The Doubled-Suture Nice Knot

Abstract

The authors describe a novel suture fixation technique that combines a doubled suture with a sliding knot. The knot can be tied in both open and arthroscopic surgery to fix torn tendons/ligaments and fractured/osteotomized bones. The advantages of the doubled-suture Nice knot include strength, adjustability, simplicity, and versatility. This technique, which has proven useful in the authors' practice for the past 10 years, has replaced metallic wires and cables for bone fixation. The doubled-suture Nice knot can also be tied over a double-button and has been used for ankle syndesmosis, acromioclavicular joint separation repair, and coracoid bone block fixation. [Orthopedics. 201x; XX(X):exx-exx.].

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e382 Copyright © SLACK inCorporAted
n tips & techniques
Section Editor: Steven F. Harwin, MD
The Doubled-Suture Nice Knot
Pascal Boileau, MD; Ghassan Alami, MD, FRCS(C); Adam Rumian, MD, FRCS; Daniel G. Schwartz, MD;
Christophe Trojani, MD, PhD; Adam J. Seidl, MD
Secure fixation is crucial for
tissue healing, whether it
is bone or soft tissue. A knot is
considered to be of good quality
if it is easy to learn and tie, has
a low profile, has good loop and
knot security, and allows accu-
rate control of the tension ap-
plied.1-4 Traditionally, flat non-
sliding knots, such as square
knots, have been used in open
surgery because they have been
perceived to be more secure
than sliding knots. With the de-
velopment of arthroscopic and
endoscopic surgery, the techni-
cal challenges of tying intracor-
poreal flat knots have contribut-
ed to the development of many
effective sliding knots.5-15
Besides the knot itself, the
type of suture used and its
configuration are also impor-
tant biomechanical parameters
that should be taken into ac-
count at the time of soft tissue
and bone repair. It has been
the authors’ experience that
doubling the suture on itself
provides a stronger means of
fixation for both soft tissue and
bone repair. However, the use
of a doubled suture means that
a specific knot must be done
to provide both progressive
tensioning and secure fixa-
tion. For the past 10 years, the
authors have been using the
doubled-suture Nice knot for
the fixation of bone fragments
and soft tissues alike, in vari-
ous surgical contexts.
In this article, the authors
describe a novel fixation tech-
nique that combines a doubled
suture with a sliding knot that
is self-stabilizing (nonslip-
ping), adjustable, easy to per-
form, and solid. The doubled-
suture Nice knot can be tied
in both open and arthroscopic
surgery to fix torn tendons/
ligaments and fractured/oste-
otomized bones. Its use with
a doubled high-strength suture
also makes it applicable in a
variety of contexts involving
large displacement forces.
Technique
A high-caliber (at least No.
1), braided, absorbable or non-
absorbable suture is used. The
suture is doubled over itself to
obtain 2 free limbs on one end
and a loop on the other (Fig-
ure 1A). The suture is passed
around the tissues to be fixed,
using a suture shuttle or a re-
movable needle mounted on the
loop end. Alternatively, a com-
mercially available “looped”
suture with needle can be used
(Figure 2). A simple square
knot is thrown using the
loop on 1 hand and the 2 free
The authors are from the Department of Orthopaedic Surgery and Sports
Traumatology (PB, DGS, CT), L’Archet2 Hospital, University of Nice-
Sophia-Antipolis, Nice, France; Saint Jérôme Hospital (GA), Montreal, Que-
bec, Canada; Spire Harpenden Hospital (AR), Hertfordshire, United King-
dom; and the Department of Orthopaedics (AJS), University of Colorado,
Aurora, Colorado.
Drs Alami, Rumian, Schwartz, Trojani, and Seidl have no relevant finan-
cial relationships to disclose. Dr Boileau is an unpaid consultant for Smith
& Nephew, is on the speaker’s bureau of Smith & Nephew, receives royalties
from Wright Medical, receives travel expenses from Smith & Nephew and
Wright Medical, and holds stock in Imascap.
Correspondence should be addressed to: Pascal Boileau, MD, Depart-
ment of Orthopaedic Surgery and Sports Traumatology, L’Archet2 Hospital,
University of Nice-Sophia-Antipolis, 151 Route de St Antoine de Ginestière,
06200 Nice, France (boileau.p@chu-nice.fr).
Received: March 29, 2016; Accepted: June 14, 2016.
doi: 10.3928/01477447-20161202-05
Abstract: The authors describe a novel suture fixation tech-
nique that combines a doubled suture with a sliding knot. The
knot can be tied in both open and arthroscopic surgery to fix
torn tendons/ligaments and fractured/osteotomized bones. The
advantages of the doubled-suture Nice knot include strength,
adjustability, simplicity, and versatility. This technique, which
has proven useful in the authors’ practice for the past 10 years,
has replaced metallic wires and cables for bone fixation. The
doubled-suture Nice knot can also be tied over a double-button
and has been used for ankle syndesmosis, acromioclavicular
joint separation repair, and coracoid bone block fixation. [Or-
thopedics. 2017; 40(2):e382-e386.]

