Tape With Broad Full-Width Core Versus Traditional Round Suture With a Round Core: A Mechanical Comparison,”5 the authors found that HTST had superior knot-tying security with greater ultimate failure to load with no difference in knot height when compared with HTSS. The authors clearly point out that the reason for increased knot security resulted from the increased surface area and internal resistance of the
The author reports no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 Published by Elsevier on behalf of the Arthroscopy Association of North America 0749-8063/19660/$36.00 https://doi.org/10.1016/j.arthro.2019.06.004
HTST versus HTSS.5 This information can be useful in the future as more techniques are developed that call on surgical knots to be tied with 2-mm HTST versus No. 2 HTSS. At the 2019 Annual Meeting of the Arthroscopy Association of North America (AANA) in Orlando, Florida, I polled many of the attendees, asking them how often do they tie 2-mm HTST and the majority of them responded infrequently; however, many of them did respond that they do tie small-width HTST. Once you get past a certain tensile strength, the mechanism of failure may solely reside with the soft tissue.3 This study allows us to start asking more questions. As the authors pointed out, this was a static, not a cyclic, load.6 Does the increased width, surface area, and contact of the HTST versus HTSS help prevent soft tissue failure as seen in vivo? Do smaller width (1.3- and 1.7-mm) HTST have ultimate failure to load, knot security, and knot height comparable with the No. 2 HTSS? I do believe we will find this out soon as more biomechanical research is carried out and newer types of suture and sizes of suture tapes are developed and tested.
References 1. Wüst DM, Meyer DC, Favre P, Gerber C. Mechanical and handling properties of braided polyblend polyethylene sutures in comparison to braided polyester and monofilament polydioxanone sutures. Arthroscopy 2006;22:1146-1153. 2. Gnandt RJ, Smith JL, Nguyen-Ta K, McDonald L, LeClere LE. High-tensile strength tape versus high-tensile strength suture: A biomechanical study. Arthroscopy 2016;32:356-363.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 8 (August), 2019: pp 2467-2468
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EDITORIAL COMMENTARY
3. Liu RW, Lam PH, Shepherd HM, Murrell GAC. Tape versus suture in arthroscopic rotator cuff repair: Biomechanical analysis and assessment of failure rates at 6 months. Orthop J Sports Med 2017;5:2325967117701212. 4. Yoo JS, Yang EA. Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace. J Orthop Traumatol 2016;17:353-360.
5. Leishman DJ, Chudik SC. Suture tape with broad fullwidth core versus traditional round suture with round core: A mechanical comparison. Arthroscopy 2019;35: 2461-2466. 6. Wetzler MJ, Bartolozzi AR, Gillespie MJ, et al. Fatigue properties of suture anchors in 408 anterior shoulder reconstructions: Mitek GII. Arthroscopy 1996;12:687-693.
Abstract: Two-millimeter high tensile strength tape (HTST) ultimate load to failure and knot security is greater than No. 2 high tensile strength suture. However, not many surgeons tie knots with 2-mm HTST. More testing needs to be done with 1.3- and 1.7-mm HTST.
See related article on page 2461
I
believe that the development of high tensile strength suture (HTSS) was one of the biggest developments to improve the repair of soft-tissue injuries, especially the rotator cuff. Before, we had all experienced, after inserting a suture, anchor failure of No. 2 nonabsorbable suture either during passing the suture through the soft tissue or during knot tying.1 With HTSS, this type of failure has all but been eliminated. High tensile strength suture tape (HTST) uses the same material as HTSS but has a flat core instead of a rounded core.2 This has led to the evolution and development of new orthopaedic surgical techniques that take advantage of the high tensile strength of both the suture and the tape and has improved outcomes in many of these different procedures.3,4 In the study by Leishman and Chudik in this issue, “Suture Tape With Broad Full-Width Core Versus Traditional Round Suture With a Round Core: A Mechanical Comparison,”5 the authors found that HTST had superior knot-tying security with greater ultimate failure to load with no difference in knot height when compared with HTSS. The authors clearly point out that the reason for increased knot security resulted from the increased surface area and internal resistance of the
The author reports no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 Published by Elsevier on behalf of the Arthroscopy Association of North America 0749-8063/19660/$36.00 https://doi.org/10.1016/j.arthro.2019.06.004
HTST versus HTSS.5 This information can be useful in the future as more techniques are developed that call on surgical knots to be tied with 2-mm HTST versus No. 2 HTSS. At the 2019 Annual Meeting of the Arthroscopy Association of North America (AANA) in Orlando, Florida, I polled many of the attendees, asking them how often do they tie 2-mm HTST and the majority of them responded infrequently; however, many of them did respond that they do tie small-width HTST. Once you get past a certain tensile strength, the mechanism of failure may solely reside with the soft tissue.3 This study allows us to start asking more questions. As the authors pointed out, this was a static, not a cyclic, load.6 Does the increased width, surface area, and contact of the HTST versus HTSS help prevent soft tissue failure as seen in vivo? Do smaller width (1.3- and 1.7-mm) HTST have ultimate failure to load, knot security, and knot height comparable with the No. 2 HTSS? I do believe we will find this out soon as more biomechanical research is carried out and newer types of suture and sizes of suture tapes are developed and tested.
References 1. Wüst DM, Meyer DC, Favre P, Gerber C. Mechanical and handling properties of braided polyblend polyethylene sutures in comparison to braided polyester and monofilament polydioxanone sutures. Arthroscopy 2006;22:1146-1153. 2. Gnandt RJ, Smith JL, Nguyen-Ta K, McDonald L, LeClere LE. High-tensile strength tape versus high-tensile strength suture: A biomechanical study. Arthroscopy 2016;32:356-363.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 8 (August), 2019: pp 2467-2468
2467
2468
EDITORIAL COMMENTARY
3. Liu RW, Lam PH, Shepherd HM, Murrell GAC. Tape versus suture in arthroscopic rotator cuff repair: Biomechanical analysis and assessment of failure rates at 6 months. Orthop J Sports Med 2017;5:2325967117701212. 4. Yoo JS, Yang EA. Clinical results of an arthroscopic modified Brostrom operation with and without an internal brace. J Orthop Traumatol 2016;17:353-360.
5. Leishman DJ, Chudik SC. Suture tape with broad fullwidth core versus traditional round suture with round core: A mechanical comparison. Arthroscopy 2019;35: 2461-2466. 6. Wetzler MJ, Bartolozzi AR, Gillespie MJ, et al. Fatigue properties of suture anchors in 408 anterior shoulder reconstructions: Mitek GII. Arthroscopy 1996;12:687-693.