Suture Materials, Needles, and Methods of Skin Closure: What Every Hand Surgeon Should Know

  • Nikola Lekic
    Correspondence
    Corresponding author: Nikola Lekic, MD, South Florida Orthopaedics, 1050 SE Monterey Rd, Suite 400, Stuart, FL 34994.
    Affiliations
    Department of Orthopaedic Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL

    South Florida Orthopaedics, Stuart, FL
    Search for articles by this author
  • Seth D. Dodds
    Affiliations
    Department of Orthopaedic Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
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Published:November 25, 2021DOI:https://doi.org/10.1016/j.jhsa.2021.09.019
      Sutures are used ubiquitously in surgery and are the most implanted materials in hand surgery. However, surgical training does not routinely include formal education on stitching materials or needles. Rather, suture familiarity is passed down by common use throughout training. We focus on a brief history and evolution of suture materials and suture needles, their material and mechanical properties, hand surgery-specific applications, other methods of skin closure (staples, skin glue, and adhesive strips), a cost analysis, and advances in musculoskeletal suturing, with a look toward the future. Equipped with a fundamental knowledge of suture needles and suture materials, hand surgeons will be better prepared to select the most appropriate, situation-specific tools.

      Key words

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      Dawn M. LaPorte, MD, has no relevant conflicts of interest to disclose.

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      Learning Objectives

      Upon completion of this CME activity, the learner will understand:
      • Suture naming and classification.
      • Suture needle composition and segments, and differences in needle points.
      • Differences in suture materials and their characteristics and mechanical properties.
      Deadline: Each examination purchased in 2021 must be completed by January 31, 2022, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.
      Copyright © 2022 by the American Society for Surgery of the Hand. All rights reserved.

      History and Evolution of Surgical Stitching

      In 150 A.D., Galen of Pergamon sutured severed tendons of gladiators.
      • Mackenzie D.
      The history of sutures.
      His writings were the first to mention catgut—twisted intestines usually made from sheep or goat—which is still used today. The etymology of the word catgut is believed to derive from the old Welsh word “kit,” which means fiddle.
      • Mackenzie D.
      The history of sutures.
      Fiddle strings were, and in some places still are, produced from these animal intestines. Eventually, “kit” gut became confused for “cat” gut.
      In 1867, Joseph Lister, the father of antisepsis, determined that gut sutures could be safely left in the body if they had no bacteria on them.
      • Mackenzie D.
      The history of sutures.
      He developed a method of sterilizing and storing catgut for future use by soaking it in carbolic acid and olive oil. He found that chromic acid, used to tan leather, would delay absorption of catgut to allow tissues a longer time to heal.
      • Mackenzie D.
      The history of sutures.
      In 1960, sterilization by irradiation was introduced, allowing suture sterilization in the final packaging.
      • Mackenzie D.
      The history of sutures.
      In 1915, George F. Merson of Edinburgh, Scotland, created the first eyeless needle, patented as “Mersutures,” in which a suture was inserted into the butt of the needle.
      • Mackenzie D.
      The history of sutures.
      This style of eyeless needle became known as “swage,” which reduced the tissue damage that was previously caused by pulling through double-stranded sutures. Mr Merson’s company eventually became Ethicon Ltd.
      • Mackenzie D.
      The history of sutures.
      We have summarized the historical advancements in surgical stitching in Table E1 (available online on the Journal’s website at www.jhandsurg.org).
      • Mackenzie D.
      The history of sutures.
      • Yag-Howard C.
      Sutures, needles, and tissue adhesives: a review for dermatologic surgery.
      • Ruff G.L.
      The history of barbed sutures.
      • Lear W.
      Instruments and materials.