n tips & techniques
MARCH/APRIL 2017 | Volume 40 • Number 2 e383
limbs on the other (treated as
a simple, undoubled suture)
(Figure 1B). The loop is
opened and both free limbs
are passed through it (Figure
1C). The knot is then dressed
by making the loop smaller
(Figure 1D). When ready to
secure the involved tissues, sur-
geons tighten down the sliding
knot by either pulling the 2 free
limbs apart (Figure 1E)—as
done during open surgery—or
pulling the free limbs (acting
as the post) back toward them,
which is most useful during ar-
throscopic surgery. As with oth-
er sliding knots, while the post
is being pulled back, the knot
can be helped down either man-
ually or with an arthroscopic
knot pusher to reduce the trac-
tion forces seen by the tissues
around which the sutures are
sliding. Another way to reduce
such traction forces is to pull
the 2 free limbs of the post sep-
arately in alternation (but still in
the same axis). Finally, 3 alter-
nating half-hitches or surgeon’s
knots are performed using the
2 separated free limbs (Figure
1F). This precludes the pos-
sibility that the free limbs will
slide back out of the loop, thus
securing the knot definitively.
As excellent as its loop security
and holding capacity may be,
the authors consider the knot
provisional until secured de-
finitively with the 3 alternating
half-hitches.16,17
ApplicATions
The following are a few
examples of the various con-
texts, open and arthroscopic,
in which the doubled-suture
Nice knot has proven useful.
Tuberosity Fixation During
Fracture Treatment With
Humeral Hemiarthroplasty or
Reverse Shoulder Arthroplasty
The authors’ technique for
tuberosity fixation using 4
horizontal cerclages and 2 ver-
tical tension-band sutures has
been published previously.18
The authors have modified
their technique in that each
cerclage and tension-band su-
tures are now made using the
Nice knot with strong (eg, No.
5 Ethibond [Ethicon, Somer-
ville, New Jersey] or No. 2 Or-
thocord [DePuy Mitek, War-
saw, Indiana]) nonabsorbable
sutures. As explained above,
the knots can be tightened in
stages without slipping. This
allows provisional fixation
while the tuberosity positions
are adjusted to achieve an ana-
tomic reduction (Figures 3-4).
Fixation of an Isolated
Greater Tuberosity After
Acute Fracture, Nonunion, or
Malunion
For fixation of an isolated
greater tuberosity after acute
fracture, nonunion, or mal-
union, the horizontal cerclage
double sutures are passed
through the hard bone of the
bicipital groove (or through
the lesser tuberosity) on one
side and through the tendons
of the infraspinatus and teres
minor distally on the other
side. This technique can also
be used for the treatment of
3- or 4-part fractures, together
with a lateral locking plate or
intramedullary humeral nail.
Cerclage Sutures for
Humerotomy or Femorotomy
Fixation During Revision
Arthroplasty
Multiple doubled sutures can
be shuttled around the diaphysis
and used for cerclage. This is
ABC
D
Figure 1: Knot technique. A doubled-over suture is passed around the tissue (A). A single square knot is thrown (B). The 2 free
limbs are passed through the loop (C). The knot is dressed (D). The knot is slid down by pulling the 2 free limbs apart (E). (The
2 limbs can also be pulled back toward the surgeon at once or alternately. A knot pusher can also be used to help the knot down
while the limbs are being pulled.) The tightened knot is ready to be secured with 3 alternating half-hitches or surgeon’s knots (F).
E F
Figure 2: A doubled-over suture with
a needle.

