# Modified Johannesburg technique sets the standard – superior biomechanical stability in chest tube fixation

## TL;DR

The Modified Johannesburg technique provides the best chest tube fixation, reducing dislodgement risks in emergency and military settings.

## Contribution

The study provides the first comprehensive biomechanical comparison of chest tube fixation techniques using cadaveric models.

## Key findings

- Modified Johannesburg technique showed highest pull-out strength across all tube sizes and materials.
- PVC tubes provided greater pull-out strength than silicone tubes, though silicone showed more elongation before failure.
- Suture rupture was the most common failure mechanism in chest tube fixation tests.

## Abstract

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.

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.

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%).

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.

The online version contains supplementary material available at 10.1007/s00068-025-03071-7.