      Sterilization and Suture Packaging

      Gamma radiation (cobalt 60) or ethylene oxide are commonly used to sterilize sutures (cold sterilization).
      • Lear W.
      Instruments and materials.
      Gamma irradiation has the ability to sterilize sealed packages, with a disadvantage of degrading some absorbable sutures.
      • Lear W.
      Instruments and materials.
      Natural gut and nylon sutures are safely and routinely sterilized with gamma radiation. Ethylene oxide gas is used to sterilize most other sutures, which then requires outer packaging sealing after treatment.
      Suture packaging provides the sterile suture protection from microorganisms and mechanical and environmental damage, and displays detailed content information (Fig. 1). Most suture inner packaging is dry; however, gut suture inner packaging is wet with an alcohol mixture. The United States Pharmacopeia (USP) and Food and Drug Administration oversee the nomenclature, safety, and regulation of sutures.
      Figure thumbnail gr1
      Figure 1Photo of suture packaging. Detailed information of the contents are displayed, including but not limited to suture diameter, suture length, needle point, needle arc, material composition, sterilization method, and expiration date.

      Suture Classification

      Suture naming is based on diameter (Table 1) and tensile strength. Large-diameter sutures are numbered greater than 0 (eg, 2 is larger than 1). Small-diameter sutures are labeled with 0s: the more 0s, the smaller the diameter (eg, 00 [2-0] is larger than 000 [3-0]). Metric sizes are by one-tenth of a millimeter (eg, 1 = 0.1 mm). Per USP standards, sutures of a specific name and diameter will have a minimum tensile strength.
      • Lear W.
      Instruments and materials.
      Sutures of minimal tensile strength that do not abide by diameter standards are clearly labeled on the packaging. For example, by USP standards, 5-0 nylon measures between 0.1 and 0.149 mm, and a 1-knot strand has a minimum tensile strength of 3.92 N. Sutures that meet the minimum tensile strength (3.92 N) but not diameter standards are labeled “USP except for diameter” (Fig. 1).
      Table 1Suture and Wire Sizes
      USP SizeCollagen SuturesSynthetic SuturesWire Gauge
      Metric SizeDiameter Range, mmMetric SizeDiameter Range, mm
      7--90.900–0.99918
      6--80.800–0.89919–20
      5--70.700–0.79920–21
      480.800–0.89960.600–0.69921–22
      370.700–0.79960.600–0.69922
      260.600–0.69950.500–0.59923–24
      150.500–0.59940.400–0.49925–26
      040.400–0.4993.50.350–0.39926–27
      2-03.50.400–0.39930.300–0.33928
      3-030.300–0.33920.200–0.24929–32
      4-020.200–0.2491.50.150–0.19932–34
      5-01.50.150–0.19910.100–0.14935–38
      6-010.100–0.1490.70.070–0.09938–40
      7-00.70.070–0.0990.50.050–0.069
      8-00.50.050–0.0690.40.040–0.049
      9-00.40.040–0.0490.30.030–0.039
      10-0--0.20.020–0.029

      Suture Needles

      Needles are made of martensitic stainless steels S42000, S42020, and S45500: hardened steels which contain supersaturated carbon that increases hardness and toughness and are the standard for surgical instrumentation.
      • Lear W.
      Instruments and materials.
      S45500 contains nickel (7.5%–9.5%) and titanium (1.5%), whereas S42000 and S42020 have no nickel or titanium, which is a potential consideration in patients with a nickel allergy.
      • Lear W.
      Instruments and materials.
      The suture needle has 3 segments: the eye, body, and point (Fig. 2). The eye of the needle, through which suture material is passed, has undergone tremendous evolution (Fig. 3), from the closed and French eye needles that require the “doubling over” of a suture strand (causing significant tissue drag/trauma) to the swaged eye needle that allows a single suture strand to be placed into the hollowed-out butt of the needle.
      • Lear W.
      Instruments and materials.
      The advent of lasers allowed for suture attachment onto very small needles and a shorter channel, allowing surgeons to grasp closer to the swaged end without damaging the needle.
      • Edlich R.F.
      • Gubler K.
      • Wallis A.G.
      • Clark J.J.
      • Dahlstrom J.J.
      • Long III, W.B.
      Wound closure sutures and needles: a new perspective.
      Prior to laser technology, the butt was manually drilled, requiring the proximal end of the needle to be at least 0.36 mm.
      • Lear W.
      Instruments and materials.
      Figure thumbnail gr2
      Figure 2The anatomy of a needle, with the needle point for piercing tissue; body that may be modified (with ribs, for example, to improve grip); and eye that attaches the suture strand to the needle. The needle radius and chord length are also depicted.
      Figure thumbnail gr3
      Figure 3Needle eyes. A Initially, a closed eye similar to the common sewing needle was the standard. The suture strand was doubled over, in a time-consuming and soft tissue trauma-promoting process, dragging the doubled-over suture and creating a greater hole in its wake. B A variation of the closed needle was the French eye needle, which facilitated suture strand loading, but maintained the doubled-over suture strand configuration. C Subsequently, the swaged needle was invented, connecting the needle and suture in a single, continuous unit, which was made possible by a hole drilled at the end of a suture needle, with an inserted suture strand that is crimped to secure it in place.
      The body of the needle connects the eye to the point. The body shape may be triangular, round, rectangular, or trapezoidal. A “round” body may be oval to improve stiffness and handling. Ribs add grip for easier handling. A rectangular body gives the needle more rigidity and helps minimize needle bending and twisting. Needle shapes include straight; curved 1/4, 3/8, 1/2, or 5/8 circles (Fig. 4); ski; compound curve; and side-cutting.
      Figure thumbnail gr4
      Figure 4Needle radius of curvature. Curved needles provide a predictable path through tissue. Curves of 1/4 of a circle are commonly used in eye surgery and microsurgery. The most common curves are 3/8 and 1/2 of a circle for general use on skin, fascia, and tendons. The 1/2–circle curves are designed for use in small spaces, requiring more pronation/supination of the wrist. Curves of 5/8 of a circle are used for deeper tissues in confined spaces, such as in the pelvis.

