Abstract
Background:
While studies have demonstrated that the “hashtag” suture pattern may improve biomechanical repair properties in radial meniscal tears, the effect of the type of suture within the hashtag is unknown.
Hypothesis/Purpose:
The purpose of this study was to evaluate the repair strength of the hashtag repair using suture tape compared to traditional 2-0 suture. It was hypothesized that suture tape, particularly in the “rebar” portion of the hashtag repair, would significantly increase construct strength compared to traditional 2-0 suture.
Study Design:
Controlled laboratory study.
Methods:
Complete radial tears were made at the midbody of 28 fresh-frozen adult lateral menisci. Specimens underwent hashtag repair with 1 of 4 different suture configurations: all 2-0 suture (2-0), all suture tape (tape), suture tape as the rebar and 2-0 suture as the horizontal component (hybrid v1), or 2-0 suture as the rebar and suture tape as the horizontal component (hybrid v2). Specimens were loaded in a tensile testing system and cyclically loaded for 500 cycles before load-to-failure testing. Load-to-failure (N), stiffness (N/mm), and mechanism of failure were recorded. Data were analyzed using analysis of variance with the Tukey multiple comparisons test.
Results:
Tape constructs demonstrated significantly higher load-to-failure compared to 2-0 constructs (189.8 ± 16.1 N vs 145.6 ± 39.6 N; P = .0357). There was no significant difference between tape and hybrid v1 constructs (189.8 ± 16.1 N vs 191.2 ± 31.8 N; P = .9997). Hybrid v2 constructs failed at significantly lower loads (141.9 ± 19.7 N) compared to both tape and hybrid v1 repairs (P = .0205 and P = .0167, respectively). Hybrid v1 constructs also showed significantly higher stiffness (16.4 ± 2.3 N/mm) compared to 2-0 (13.2 ± 2.8 N/mm) and hybrid v2 (12.7 ± 1.7 N/mm) constructs (P = .0497 and P = .0182, respectively).
Conclusion:
Suture tape increased the hashtag repair strength and stiffness in radial meniscal tears in cadaveric menisci, with the improved strength attributed to suture tape in the rebar limb. The horizontal suture type did not significantly affect construct strength or stiffness. These data suggest that suture tape may significantly improve the biomechanical repair strength of hashtag radial meniscal tear repairs.
Clinical Relevance:
Radial meniscal tears are difficult to repair and are associated with poor prognosis, necessitating further research into optimal repair constructs.
Radial meniscal tears are among the most complex subtypes of meniscal injuries and are associated with a poor prognosis. 8 As these tears propagate from the large, avascular white-white zone to the more vascularized peripheral red-white and red-red zones, the native hoop tension of the meniscus progressively decreases. This loss of hoop stress function significantly disrupts the load transmission in the knee joint, creating a scenario similar to a total meniscectomy.18,22,26 The subsequent meniscal deficiency has been shown to cause severe adverse effects, including meniscal extrusion and early arthritis.8,10,26 Therefore, while radial meniscal tears have historically been treated with either meniscectomy or nonoperative management, 21 recent research has shifted to recommend surgical repair whenever possible.1,3
Despite advances in repair techniques, only approximately 60% of repairs have been shown to go on to complete healing postoperatively. 17 Thus, strategies to better repair radial meniscal tears are being studied.13,23 While the parallel stitch remains the traditional repair method, several studies have suggested that the addition of a vertical mattress suture to act as a ripstop significantly increases the strength of these repairs, producing a configuration referred to as “hashtag” constructs.9,14,24 A clinical study of the hashtag repair found that 66% of patients demonstrated complete healing and 28% of patients showed partial healing at 18 months of follow-up, an overall favorable postoperative outcome. 20 Our group previously reported no difference in biomechanical load-to-failure in the hashtag repair regardless of knot-tying configuration (eg, meniscus-based, capsule-based, hybrid, etc). 16 However, to our knowledge, there are no studies that have investigated the impact of suture material and suture design on radial meniscal tear repair strength in human tissue.
