The SH-9Hospital knotting technique: analysis of innovation claims and biomechanical testing

We did read with great interest the article entitled “A novel and efficient surgical knotting technique for high-tension closures” in the Annals of Translational Medicine (1). This technique was initially described and demonstrated in our 2019 publication, “Wound closure under tension: it takes brains, not brawn” (2), and we appreciate the valuable biomechanical validation study of this method by Chang et al. (1).

In our publication (2), we have described an approach for independently closing high-tension wounds without clamp stabilization. The technique employs a clockwise surgeon’s knot (double knot) followed by an anticlockwise sliding knot, with the innovation lying in the controlled formation and advancement of the loop. This allows progressive wound edge approximation and secure closure without compromising structural integrity or requiring additional assistance. These fundamental elements align closely with the methodology represented by Chang et al. (1).

To maintain clarity in the surgical literature and support the field’s collaborative nature, accurate attribution of technical innovations is essential. While we commend the thorough validation their study provides, we note that characterizing this previously published technique with institutional branding (SH-9Hospital) may inadvertently fragment rather than unify surgical knowledge. We believe that maintaining clear chronology and attribution of surgical innovations ultimately benefits our entire community.

We would like to underline that the author’s biomechanical testing provides important quantitative validation of this approach. However, we note that the assessment of “ultimate tensile load (UTL)”, defined by the authors as “suture breakage of the knot”, actually measures “breaking strength” as standardized by the United States Pharmacopeia (USP) rating system (3). Since both techniques utilized identical suture material (polyglycolic acid, USP #1), similar breaking strengths were expected. A more discriminating evaluation might have focused on knot security—the stability under tension before slippage—as this better reflects clinical performance. While breaking strength and knot security may appear similar, they measure distinct properties: material failure versus functional stability under load.

We appreciate the demonstration that this approach significantly reduces operative time by eliminating the need for assistant involvement in knot stabilization. Their clinical experience confirms our long-term observations regarding the technique’s reliability and efficiency in practice. The mechanical testing data they have provided offers valuable objective support for the method’s effectiveness.

Finally, we would like to thank the authors’ contribution of mechanical testing data. We look forward to future studies that will continue to advance our understanding of surgical knotting techniques, particularly those focusing on knot security measurements that can further optimize wound closure outcomes.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-24-201/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-24-201/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Chang Y, Yu D, Wang L, et al. A novel and efficient surgical knotting technique for high-tension closures. Ann Transl Med 2021;9:375. [Crossref] [PubMed]
2. Kyriazidis I, Ali SR, Maklad M, et al. Wound closure under tension: it takes brains, not brawn. Aesthet Surg J 2019;39:NP11-2. [Crossref] [PubMed]
3. United States Pharmacopoeia. Vol. 29. RockvilUnited States Pharmacopeial Convention; 2006.