e384 Copyright © SLACK inCorporAted
n tips & techniques
much easier than passing wires
or cables and is less traumatic to
the surrounding soft tissues, both
during insertion and in case of an
unexpected breakage. Two, 3, or
4 cerclages are set up and, again,
partially and progressively tight-
ened while the osteotomy frag-
ment is reduced anatomically.
Suture is less likely than wires or
cables to irritate the surrounding
tissues; yet, if for any reason the
doubled-suture cerclage needs
to be removed, it is much easier
to cut with scissors and pull out
(Figure 5).
Fixation of Small Butterfly
Fragments
A butterfly (wedge) frac-
ture fragment is often encoun-
tered when performing open
reduction and internal fixation
of fractures of, for instance,
the clavicle or distal fibula. An
attempt to fix such a butterfly
fragment with a lag screw can
result in its fragmentation or
devitalization. However, it is
a simple matter to pass 1 or 2
doubled sutures around it and
secure it with the Nice knot.
Arthroscopic Applications
The authors systematically
use the Nice knot when per-
forming side-to-side rotator cuff
repairs or anchorless, transos-
seous repairs (Figure 6).19 In
some situations, they also pass a
doubled suture through the eye-
let of an anchor and use it with
the Nice knot as they would any
other sliding arthroscopic knot.
The authors have also used
this technique in the fixation
of both posterior and anterior
bone blocks for the treatment of
shoulder instability. Finally, the
doubled-suture Nice knot can
also be tightened over a double-
button for anterior cruciate liga-
ment graft fixation, ankle syn-
desmosis, or all-arthroscopic
reconstruction of acromiocla-
vicular joint disruptions.20
A B
C
Figure 3: Tuberosity fixation during hemiarthroplasty for proximal humerus fracture (left shoulder, anterosuperior “sa-
ber” incision). Note that 2 cerclages have already been placed to fix the greater tuberosity to the prosthesis (after bring-
ing the arm into external rotation for anatomic tuberosity reduction). This figure illustrates the 2 final cerclages around
both tuberosities, their doubled sutures having been shuttled around with a regular needle-loaded suture. With the lower
blue cerclage, a Nice knot is prepared and left loose; on the upper green cerclage, a Nice knot is tightened provisionally
(A). The tuberosity reduction is adjusted as required, then the lower blue cerclage Nice knot is tightened (B). The upper
green cerclage can now be tightened definitively, then both knots are secured and cut (C). Final appearance with all 4
cerclages and 2 vertical tension bands in place (D).
D
Figure 4: Preoperative (A) and 6-month postoperative (B) radiographs of tuberosity fixation during hemiarthroplasty
for a 4-part fracture-dislocation using 4 cerclages and 2 tension-band sutures with the doubled-suture Nice knot. Axial
(C) and coronal (D) computed tomography scans 6 months postoperatively showing a preserved tuberosity reduction
and good bone healing.
C
D
BA