There has been an emergence of suture tapes in other orthopaedic injury repairs, with a reported increase in strength and decrease in irritation.4,7,11 Recent research in porcine meniscal models has suggested that suture tapes may demonstrate improved biomechanical properties compared to high-strength wire sutures, including higher maximum load-to-failure and stiffness.15,25 Furthermore, these studies have shown discrepancies in mechanism of failure based on suture composition, with wire suture constructs failing more frequently by suture rupture, while suture tape constructs fail almost exclusively by suture pullout.15,25 To our knowledge, no research has assessed the biomechanical strength of suture tapes compared to wire sutures in human radial meniscal tear repairs.
This study aimed to compare the biomechanical performance between traditional 2-0 wire suture and tape-type suture in the hashtag radial meniscal tear repair. Furthermore, this study aimed to scrutinize the impact that suture composition of individual components has on repair strength. We hypothesized that suture tape, particularly in the rebar portion of the hashtag repair, would increase the strength of hashtag radial tear repair constructs compared to 2-0 wire suture as evidenced by significantly higher load-to-failure values.
Methods
Study Population
Institutional review board approval was deemed unnecessary because the tissues had been donated for research purposes, and no genetic information was used, nor was there any contact with family members. Permission was obtained for use of these tissues for research from the donors’ families by the tissue-collecting organization. A total of 28 adult lateral menisci attached to their tibial bone blocks were obtained from 28 donors. The laterality of the menisci was as follows: 2-0 (2 right, 5 left), tape (4 left, 3 right), hybrid v1 (4 right, 3 left), and hybrid v2 (4 right, 3 left). The specimens were stored at −20°C and thawed at room temperature before tear creation, repair, and biomechanical testing.
Sample Preparation and Tear Creation
Lateral meniscus samples were dissected from the tibial bone block at the posterior and anterior lateral roots. Samples were photographed and the width and maximum height at the midbody were recorded using calipers. Using a No. 11 scalpel blade, we generated full-thickness radial tears at the midbody of the meniscus.
Repair Constructs
Specimens were randomized into 4 groups of 7 to receive 1 of 4 hashtag repair configurations with 2-0 braided suture (Smith & Nephew; Ultrabraid, Ref. 72204328) and/or suture tape (Smith & Nephew; MiniTape, Ref. 72205128) using a straight needle (Figure 1B). The 4 construct variations included all 2-0 suture (2-0) (Figure 1C), 2-0 suture in the horizontal component and suture tape in the rebar component (hybrid v1) (Figure 1D), all suture tape (tape) (Figure 1E), and suture tape in the horizontal component and 2-0 suture in the rebar component (hybrid v2) (Figure 1F). All specimens were repaired using the all-capsule rebar suture pattern (Figure 1A). 14 Suture placement order was standardized, with both rebar sutures placed first, followed by the outer horizontal suture, and finally the inner horizontal suture. All sutures were secured using 4 square knots.
Lateral meniscus repair constructs. (A) Diagrammatic representation of all-capsule rebar (ACR) repair from several views. Blue = rebar, green = horizontal. (B) Diagrammatic representation of meniscal repair constructs. White = 2-0 suture, blue = suture tape. Hybrid v1 repair consists of suture tape on the rebar with 2-0 suture on the horizontal, while hybrid v2 repair is the inverse configuration. (C-F) Lateral meniscus repair constructs after undergoing ACR repair with 2-0, hybrid v1, tape, and hybrid v2 configurations, respectively.
Biomechanical Testing
Repaired menisci were glued (Loctite, Super Glue Gel Control) and clamped between sandpaper before being loaded on a materials testing system (Instron 5944) with 2-kN load cell using custom clamps (Figure 2A). Each specimen underwent preconditioning of 2 to 5 N for 20 cycles before cyclic loading of 5 to 30 N for 500 cycles at a rate of 10 mm/min (Figure 2B). A 30-minute rest period was then given. Specimens were then subjected to a single trial of load-to-failure at 10 mm/min, with failure calculated as a >90% drop in maximum load. Stiffness (N/mm) was calculated as the slope of the best-fit line of the load (N) versus extension (mm) curve during load-to-failure, with all coefficients of determination ≥0.99. Specimens were kept moist with physiological saline throughout testing.
