The use of cerclage alone or as a supplement to other forms of internal fixation is common in orthopedic practice. It enhances tissue healing by providing reliable fixation. Developments in instrumentation and technique have advanced in the field of arthroscopic and open surgery. Therefore, original simple solutions can be used to solve complex and classical situations. The Nice knot is a doubled stranded knot described by Boileau et al1 and its original application was proposed for tuberosity osteosynthesis in proximal humerus fractures. New alternative uses for shoulder surgery (arthroscopic cuff repair, cerclage sutures for humerotomy during revision arthroplasty, bone block fixation in treatment for shoulder instability, and fixation of small butterfly fragments in clavicular fractures) have been published.
The Nice knot has been used vastly in shoulder surgery—for fixation of bone fragments and soft tissues in various surgical contexts.
This knot is easy to learn and tie, has a low profile, has good loop and knot security, and fundamentally allows accurate control of the tension applied.2
Arthroscopy is widely used for repair of ligamentous wrist lesions such as triangular fibrocartilage complex (TFCC) ligament or scapholunate ligament (SLI). Many techniques have been described including the use of different knots. This article aims to describe the utilization of the Nice knot in wrist arthroscopy to repair the TFCC or the SLI. We modified the techniques described by Mathoulin3 for these repairs in order to simplify the realization of the knot by replacing it by a Nice knot.
SURGICAL TECHNIQUE OF THE NICE KNOT
A high caliber, braided, nonabsorbable suture is used for bone fixation (Fig. 1). In contrast, thinner monofilament sutures are used for soft tissue. The suture is doubled over itself to obtain 2 free limbs on one end and a loop on the other. By doubling the suture on itself, it provides a stronger means of fixation. The loop end is passed around the tissues to be fixed using a retriever or a needle. A simple square knot is thrown using the loop on one hand and the 2 free limbs on the other (treated as a simple undoubled suture). The loop is opened and both free limbs are passed through it. The knot is then dressed by making the loop smaller. When ready to secure the involved tissues, surgeon tighten down the sliding knot by either pulling the 2 free limbs apart or pulling the free limbs back toward them. Finally, 3 alternatives half-hitches are performed using the 2 separated free limbs. This secures the knot definitively. The knot is considered provisional until secured with the 3 alternating half-hitches or surgeon’s knots.
TFCC INJURY REPAIR
We recommend the utilization of the Nice knot in foveal TFCC repair, described in the scenario of a Palmer 1B lesion (Palmer) or stage 1 in the Atzei-Ewas classification.4 It is known that the reattachment of the ligament to the fovea is necessary to restore stability of the distal radioulnar joint (Fig. 2).5
The hand is suspended under regional anesthesia on 10 to 15 N traction. The forearm is placed in supination. The camera enters the 3 to 4 portal to visualize the TFCC. A 6R portal is realized to assess the TFCC foveal avulsion and debride the synovitis.
Two obliquely upward-directed 21-G needles are introduced throw the capsule and the TFCC, respectively, volarly and dorsally of the styloid process. The needles must exit at the ulnar portion of the TFCC near from the foveal insertion.
Two absorbable monofilament suture such as 3-0 PDS are used. The suture are doubled and inserted in the needles. The loop inserted in the volar needle is retrieved through the dorsal needle using the second loop.
- Option1: a small skin incision is made between the 2 needles that are separated of 1 cm. Dissection is realized to expose the ulnar styloid process. A bone tunnel with a 1.5 mm drill is made from volar to dorsal. The 2 free limbs are passed through the tunnel.
- Option 2: a small skin incision is made on the dorsal side of the ulnar styloid. The 2 free limbs are passed through a subcutaneous dissection from volar to dorsal.
The Nice knot is realized as previously described and secured with the wrist in extension and ulnar deviation. Its permits a double suture of the TFCC back to its insertion into the fovea.
A splint is applied for 5 weeks in neutral pronosupination.
SCAPHOLUNATE LIGAMENTOUS INJURY REPAIR
As described by Mathoulin,3 this repair aims to reconstruct the dorsal capsuloscapholunate septum at the same time of the SLI—there are sutured to each other and also to the dorsal capsule (Fig. 3).
Under regional anesthesia, the hand is suspended on 10 to 15 N traction. The scope is introduced through the 3 to 4 portal. A shaver is introduced into the 6R portal to perform the synovectomy. The arthroscope and the shaver are then introduced through the midcarpal portal. The scope is introduced into the 6R portal. An absorbable monofilament suture (3-0 PDS) doubled in passed through a 21-G needle. The needle is inserted via the 3 to 4 portal through the joint capsule and the scapholunate interosseous ligament on the scaphoid side. A second needle and double suture are then inserted parallel to the first needle into the scapholunate interosseous ligament stump attached to the lunate. The scope is introduced to the midcarpal joint. A mosquito hemostat is used to pass one loop into the other to be pulled out.
Reduction of the scapholunate gap is testing by pulling on the limbs. When the reduction is satisfactory, the arm is taken off traction, a small skin incision is made and the Nice knot is realized and tied on the dorsal capsule. The incision permits to check that the knot is not applied on an extensor tendon. Scapholunate interval is usually pinned or screwed as a complementary fixation.
A splint is applied for 6 weeks with wrist in extension.
Advantages of the Nice Knot
This simple and easy knot to perform provides an effective alternative in difficult situations, even to surgeons with no experience in knot tying techniques. It is doubled suture so it provides, in theory, doubled strength. This knot permits accurate the tensioning of the suture. The loop in the Nice knot prevents slipping, but is loose enough that it can be undone if it is not secured yet. This option provides many advantages such as easier handling, better adaptation to bone surface, decreased soft tissue irritation, no risk of metalosis, no interference with radiologic imaging, less palpatory discomfort in superficial areas like metacarpals and proximal ulna and therefore less need of second surgery.
Besides the knot itself, the type of suture used and its configuration are also important.
Biomechanical parameters should be taken into account at the time of soft tissue and bone repair. Collin et al2 proved that Nice knot has better results for stiffness and dynamic stiffness, providing a decrease in the risk of suture construct elongation during dynamic stress. Hill et al6 showed that the Nice knot with 2 and 3 half-hitches was the only knot to experience material failure as the primary mode of ultimate failure, indicating the knot is not the weak link in the overall construct.
The Nice knot is a simple knot, easy to use under arthroscopy to repare SLI and TFCC tears.
1. Boileau P, Alami G, Rumian A, et al. The doubled-suture Nice knot. Orthopedics. 2017;40:e382–e386.
2. Collin P, Laubster E, Denard PJ, et al. The Nice knot as an improvement on current knot options: a mechanical analysis. Orthop Traumatol Surg Res. 2016;102:293–296.
3. Mathoulin CL. Indications, techniques, and outcomes of arthroscopic repair of scapholunate ligament and triangular fibrocartilage complex
. J Hand Surg Eur. 2017;42:551–566.
4. Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011;27:263–272.
5. Haugstvedt JR, Berger RA, Nakamura T, et al. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex
to the dynamic stability of the distal radioulnar joints. J hand Surg Am. 2016;31:445–451.
6. Hill SW, Chapman CR, Adeeb S, et al. Biomechanical evaluation of the Nice knot. Int J Shoulder Surg. 2016;10:15–20.