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MARCH/APRIL 2017 | Volume 40 • Number 2 e385
Other Possible Applications
The authors have also used
the doubled-suture Nice knot
for tension banding of olecra-
non fracture and for patellar
fracture fixation. This novel
fixation technique has proven
useful in their practice for the
past 10 years, replacing metal-
lic wires and cable fixation.
Discussion
Advantages
The doubled-suture Nice
knot has several advantages.
First, its use of a doubled-over
suture theoretically doubles
the suture’s strength. The ten-
sion in each strand is halved,
as is the risk of breakage. The
doubling of the suture also re-
sults in increased internal fric-
tion, which translates into ex-
cellent loop and knot security.1
Second, tightening the knot
by pulling the free limbs apart
results in a feel similar to that
of flattening a half-hitch or
surgeon’s knot, allowing more
accurate and adjustable ten-
sioning of the suture.
Third, the tightening pro-
cess can be stopped and re-
sumed at any stage, as the loop
security of the knot prevents
it from slipping. Thus, when
repairing a tissue under ten-
sion, 2 or more sutures can be
placed an appropriate distance
apart and the Nice knot can be
prepared on each of them (Fig-
ure 4). Provisional tightening
can then be performed and the
reduction adjusted as required
before the knots are finally
tightened and secured. This is
in stark contrast to tying a sim-
ple knot, which requires imme-
diate and irreversible locking,
constant tension on the limbs,
or other extra (and sometimes
unreliable) maneuvers by an
assistant to prevent slippage.
Fourth, as long as it has not
yet been secured, the knot can
be completely undone by sim-
ply pulling the free limbs back
out of it. Once that is done, the
knot unravels automatically
and the doubled suture can be
reused immediately.
Fifth, despite the above
advantages, the Nice knot re-
mains a low-profile, simple
knot compared with other ex-
isting sliding knots. By com-
bining a relatively simple ini-
tial knot with equally simple
security knots, the Nice knot
provides knot security with-
out excessive complexity and
bulkiness. Bulkiness is espe-
cially undesirable when a knot
made with nonabsorbable su-
ture is left adjacent to articular
cartilage or moving tendons.12
Needled double sutures are
available and can be used with
either an absorbable (Doubled
PDS; Ethicon) or a nonabsorb-
able (NiceLoop; Tornier Inc,
Bloomington, Minnesota) su-
ture (Figure 2).
Comparison With Related
Knots
The closest relative to the
doubled-suture Nice knot is
the “modified racking hitch”
knot. Although derived from
the same “cow hitch” prede-
cessor, the modified racking
hitch is less straightforward
and symmetric.21 Thus, in ad-
dition to being more difficult
to perform, the internal friction
and interference is increased
in the modified racking hitch
knot, making it also relatively
more difficult to slide. The
simpler “racking hitch” knot,
which the senior author (P.B.)
used prior to the Nice knot,
had too little internal interfer-
ence and therefore not enough
holding power.
An even more complex
knot, the “giant knot,” is re-
Figure 5: Nice knot for humerotomy fixation. Preoperative anteroposterior ra-
diograph of an uncemented humeral stem requiring revision. A humerotomy
was required for stem extraction (A). Anteroposterior radiograph of the revised
prosthesis showing good fixation of the humerotomy. The subtle notches seen
on the outside of the diaphysis (arrows) are the radiographic evidence of the
presence (and strength) of the doubled-suture Nice knots (B).
BA
Figure 6: Two doubled-suture Nice knots secured and cut after being used in
a transosseous, anchorless rotator cuff repair.

e386 Copyright © SLACK inCorporAted
n tips & techniques
ported to have enough inter-
nal interference after being
“flipped” to not require se-
curing with additional knots.8
Concern has previously been
expressed regarding the effect
of such post switching on knot
tightness and tissue apposi-
tion.12 In addition, this knot is
performed with a single, not a
double, suture.
Comparisons between these
various knots have yet to be
made with objective laboratory
testing. The mentioned phe-
nomena and the authors’ clini-
cal experience with all of the
above knots together support
their conclusion that the Nice
knot strikes the best balance
among all of the attributes of
the ideal sliding knot.
Limitations
The strength of this tech-
nique may be underestimated
while the knot is tightened.
This may lead to ischemia of
the tissues being fixed. Fur-
thermore, later on, the weak-
est link in the construct may
be the bone or soft tissues
themselves. Thus, the sur-
geon should not subject them
to unreasonable biomechani-
cal conditions (eg, acceler-
ated weight bearing or resisted
range of motion) simply be-
cause a stronger fixation tech-
nique has been employed.
conclusion
The doubled-suture Nice
knot is helpful and remarkably
easy to execute. The authors
encourage other surgeons to
employ it. Whether in trauma
or elective surgery, in open
surgery or arthroscopy, its ap-
plications are numerous. Its
strength and effectiveness can
provide the surgeon with con-
fidence and efficiency in vari-
ous critical surgical situations.
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