Biomechanical testing. (A) Hybrid v1 repair loaded in Instron machine before testing. (B) Hybrid v1 repair after completion of cyclic loading. (C) Hybrid v1 repair after load-to-failure testing with a “horizontal cut-through” failure mechanism.
Statistical Analysis
Given previously reported differences in the ultimate failure loads of high-strength wire sutures and suture tapes in the porcine meniscus, an a priori power analysis (G*Power) determined that 24 total samples (6 per group) would achieve a power of 0.9 at an alpha level of .05 to detect a 40% difference in failure load.15,25 The ultimate load-to-failure (N) and stiffness (N/mm) were compared via 1-way analysis of variance with the Tukey multiple comparisons test and significance determined at a P value <.05. Mechanism of failure was recorded for all specimens (Figure 2C). Failure mechanism was determined by the change within the construct that resulted in the ultimate drop in maximum load.
Results
The lateral meniscus dimensions were not significantly different between the 4 groups (Table 1). In all hybrid v2 and tape constructs, the mechanism of failure occurred due to cut-through of the horizontal suture component (Figure 2C). In one 2-0 and one hybrid v1 construct, the failure mechanism was due to rupture of a horizontal suture knot; otherwise, the remaining 6 constructs in each group failed due to cut-through of the horizontal suture component.
Lateral Meniscus Dimensions of 4 Groups a
Descriptive statistics for the specimen widths and heights as measured at the midbody via calipers. Estimated cross-sectional area was calculated assuming approximately a right triangular cross section at the radial tear, according to the formula: Estimated cross-sectional area = ½× (midbody width) × (midbody height).
There was a significant difference in the ultimate load-to-failure for tape constructs compared to 2-0 constructs (P = .036) (Figure 3A). Interestingly, there was no significant difference between tape and hybrid v1 constructs (Figure 3A). However, hybrid v2 constructs failed at significantly lower loads compared to both tape and hybrid v1 repairs (P = .021 and P = .017, respectively) (Figure 3A). There was no significant difference between the load-to-failure of 2-0 and hybrid v2 constructs (Figure 3A).
Biomechanical comparison of hashtag repair constructs. Comparison of (A) load-to-failure and (B) stiffness values in 2-0, hybrid v1, tape, and hybrid v2 repair constructs, respectively. Data are presented as mean ± SD and compared by 1-way analysis of variance with the Tukey multiple comparisons test. *P < .05. ns, not significant.
We observed a similar result when comparing the calculated stiffness of the 4 groups. There was a significant difference in stiffness for hybrid v1 constructs compared to 2-0 constructs (P = .049) and hybrid v2 constructs (P = .018) (Figure 3B). There was no significant difference between hybrid v1 and tape constructs (Figure 3B). There was also no significant difference between tape and hybrid v2, tape and 2-0, and 2-0 and hybrid v2 constructs (Figure 3B).
Discussion
This study sought to investigate the biomechanical impact of suture tape within the hashtag radial meniscal tear repair. Using cadaveric human menisci, we observed a significant increase in the load-to-failure and stiffness of repair constructs that utilized suture tape compared to traditional high-strength wire suture (2-0). Through the creation of 2 hybrid orientations, we were able to further elucidate that the added biomechanical stability was likely attributed to the use of suture tape in the rebar limb. We also observed tissue failure as the predominant failure mechanism in all groups, with all tissue failure occurring due to the eventual cut-through of the horizontal suture across the tear. This mechanism of failure further underscores how the rebar limbs function as a ripstop to resist the horizontal suture from failing in the direction of the load.
