"The Gordian knot of it he will unloose": Lessons learned from studies of half-hitch surgical knots and implications for practicing surgeons: A systematic review.

Background: Insecure surgical knots can cause surgical complications ranging from wound dehiscence to massive exsanguination and death. Most surgeons tie half-hitch knots, of which some configurations are prone to slippage. We aim to characterize the securities of different half-hitch knot configurations.

Methods: A literature search was conducted using PubMed and Embase for studies in which comparisons of knot security were made between different half-hitch knot configurations. Two reviewers screened and selected articles.

Results: From 2,204 abstracts identified, 14 were selected for inclusion. In all 8 of the studies in which there was a direct comparison between knots tied with opposite throws on the same post, which are tied when greater tension is applied to the same strand end, and knots tied with any throws on alternating posts which are tied when the strand on which greater tension is applied switches between the strand ends, there was at least one comparison of configurations in which any throws on alternating posts knots were more secure than opposite throws on the same post knots. There was also less variability in the securities of any throws on alternating posts knots than opposite throws on the same post knots. Knots tied with identical throws on the same post were less secure than opposite throws on the same post and any throws on alternating posts.

Conclusions: The securities of half-hitch knots exist on a spectrum. any throws on alternating posts knots were consistently the most secure independent of whether throws were opposite or identical, and identical throws on the same post knots were less secure than opposite throws on the same post and any throws on alternating posts. Surgeons should consider any throws on alternating posts knots as opposed to the more commonly utilized opposite throws on the same post knots.