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. 2022 Aug 12;10(8):23259671221107034.
doi: 10.1177/23259671221107034. eCollection 2022 Aug.

Biomechanical Comparison of a Novel Multiplanar, Perpendicular Whipstitch With the Krackow Stitch and Standard Commercial Whipstitch

Stefano Muscatelli  1 , Kempland C Walley  1 , Conor S Daly-Seiler  1 , Joseph A Greenstein  1 , Aaron Sciascia  2 , David P Patterson  1   3 , Michael T Freehill  4
Affiliations

Biomechanical Comparison of a Novel Multiplanar, Perpendicular Whipstitch With the Krackow Stitch and Standard Commercial Whipstitch

Stefano Muscatelli et al. Orthop J Sports Med. .

Abstract

Background: Using alternating orthogonal suture throws with the looped whipstitch technique may allow enhanced suture fixation.

Hypothesis: It was hypothesized that this novel multiplanar, perpendicular looped whipstitch (MP) technique would have improved biomechanical properties compared with the standard looped whipstitch (WS) and Krackow stitch (KS).

Study design: Controlled laboratory study.

Methods: A total of 30 cadaveric tibialis anterior tendons were randomly assigned into 3 groups of 10. Tendons were secured to a custom clamp, and the other end was sutured using 1 of 3 techniques: the KS, WS, or novel MP. The MP was performed with alternating orthogonal throws starting right to left, then front to back, left to right, and back to front. Each technique used 4 passes of No. 2 FiberWire spaced 5 mm apart and ending 10 mm from the tendon end. Tendons were preloaded to 5 N, pretensioned to 50 N at 100 mm/min for 3 cycles, returned to 5 N for 1 minute, cycled from 5 to 100 N at 200 mm/min for 100 cycles, and then loaded to failure at 20 mm/min. Elongation was recorded after pretensioning and cycling and was measured both across the suture-tendon interface and from the base of the suture-tendon interface to markings on the suture limbs (construct elongation). One-way analyses of variance were performed, with Bonferroni post hoc analysis when appropriate.

Results: There were no differences in cross-sectional area or stiffness among the 3 techniques. The ultimate load for WS (183.33 ± 57.44 N) was less compared with both MP (270.76 ± 39.36 N) and KS (298.90 ± 25.94 N) (P ≤ .001 for both). There was less construct elongation for KS compared with WS and MP for total displacement, measured from pretensioning to the end of cycling (P < .001). All 3 techniques saw a decrease in length (shortening) at the suture-tendon interface during testing. There was more shortening at the suture-tendon interface for WS compared with KS (P = .006).

Conclusion: The KS appears superior, as it maximized strength while minimizing construct elongation or graft shortening. The ultimate load of the MP technique was greater than that of the standard technique but not significantly different from that of the KS technique.

Clinical relevance: The KS is preferred. If using a WS, multiplanar, perpendicular passes should be considered.

Keywords: Krackow; biomechanics; fatigue testing; tendon; ultimate failure load; whipstitch.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: The cadaveric tendons used in this study were donated by RTI Surgical, and the suture material (FiberWire and FiberLoop) was donated by Arthrex. The University of Michigan Research Advisory Committee provided grant funding for supplies. dsdf S.M. has received education payments from Pinnacle. D.P.P. has received education payments from Arthrex. M.T.F. has received education payments from Evolution Surgical, consulting fees from Stryker, speaking fees from Smith & Nephew, and hospitality payments from Wright Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Three suturing techniques, including the (A) standard whipstitch; (B) multiplanar, perpendicular whipstitch; and (C) Krackow stitch.
Figure 2.
Figure 2.
Technique for the multiplanar, perpendicular whipstitch: (A) right to left, (B) front to back, (C) left to right, and (D) back to front.
Figure 3.
Figure 3.
Tendon biomechanical testing setup.
Figure 4.
Figure 4.
Description of the measurement and calculation of elongation variables.
Figure 5.
Figure 5.
Decrease in tendon length at suture-tendon interface (shortening) because of the purse-string effect in a multiplanar, perpendicular looped whipstitch trial.
Figure 6.
Figure 6.
Suture-tendon interface elongation between each group at each time point. *WS has significantly more shortening compared with MP (P = .03) and KS (P = .004). **WS has significantly more shortening compared with KS (P = .006). Tcyc, displacement due to cycling; Tpre, displacement due to pretension; Ttotal, total displacement throughout the entire time period from preload to end of cycling.
Figure 7.
Figure 7.
Construct elongation between each group at each time point. *WS has significantly more elongation compared with KS (P = .001). **MP has significantly more elongation compared with WS (P = .01) and KS (P < .001). ***WS has significantly more elongation compared with KS (P = .001). ****KS has significantly less elongation compared with WS and MP (P < .001). Tcyc, displacement due to cycling; Tpre, displacement due to pretension; Ttotal, total displacement throughout the entire time period from preload to end of cycling.
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