      Common Needle Points: Tapered and Triangular

      Needle points are commonly represented by a 2- or 3-letter code (Table 2). Triangular configurations are reverse cutting or cutting (Fig. 5). Cutting needles contain a triangular apex facing the arc, with an increased cutout risk, whereas reverse cutting needles’ triangular apex faces away from the arc, decreasing the cutout risk (Fig. 6). Various combinations of points and bodies exist (eg, taper-cut needles have triangular points with round/oval bodies).
      Table 2Suture Codes and Definitions With Point and Body Characteristics Commonly Used in Hand Surgery
      CodeDefinitionSymbolPointNeedle Body Arc
      BVBlood vesselTaper3/8
      CT; MO; RB; SHCircle taper; mayo; renal bypass (artery); small half (circle)Taper1/2
      STStraight taperTaperStraight
      URUrologyTaper5/8
      FSFor skinReverse cutting3/8
      OSOrthopedic surgeryReverse cutting1/2
      P; PSPlastic; plastic surgeryReverse cutting3/8; 1/2
      VTaper-cut surgical needleReverse cuttingStraight; 1/4; 3/8; 1/2
      KS; TSKeith straight; tendon straightcuttingStraight
      Figure thumbnail gr5
      Figure 5Needle points. Common needle points are A cutting, B reverse cutting, and C tapered. A In hand surgery, cutting needles are seldom used. B Reverse cutting needles are most commonly used for the skin, fascia, tendons, and/or nerves. C Tapered needles are most commonly used for blood vessels, dura, and/or nerves.
      Figure thumbnail gr6
      Figure 6Cutting needle points and tissue trauma. Illustration of A a cutting needle’s path and B a reverse cutting needle’s path through tissue. A Note that the cutting needle leaves behind a hole in the tissue with the apex of the triangular hole close to the edge of the wound, allowing for easier tear-through. B In the reverse cutting needle illustration, the base of the triangle is closest to the edge of the wound, allowing for a greater contact area between the tissue and suture material, therefore decreasing the risk of tear-through.
      Tapered needles have round bodies that taper into a sharp point without cutting edges (Fig. 5C). Tapered needles cause the least tissue trauma as the needle point pierces, and the round body gently stretches the tissue as it advances. The tissue elastically recoils, leaving behind a small-profile hole. The taper ratio is the ratio of the length of the tapered portion to its diameter. Greater taper ratios minimize resistance of needle penetration through tissue.
      • Edlich R.F.
      • Gubler K.
      • Wallis A.G.
      • Clark J.J.
      • Dahlstrom J.J.
      • Long III, W.B.
      Wound closure sutures and needles: a new perspective.
      Manufacturers alter taper ratios for clinical, financial, and proprietary purposes. Labeling of needle points may be confusing: for clarity, look at the packaging (Fig. 1).

