Strength Retention of Chromic Gut and Synthetic

Absorbable Sutures in a Nonhealing

Synovial Wound
MARKWALTON,M.Sc., PH.D.

The rate at which absorbable sutures lose their radiotherapy, and systemic factors such as
mechanical strength in a slow healing wound is malnutrition can affect the ability of a tissue
clinically important, particularly because the fac- to heal. One or several of these factors may be
tors inhibiting normal healing are not always ap-
parent at the time of closure. Sutures of chromic present in a wound but unapparent at the
catgut and two monofilament absorbable synthetic time of wound closure. The role of sutures
suture materials (polydioxanone and polyglycon- has added importance in the nonhealing
ate) were used to close a synovial incision in the wound because they are required to carry the
knees of sheep. A corticosteroid was applied mechanical loads associated with maintain-
around the wound resulting in minimal tissue heal-
ing when the sutures were retrieved up to six ing closure for a longer period of time. Ab-
weeks later. The failure load and maximum tensile sorbable sutures are commonly used in
strength of the retrieved sutures were measured. wound closure, so clearly it is important to
The mechanical degradation of the materials fol- test their strength retention in nonhealing
lowed a pattern similar to that in normally healing
wounds.
wounds except that the early fragmentation of
chromic gut and polydioxanone occurred far less In a previous experimental study, the
frequently and neither weakened further after strength of three materials (chromic gut,
three weeks. Polyglyconate was significantly the polydioxanone, and polytrimethylene car-
strongest material up to three weeks but thereafter bonate, subsequently renamed polyglycon-
continued to weaken. The strength of absorbable ate) in the form of No. 2-0 absorbable su-
sutures was retained longer than in a healing lesion
probably because of the absence of the phagocytic tures, was measured up to six weeks after
cells of an inflammatory tissue. closing a surgical incision through healthy sy-
novial tissue in sheep knee Joints.4 There is
In orthopedic practice there are many situa- some doubt concerning the validity of extrap-
tions in which the healing potential of wound olating the results obtained from that study
tissues is limited or absent. Local infection, to predict suture performance in a nonhea-
aseptic wound contamination, interposition ling wound, because the two situations have
of tissue or implanted materials, tissue necro- different physiologic environments. In nor-
sis, steroid therapy, impaired blood supply, mal wound healing, a rampant localized in-
flammatory reaction develops, whereas this
From the Department of Orthopedic Surgery, Univer- reaction is absent when healing does not oc-
sity of Otago Medical School, Dunedin, New Zealand.
Supported by the New Zealand Medical Research cur. Therefore, the previous study was re-
Council and the American Cyanamid Company. peated, but the strength retention of the su-
Reprint requests to Mark Walton, Ph.D., Department tures was measured after the wound had been
of Orthopaedic Surgery, Dunedin Hospital, Private Bag,
Dunedin, New Zealand. treated with a local application of corticoste-
Received: November 28. 1989. roid, which inhibits an inflammatory reac-

