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Square Knot Two-Hand Technique

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9By further supinating left hand, white strand slides onto left index finger to form a loop as purple strand is grasped between left index finger and thumb.

11Horizontal tension applied with left hand away from and right hand toward the operator. This completes the second half hitch.

inward by pronation with thumb carrying purple strand through loop of white strand. Purple strand is grasped between right thumb and index finger.

The final tension on 12 the final throw

should be as nearly horizontal as possible.

One-Handed Technique

Square Knot One-Hand Technique

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Wherever possible, the square knot is tied using the two-hand technique. On some occasions it will be necessary to use one hand, either the left or the right, to tie a square knot. These illustrations employ the left-handed technique.

The sequence of throws illustrated is most commonly used for tying single suture strands. The sequence may be reversed should the

surgeon be holding a reel of suture material in the right hand and placing a series of ligatures. In either case, it cannot be too strongly emphasized that the directions the hands travel must be reversed proceeding from one throw to the next to ensure that the knot formed lands flat and square. Half hitches result if this precaution is not taken.

1White strand held between thumb and index finger of left hand with loop over extended index finger. Purple strand held between thumb and index finger of right hand.

over white strand on left index finger by moving right hand away from operator.

3With purple strand supported in right hand, the distal phalanx of left index finger passes under the white strand to place it over tip of left index finger. Then the white strand is pulled through loop in preparation for applying tension.

The first half hitch is completed by advancing tension in the horizontal plane with the left hand drawn toward and right hand away from the operator.

Surgeon’s or Friction Knot

Surgeon's or Friction Knot

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The surgeon's or friction knot is recommended for tying PANACRYL* braided synthetic absorbable suture, Coated VICRYL* (polyglactin 910) suture, ETHIBOND*

EXCEL polyester suture, ETHILON* nylon suture, MERSILENE* polyester fiber suture, NUROLON* nylon suture,

PRONOVA* poly (hexafluoropropyleneVDF) suture, and PROLENE* polypropylene suture.

The surgeon's knot also may be performed using a one-hand technique in a manner analogous to that illustrated for the square knot one-hand technique.

1White strand placed over extended index finger of left hand and held in palm of left hand. Purple strand held between thumb and index finger of right hand.

over white strand by moving right hand away from operator at an angle to the left. Thumb and index finger of left hand pinched to form loop in the white strand over index finger.

3Left hand turned inward by pronation, and loop of white strand slipped onto left thumb. Purple strand grasped between thumb and index finger of left hand. Release right hand.

Left hand rotated by supination extending left index finger to pass purple strand through loop. Regrasp purple strand with right hand.