      Suture Material Characteristics

      Material properties

      Versions of natural (eg, catgut, silk) and synthetic sutures may be absorbable or nonabsorbable.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      Natural sutures have favorable handling properties with primary disadvantages that include substantial tissue reaction and, with catgut sutures, the potential for prion disease (bovine spongiform encephalopathy).
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      Synthetic sutures contain long strands of polymers, whose combinations contribute to tensile strength. Generally, synthetic sutures retain tensile strength longer than natural sutures secondary to a decreased tissue reaction. Examples of nonabsorbable synthetic sutures are nylon and Prolene (polypropylene). Examples of absorbable synthetic sutures are PDS (polydioxanone) and Vicryl (glycolide and lactide).

      Absorption

      Natural absorbable sutures break down by enzymatic degradation through proteases released by phagocytes during the inflammatory phase of wound healing.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      Synthetic absorbable sutures undergo hydrolysis into monomers.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      Specific combinations of monomers provide unique properties for synthetic sutures. For example, adding glycolide provides stiffness and increases hydrolysis. Vicryl sutures (90% glycolide and 10% lactide) absorb faster than PDS (polydioxanone) and newer sutures with high concentrations of lactide.
      • Ratner B.D.
      Biomaterials Science: An Introduction to Materials in Medicine.
      Tensile strength diminishes as sutures resorb. Nonabsorbable sutures maintain tensile strength much longer than absorbable sutures. The suture material is retained long after tensile strength is lost. Absorption may occur over days to weeks, depending on the suture properties and patient condition (Table 3).
      • Lear W.
      Instruments and materials.
      Table 3A List of Accelerants to Degradation of Absorbable Sutures
      Acidic or basic environment
      Dilute milieu (lower salt concentrations)
      High tension
      Gamma irradiation
      Many free radicals
      Infection
      Elevated temperature
      Protein deficiencies
      Synovial fluid

      Surface architecture influences: monofilament, polyfilament (braided), and barbed suture

      Monofilament sutures (eg, nylon, Monocryl) contain smooth surfaces, resulting in less tissue trauma, less capillarity, and a lower infection risk from harboring bacteria.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      Monofilaments may stretch and require careful knotting, as the smooth surfaces allow for insecure knots. Suture microfractures may occur with careless needle-holder handling, predisposing them to early failure.
      The surface areas of polyfilament sutures (eg, Ethibond, Vicryl) are thousands of times greater than those of monofilament sutures.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      Braided sutures afford easy handling and favorable knotting properties, where the between-braid friction provides knot security.
      • Tajirian A.L.
      • Goldberg D.J.
      A review of sutures and other skin closure materials.
      However, braided sutures have greater tissue drag (resistance through soft tissue), causing increased tissue trauma. Furthermore, an increased surface area allows fluid pooling in crevices between filaments, potentially harboring and protecting bacteria from phagocytic cells.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      ,
      • Tajirian A.L.
      • Goldberg D.J.
      A review of sutures and other skin closure materials.
      Additionally, braided sutures incite greater inflammation than monofilament sutures.
      • Tajirian A.L.
      • Goldberg D.J.
      A review of sutures and other skin closure materials.
      Barbed monofilament sutures obviate knot tying. There has been concern over the irregular surface of barbed sutures creating small crevices for bacteria to possibly form biofilm.
      • Dhom J.
      • Bloes D.A.
      • Peschel A.
      • Hofmann U.K.
      Bacterial adhesion to suture material in a contaminated wound model: comparison of monofilament, braided, and barbed sutures.
      However, studies have demonstrated that barbed sutures do not increase surgical site infection risks when compared to traditional suture types in clean wounds, and have even demonstrated lower risks of surgical site infection compared to traditional braided interrupted subcutaneous sutures.
      • Dhom J.
      • Bloes D.A.
      • Peschel A.
      • Hofmann U.K.
      Bacterial adhesion to suture material in a contaminated wound model: comparison of monofilament, braided, and barbed sutures.
      ,
      • Thacher R.R.
      • Herndon C.L.
      • Jennings E.L.
      • Sarpong N.O.
      • Geller J.A.
      The impact of running, monofilament barbed suture for subcutaneous tissue closure on infection rates in total hip arthroplasty: a retrospective cohort analysis.
      While a barbed suture package may be more expensive, the overall cost and surgical time are generally lower with barbed sutures.
      • Dhom J.
      • Bloes D.A.
      • Peschel A.
      • Hofmann U.K.
      Bacterial adhesion to suture material in a contaminated wound model: comparison of monofilament, braided, and barbed sutures.
      • Thacher R.R.
      • Herndon C.L.
      • Jennings E.L.
      • Sarpong N.O.
      • Geller J.A.
      The impact of running, monofilament barbed suture for subcutaneous tissue closure on infection rates in total hip arthroplasty: a retrospective cohort analysis.
      • Morris M.R.
      • Bergum C.
      • Jackson N.
      • Markel D.C.
      Decreased bacterial adherence, biofilm formation, and tissue reactivity of barbed monofilament suture in an in vivo contaminated wound model.