294
Number 267
June. 1991 Suture Strength in Nonhealing Wounds 295

tion and thereby severely curtails the ability minute and a record was made of the applied load
of the tissues to heal.’ when the suture failed in tension. Analyses ofvari-
ance were calculated to determine statistical signifi-
MATERIALS AND METHODS cance between values.
The surgical method has been described
p r e v i ~ u s l y Briefly,
.~ adult cross-bred ewes were RESULTS
anesthetized by induction with thiopental fol-
lowed by maintenance using halothane in a ni- A total of 90 knee wounds were closed. Of
trous oxide/oxygen mixture. One knee was shaved these, two became infected and six healed de-
and a medial parapatellar incision using sterile spite the steroid treatment. The procedure
techniques was made to the depth of the joint cap- was therefore repeated on an additional eight
sule. Care was taken to make a single straight inci- animals.
sion through the capsule and synovial tissue.
A No. 2-0 suture of the test material was sewn
The skin always healed normally. How-
across the wound using a mattress stitch. Before ever, there was minimal healing beneath the
tightening, 1 ml of triamcinolone (Kenacort-A 40, skin, with the soft tissues appearing pale with
E. R. Squibb & Sons, Princeton, New Jersey) was the absence of visible blood vessels. There
injected into the joint cavity using a syringe. Some was no indication of an inflammatory re-
of the steroid was encouraged to spill out of the
wound and onto adjacent tissues but not on the
sponse in or around the wound. In most
skin or subcutaneous tissue. The wound was cases, even at six weeks the configuration of
closed with sufficient tension to make it water- the tissues and sutures was not much differ-
tight. Rather than tying a distal knot, the leading ent from that at operation, with the sutures
end of the thread was brought forward and a single still in their implanted positions. By the third
knot was tied proximally, thus aiding later re-
trieval. The remaining length of test suture was and fourth weeks, the polyglactin 9 10 and
retained for mechanical testing. polyglycolic acid sutures were either very
Superficial layers were closed with No. 2-0 su- weak but intact or extensively fragmented. At
tures of polyglactin 910 (Vicryl, Ethicon, Somer- six weeks only knots were present. Conse-
ville, New Jersey) or polyglycolic acid (Dexon, quently, from four weeks there was dehis-
Davis & Geck, Manati, Puerto Rico). After recov-
ery from anesthesia, the animals were kept over- cence of the tissues superficial to the synovial
night in canvas slings that allowed them to stand wound, though occasionally they were joined
or supported them if required. They were then re- by a thin membrane.
turned to open fields. The sutures were retrieved Normally, the synovial wound parted as
from groups of six animals at one, two, three, four, the test suture was unthreaded. In some, lim-
and six weeks and wrapped in saline-dampened
swabs for up to two hours at room temperature ited vascularization was accompanied by frag-
until mechanically tested. ile edematous repair tissue, which could be
This surgical procedure was repeated in groups easily parted using forceps. All test sutures
of 30 animals for chromic gut (Ethicon, Somer- could be readily pulled through the tissue and
ville, New Jersey) green polyglyconate (Maxon, retrieved.
Davis & Geck; formerly called polytrimethylene
carbonate) and violet polydioxanone (PDS, Eth- Polydioxanone displayed signs of degrada-
icon). tion as early as two weeks with the appear-
Each type of suture material was from the same ance of short lengths along which the violet
batch obtained from commercially available dye was absent; these were the same locations
stocks and was verified to be within the period where the material fractured during mechan-
before expiration of the storage date. All sutures
were handled in an identical manner. ical testing. Over subsequent periods the
At least three diameter measurements were polydioxanone had frequently hardened so
taken along the length of each suture sample using that great care had to be taken to extract the
a Nikon Measurescope with digital counter (To- brittle sutures to avoid breakages. Six of the
kyo, Japan). Each sample was cut into three 30 polydioxanone sutures had broken in at
lengths, which in turn were clamped between 2.5-
cm-sided, rubber-faced jaws of an Instron 1193 least one place before retrieval. With the ex-
materials testing machine (High Wycombe, En- ception of one specimen that was fragmented
gland). Crosshead speed was set at 200 mm per at four weeks, polyglyconate sutures were re-
 Clinical Orthopaedics
296 Walton and Related Research

trieved intact at all time intervals, although

they were very weak at six weeks. Chromic
gut was readily retrieved intact from all speci- 80 Polyglyconole
mens, although a few threads were frayed or l o o r - Gul
A Chromic
Polydioxonone

thinned at three weeks.

