The Chula Knot: A New Sliding Locking Knot With a Special

Property
Somsak Kuptniratsaikul, M.D., Trai Promsang, M.D., and Kitiphong Kongrukgreatiyos, M.D.

Abstract: There are many types of sliding locking knots used in arthroscopic surgery. Each type has its advantages and
disadvantages. This technical note describes a new sliding locking knot, the Chula knot. This knot has been used for
arthroscopic shoulder surgery in more than 500 cases at our hospital. The Chula knot has a special property in that it can
be unfastened and retightened in case of premature locking and unintended loop loosening. This retensioning ability
cannot be found in other configurations of arthroscopic knots. The Chula knot also has other benefits: It has high ultimate
tensile strength and is easy to tie.

T here are many types of sliding locking knots used

in arthroscopic surgery. Each type has its advan-
tages and disadvantages.1-3 Successful results of
 The surgeon makes a second overhand throw with
the loop strand wrapped around itself (Fig 2).
 The surgeon brings the loop strand in front of the first
arthroscopic surgery rely on the security of arthroscopic throw and passes under the loop strand (Fig 3).
knot tying.4 This technical note describes a new sliding  The surgeon applies tension on the post strand until a
locking knot, the Chula knot. This knot has been used snug knot is created (Fig 4). A small locking loop is
for arthroscopic shoulder surgery in more than 500 established in the knot. The knot will slide forward
cases at our hospital. The Chula knot configuration is by pulling the post strand. A knot pusher helps in
similar to the Weston knot except for a change at the guiding and pushing the knot on the post strand.
final throw. Even though the configuration is mostly
similar, the property of the knot is very different. The
Chula knot has a special property in that it can be
retightened in case of unintended loop loosening. The
Chula knot also has other benefits: It has high ultimate
tensile strength and is easy to tie.

Surgical Technique
 The surgeon separates the 2 suture strands into a
short post strand and a longer loop strand.
 The surgeon makes 1 overhand throw with the loop
strand under the post (Fig 1).

From the Department of Orthopaedics, King Chulalongkorn Memorial

Hospital, Bangkok, Thailand.
The authors report that they have no conflicts of interest in the authorship
and publication of this article.
Received January 20, 2014; accepted May 8, 2014.
Address correspondence to Trai Promsang, M.D., Department of Ortho-
paedics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
E-mail: dr.traipromsang@gmail.com
Ó 2014 by the Arthroscopy Association of North America. Open access
under CC BY-NC-ND license.
2212-6287/1447 Fig 1. Make 1 overhand throw with the loop strand under
http://dx.doi.org/10.1016/j.eats.2014.05.007 the post.

Arthroscopy Techniques, Vol 3, No 4 (August), 2014: pp e465-e467 e465

e466 S. KUPTNIRATSAIKUL ET AL.

Fig 2. Make a second overhand throw with the loop strand

wrapped around itself.
Fig 4. Apply tension on the post strand until a snug knot is
created.

 The tension of the post strand is maintained by use of

the knot pusher. The loop strand is then pulled until
the locking loop is snug with the knot.
 The surgeon places 3 additional reversing half-hitches
on alternating posts to secure the knot.5,6
 If unintended premature locking occurs after
throwing the knot intraoperatively, an arthroscopic
probe can be inserted and then used to hook the post
limb and rotate in a clockwise direction. Minimal

Fig 3. Bring the loop strand in front of the first throw and
pass under the loop strand. Fig 5. Chula knot intraoperatively in labral repair case.
 CHULA KNOT
Table 1. Tips to Unfasten Knot
Be sure that the suture anchor is well fixed.
Use a probe to hook the post limb.
Rotate the probe in a clockwise direction.
Pull on the knot with minimal force until a clicking sensation of the
knot being unfastened is felt.
force is applied while pulling on it. The Chula knot
can then be unfastened. After that, it can be retight-
ened by pulling the post limb and locking the knot
again (Video 1).
Discussion
We have successfully used the Chula knot in more
than 500 arthroscopic surgery cases (Fig 5). We have
experienced the consistent reliability and loop security
of the Chula knot by checking intraoperatively using an
arthroscopic probe. Interestingly, the Chula knot has a
unique, special property that cannot be demonstrated
in other knot configurationsdretensioning ability.
Unintended premature locking of an arthroscopic knot
causes loop loosening and leads to poor fixation. To
solve this problem, the Chula knot can be unfastened
and the loop can again be tightened even though the
e467
knot is already locked (Table 1). The risk in unfastening
the knot by using an arthroscopic probe to hook and
pull the knot is that the suture anchor may be pulled
out in severely osteoporotic bone. An additional benefit
of the Chula knot is that it has a low profile, which
decreases the chance of knot impingement in the joint.
Finally, use of the knot is easy to learn and master.
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