      Tissue reactivity

      The Sewell scoring system is used to formally grade tissue reactivity, which includes the number of cells per high-powered field and the width of inflammation, weighted by the types of inflammatory cells present (eg, neutrophils are scored higher than lymphocytes).
      • Sewell W.R.
      • Wiland J.
      • Craver B.N.
      A new method of comparing sutures of ovine catgut with sutures of bovine catgut in three species.
      Natural sutures incite a greater inflammatory response than synthetic sutures.
      • Tajirian A.L.
      • Goldberg D.J.
      A review of sutures and other skin closure materials.
      Of the nonabsorbable sutures, silk has the most reactivity; of the absorbable sutures, catgut has the most reactivity (Table 4).
      • Lear W.
      Instruments and materials.
      ,
      • Molea G.
      • Schonauer F.
      • Bifulco G.
      • D'Angelo D.
      Comparative study on biocompatibility and absorption times of three absorbable monofilament suture materials (polydioxanone, poliglecaprone 25, glycomer 631).
      Table 4Tissue Reactivity of Absorbable Sutures, In Order From Most Reactive (1) to Least Reactive (4)
      • 1.
        Catgut (purified bovine/sheep collagen)
      • 2.
        Polyglycolic acid (Vicryl)
      • 3.
        Polytrimethylene carbonate (Maxon)
      • 3.
        Polydioxanone (PDS)
      • 4.
        Poliglecaprone (Monocryl)
      • 4.
        Polyglytone (Caprosyn)

      Antimicrobial agents

      Sutures coated with antimicrobials were designed to prevent bacterial and fungal colonization and thus decrease the risk of surgical site infections, particularly against common pathogens, including Staphylococcus aureus (both methicillin-sensitive and methicillin-resistant), Staphylococcus epidermidis, Escherichia coli, and Klebsiella pneumonia.
      • Yag-Howard C.
      Sutures, needles, and tissue adhesives: a review for dermatologic surgery.
      Triclosan is the most prevalent antimicrobial suture-coating agent. Commonly used in hand sanitizers and cleaners, triclosan is biocompatible, is nontoxic, has a broad spectrum without resistance, and does not interfere with wound healing.
      • Yag-Howard C.
      Sutures, needles, and tissue adhesives: a review for dermatologic surgery.
      A large meta-analysis demonstrated that triclosan-coated sutures significantly reduced the 30-day risk of surgical site infections by 27%, with similar findings across other systematic reviews of randomized controlled trials.
      • Ahmed I.
      • Boulton A.J.
      • Rizvi S.
      • et al.
      The use of triclosan-coated sutures to prevent surgical site infections: a systematic review and meta-analysis of the literature.
      • Wang Z.X.
      • Jiang C.P.
      • Cao Y.
      • Ding Y.T.
      Systematic review and meta-analysis of triclosan-coated sutures for the prevention of surgical-site infection.
      • Edmiston Jr., C.E.
      • Daoud F.C.
      • Leaper D.
      Is there an evidence-based argument for embracing an antimicrobial (triclosan)-coated suture technology to reduce the risk for surgical-site infections?: a meta-analysis.
      Ethicon adds “PLUS” to the name of a suture to denote antimicrobial coating (eg, Vicryl PLUS).