Clinically, the most relevant parameter is
the load required to break the suture. How-
ever, a weaker material may have a higher
failure load than a stronger one because it is
manufactured as a thicker strand (yet still
within the United States Pharmacopoeia
(USP) standard). Thus, for each material, it is
necessary not only to measure the tensile
load at which the material fails but also to Weeks After Implant
calculate the tensile breaking strength, i. e., FIG.2. Retention of failure load.
the failure load in relation to the cross-sec-
tional area of the thread.
Before they were implanted, chromic gut weaken throughout the study period, reach-
and polydioxanone sutures could sustain sim- ing a failure load of 0.20 kg at six weeks, mak-
ilar loads (4.76 kg and 4.90 kg, respectively; ing it significantly weaker (pI 0.00 1) at that
Fig. 1). Subsequent weakening with increas- stage than the other two materials (Fig. 2).
ing implantation time was more rapid with Polyglyconate maintained a more consistent
gut, but average values from three weeks on- level of performance throughout the experi-
ward were similar in chromic gut and poly- ment as demonstrated by standard errors that
dioxanone (0.93 kg and 1.57 kg, respec- were one third or less those of the other two
tively). In comparison, polyglyconate had a materials.
mean failure load of 6.94 kg, which was signif- There was a considerable increase in the
icantly stronger (p I 0.001) than the other diameter of the gut sutures from 0.381
materials. This superior strength continued -t 0.003 mm to 0.558 ~t 0.0 18 mm during the
up to three weeks, but then, unlike chromic first week. However, there was no subsequent
gut and polydioxanone, it continued to significant change from then on. Neither
polyglyconate sutures at 0.387 k 0.003 mm
nor polydioxanone at 0.357 0.002 mm*
changed significantly during the study pe-
riod.
Poiyglyconote
0Polydioxonone Chromic gut was the weakest material, and
0Chromic Gut its strength fell rapidly over the first week be-
cause of its rapid decrease in failure load and
its considerable increase in diameter. The
tensile strength of the synthetic materials fell
in parallel over the first three weeks, though
polyglyconate was the stronger of the two
(Figs. 3 and 4). From then on, polydioxanone
retained a mean value of 14.5 kg/cm2,
0 1 2 3 6 5 6 whereas pol yglyconate continued to decline,
Weeks After Implant reaching 1.71 kg/cm2 at six weeks. At each
FIG.I . Failure load of suture materials retrieved time interval the mean value of polydioxan-
after various intervals of implantation in a non- one was calculated from a range of results,
healing synovial wound. and the standard errors of the mean were
Number 267
June, 1991 Suture Strength in Nonhealing Wounds 297

insuk4 In that environment, chromic gut

6oooL
5000
continued to lose strength after the first week,
probably because of phagocytosis, which
thinned the thread, causing it to break into
short lengths. The two synthetic materials re-
tained a higher tensile strength for longer, but
3000 polydioxanone had lost color and broken
into multiple fragments by four weeks,
whereas polyglyconate survived intact to six
weeks. Yet even the chromic gut sutures held
1000 the incised but otherwise healthy tissues to-
gether sufficiently for them to heal over the
first two weeks.
Weeks After Implant By comparison, in the present study, chro-
mic gut weakened in a similar manner but
FIG. 3. Tensile strength of suture materials re-
trieved after various intervals of implantation in a not to such low values and survived intact.
nonhealing synovial wound. Polydioxanone lost strength faster after two
weeks but had increased longevity because of
a lower incidence of fragmentation. The rate
consistently higher relative to those of chro- of loss of strength of polyglyconate was al-
mic gut and polyglyconate. most identical in both types of wounds.
Fragmentation of chromic gut and poly-
DISCUSSION dioxanone occurred far less frequently than
This study has shown that when a cortico- in the comparable healing wound. The chro-
steroid severely impedes wound healing in a mic gut was not absorbed because of the ab-
synovial wound of a sheep, chromic gut loses sence of macrophages that would have been
strength rapidly over the first week but from present had inflammatory tissue formed. The
then on retains approximately 12%ofits origi- readiness with which the chromic gut suture
nal strength. Polydioxanone and polyglycon- pulled out of the nonhealing wound was in
ate synthetic absorbable sutures lose their complete contrast to retrieval from early in-
strength slowly for three weeks, after which flammatory tissue when it was difficult and
polydioxanone retains 15% of its original later impossible to retrieve the thread be-
strength, whereas polyglyconate continues its
steady decline for six weeks. Chromic gut
swells considerably; polydioxanone becomes
brittle and occasionally fractures, whereas
polyglyconate remains unaltered in its han-
dling characteristics. Despite these time-de-
pendent changes, the wound edges were
maintained in apposition by the various su-
tures over the six weeks of the experiment.
Sutures of all three tested materials were still
present in their original placement despite
the absence of any healing and the early post-
operative remobilization of the joint.
In an experiment that was identical except
that the wound was allowed to heal normally,
the sutures became embedded in inflamma-
tory tissue formed in reaction to the surgical FIG.4. Retention of tensile strength.
 Clinical Orthopaedics
298 Walton and Related Research

