Modified Johannesburg technique sets the standard - superior biomechanical stability in chest tube fixation.

BACKGROUND: Chest tube dislodgement is a frequent and potentially life-threatening complication after thoracic trauma. Reliable fixation is essential, particularly in emergency and combat casualty care. Several suture techniques exist, but comparative biomechanical evidence is limited. METHODS: This prospective biomechanical cadaveric study compared three fixation techniques-Purse String (PS), Roman Sandal (RS), and Modified Johannesburg (JO) technique -across three tube sizes (20, 24, 28 Charrière) and two materials (polyvinyl chloride (PVC) and silicone). A total of 360 tests were performed on porcine thoracic wall specimens under standardized conditions. Specimens were subjected to vertical load-to-failure testing with continuous measurement of force and elongation. RESULTS: The Modified Johannesburg technique consistently demonstrated the highest pull-out strength across all tube sizes and materials, significantly outperforming both RS and PS (p < 0.0001). RS ranked second and showed significantly greater stability than PS in all conditions (p < 0.0001). Effect size analysis revealed large differences between JO and PS (r = 0.87) and between RS and PS (r = 0.50), and a medium effect between JO and RS (r = 0.36). PVC tubes provided significantly greater pull-out strength than silicone tubes (147.0 ± 54.2 N vs. 128.5 ± 42.2 N; p = 0.01071), although silicone tubes exhibited greater elongation prior to failure. Tube size had a modest influence on stability, with larger tubes tending toward higher pull-out strength, but pairwise differences did not reach significance. The predominant failure mechanism was suture rupture (78.9%), followed by tube rupture (11.1%), knot loosening (8.1%), and skin failure (1.9%). CONCLUSIONS: The Modified Johannesburg Technique offers superior biomechanical stability for chest tube fixation, regardless of tube size or material. This technique should be considered the preferred method in high-risk environments, including military and emergency care, to minimize dislodgement and enhance patient safety.