While several other studies have observed improved biomechanical strength with the hashtag repair, our data are among the highest load-to-failures reported. Nakanishi et al 19 evaluated the hashtag repair in porcine menisci with and without a cross-tie configuration of the rebar limbs, with no reported significant difference in failure values between the orientations and a load-to-failure of 145.2 ± 39.1 N in the traditional hashtag repair. They also noted a similar failure mechanism to the present study, with all but one repair exhibiting tissue failure due to suture cut-through. Stender et al, 24 who also used 2-0 suture tied in the same orientation as the present study, recorded a load-to-failure value of 86.08 ± 23.58 N. However, their load-to-failure was conducted immediately after cyclic loading, and ours commenced after a 30-minute rest period. Massey et al 14 noted a load-to-failure of 124.1 ± 27.1 N. They did, however, observe a higher proportion of failures due to suture rupture (50%) in the hashtag group. Still, our primary mechanism of failure, horizontal suture cut-through, matches that of many previous studies on hashtag repairs.14,19,24 It is possible that slight methodological differences, species of tested samples, and specimen variability can explain a portion of the discrepancies observed between similar past studies and the present study. Nonetheless, the high load-to-failure and stiffness values recorded here are similar to previous publications by our research group and show promise that suture tape can contribute to optimizing biomechanical stability in these repairs.9,16
Buckley et al 5 conducted a biomechanical cadaveric study comparing the hashtag repair with and without a transtibial 2-tunnel suture fixation augmentation and found that there was no significant difference in load-to-failure. The maximum load of the hashtag repairs in their study was higher than that in our present study, at 349 ± 149 N. However, the specimens in their study maintained native horn/root attachments and capsule, which may explain the added strength compared to our specimens. In a similar study comparing traditional double horizontal mattress sutures to the transtibial 2-tunnel suture fixation, both without any addition of a ripstop, transtibial 2-tunnel suture fixation resulted in nearly doubled load-to-failure compared to double horizontal mattress sutures alone (196 vs 106 N). 2 Thus, it remains to be determined if the strength and efficacy of the repair construct in the present study could yet be increased with a similar augmentation.
There are several limitations to our study. As a controlled biomechanical laboratory study, these data function as a time-zero representation of construct strength and do not elucidate how these repairs will function on the continuum of tissue healing and rehabilitation. Furthermore, the present study was only powered to detect a 40% increase in load-to-failure among constructs. Given our small sample size, we may be unable to identify smaller but still clinically meaningful differences in load-to-failure. Additionally, while the present study utilizes load-to-failure, stiffness, and failure mechanism to understand the impact of suture type within these repairs, our analysis did not include data on cyclic displacement at the tear site, which may better approximate the smaller, repetitive forces that act to prevent healing. Our specimen preparation did not fully preserve native meniscal anatomy, including the tibial attachments and capsule, which may alter the biomechanical properties of the tissue and make comparisons to other studies more difficult. Furthermore, it is possible that the testing system used in the present study does not properly estimate native in vivo forces observed at radial meniscal repair sites. However, several studies have found similar methodology to be effective in evaluating the biomechanical properties of meniscal tear repair constructs.2,5,24
Further studies should be completed to understand whether the observed results apply in other meniscal variants, including the medial meniscus and pediatric menisci, both of which have been shown to have different biomechanical properties.6,12 We recommend that clinical studies should be conducted to evaluate the in vivo efficacy and patient satisfaction of suture tapes for radial meniscal tear repairs.
Conclusion
Suture tape increases the strength and stiffness of the hashtag radial meniscal tear repair in cadaveric menisci, with the improved strength attributed primarily to suture tape in the rebar component. The suture composition of the horizontal component of the repair did not significantly affect the strength or stiffness of the construct.
Footnotes
Submitted July 22, 2025; accepted January 15, 2026.
One or more of the authors has declared the following potential conflict of interest or source of funding: H.B.E. received research support from DJO, compensation for services other than consulting from Arthrex, consulting fees from OrthoPediatrics Corp, and support for education from Pylant Medical. M.R.S. received consulting fees from WishBone Medical. M.A.T. received consulting fees from OrthoPediatrics Corp. T.G. received support for education from Paladin Technology Solutions and hospitality payments from Arthrex and is an associate editor for AJSM. M.C.M. received support for education from Evolution Surgical and Arthrex. K.G.S. received consulting fees from OrthoPediatrics Corp and nView Medical and support for education from Evolution Surgical. 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.