TABLE 1. Comparison of Results From Nonimplanted Lengths of Sutures

With a Previous Study4
C’huracteristics Chromic Gut Polygiyconate Polydioxanone

Failure load (kg)

Healing 4.810 f 0.140 6.680 f 0.160 4.890 3: 0.050
Nonhealing 4.760 +- 0.220 6.940 f 0.130 4.900 31 0.030
Diameter (mm)
Healing 0.396 f 0.008 0.406 f 0.000 0.357 3: 0.004
Nonhealing 0.381 f 0.003 0.387 -t 0.003 0.357 3: 0.002
Tensile strength (kg/cm2)
Healing 4032.000 f 158.000 4933.000 t 150.000 478 1.000 3: 87.000
Nonhealing 4194.000 f 202.000 5916.000 +- 117.000 4907.000 f 66.000

cause of its partial r e ~ o r p t i o nIt. ~would also the superficial tissues absorbed over the same
appear that the absence of inflammatory tis- time period as they had in the normally heal-
sue influences polydioxanone degradation ing synovial wound.4 Therefore, their disso-
because it fragments far less frequently in the lution appears to be only by hydrolysis, so the
nonhealing wound. presence or absence of macrophages has little
The synthetic suture materials degrade in influence on this process. This observation
two steps. First, hydrolysis depolymerizes has been previously recorded for polyglactin
their long molecular chains to much shorter 9 Though the braided form of these two
polymers and second, the shorter polymers suture materials gives them superior han-
then undergo phagocytosis.’ The early loss of dling characteristics, their longevity within
strength of polydioxanone during the first tissues of the experimental model was clearly
three weeks must therefore have been due to inferior to the two monofilament suture ma-
hydrolysis. The second phase of phagocytosis terials. The monofilament synthetic sutures
that caused fragmentation in the healing should, therefore, be the preferred choice of
wound did not occur in the steroid-treated the surgeon if delayed healing is suspected.
wounds because of the absence of phagocytic
cells. The polyglyconate lost strength in a
near linear manner, suggesting a steady chem- ACKNOWLEDGMENT
ical degradation with no cellular involve- The author thanks Mrs. Jacqui Thomson for her tech-
ment. nical assistance.
There was little difference between the val-
ues in this and the previous study for failure
REFERENCES
load and tensile strength of chromic gut and
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However, the tensile strength of polyglycon- to experimental skin injury in rats. Biochem. Phar-
ate was much higher because of a slightly in- macol. 17[Suppl.]:51, 1968.
2. Katz, A. R., and Turner, R. J.: Evaluation of tensile
creased failure load and marked decrease in and absorption properties of polyglycolic acid su-
diameter. This would suggest that there has tures. Surg. Gynecol. Obstet. I3 I :70 I . 1970.
been a change in polymer formulation or 3. Salthouse, T. N., and Matalaga, B. F.: Polyglactin
manufacture during the interval between the 910 suture absorption and the role of cellular en-
zymes. Surg. Gynecol. Obstet. 142544, 1976.
two studies.
4. Walton, M.: Strength retention of chromic gut and
Visual assessment suggested that the poly- monofilament synthetic absorbable suture materials
glactin 910 and polyglycolic acid sutures in in joint tissues. Clin. Orthop. 242:303. 1989.