      Mechanical properties

      Hand surgeons must choose appropriate suture needles and suture materials for various tissues based on a number of factors: for example, size (Table 5) and tissue type (Table 6). Other aspects of selecting 1 suture over another may depend on the mechanical properties of the tissues being repaired, as well as the mechanical properties of the sutures themselves. For instance, one must consider the surgical application (Table 7), knot security, ease of handling, predictability of mechanical performance, tissue drag, capillarity, tissue reaction, and even cost.
      Table 5Common Applications Based on Suture Size
      USP SizeDiameter, mmCommon Applications
      10-0 to 8-00.02–0.04Microsurgery (eg, small vessels in the hand)
      7-0 to 6-00.05–0.07Epitendinous repair, large neurovascular structures
      5-0 to 4-00.1–0.15Large neurovascular structures, skin closure
      3-0 to 2-00.2–0.3Skin closure, vessel ligation, small tendons, small joint capsule
      0–10.35–0.4Fascia, muscle, large joint capsule
      2–50.5–0.7Large tendon repair
      6–70.8–0.9Surgical steel–cerclage wiring of fractures
      Table 6Suture Material and Needle Options Based on Surgical Tissue Type∗
      TissueSutureNeedleExample(s)Notes
      BonePerm, braidedTenodesis with bone tunnels (Fiberwire)Alternate: suture anchors with permanent sutures
      FasciaAbs (superficial);

      Perm (deep)
      Extensor retinaculum (2-0 Vicryl)Tapered needles decrease tissue damage and cutout
      MusclePerm, synthetic, braided⊙/▼Muscle repair of forearm (3-0 Ethibond)Goal: decrease scarring with perm or synthetic suture, which can affect contractility
      TendonChoice 1: Perm, braided

      Choice 2: Perm, monofilament

      Choice 3 (rare): Abs
      ⊙/▼Zone II flexor tendon repair–braided core (3-0 Fiberwire); monofilament epitendinous

      (6-0 Prolene)
      Tapered needles = less trauma. Reverse cutting needles = ease of penetration
      NervePerm, monofilamentUlnar nerve repair at elbow (8-0 nylon)Goal: decrease scarring or neuroma risk
      Blood vesselsPerm, monofilamentMicrovascular repair (9-0 or 10-0 nylon)Avoid cutting needles to minimize trauma or hole size
      Abs, absorbable; Perm, permanent.
      ⊙ denotes tapered needle point.
      ▼ denotes reverse cutting needle point.
      Table 7Characteristics and Applications of Absorbable Sutures Commonly Used in Hand Surgery
      SutureCategoryMaterialStrength Retention, dApplication
      Plain catgutNaturalPurified bovine or sheep collagen5–7General soft tissue approximation
      Chromic catgutNaturalPurified bovine or sheep collagen coated with chromic salts21–28General soft tissue approximation
      Fast catgutNaturalPurified bovine or sheep collagen heat treated3–5Dermis
      VicrylSyntheticPolyglycolic acid60% at 21General soft tissue
      Vicryl rapideSyntheticPolyglycolic acid, heat treated50% at 5Superficial skin
      Vicryl PLUSSyntheticPolyglycolic acid, triclosan-coated50% at 21General soft tissue
      DexonSyntheticPolyglycolic acid50% at 15General soft tissue
      MonocrylSyntheticPoliglecaprone50% at 7Skin closure
      PDSSyntheticPolydioxanone4–0; 36% at 42

      3–0; 60% at 42
      General soft tissue, where swelling is expected
      PDS IISyntheticPolydioxanone, heat treated50% at 28General soft tissue, where swelling is expected
      MaxonSyntheticPolytrimethylene carbonate50% at 28General soft tissue

      Tensile strength

      Tensile strength, measured by a tensiometer, is the weight necessary to break a suture divided by the cross-sectional area of the suture. The relationship is nonlinear, as the cross-sectional area is πr2. Consequently, a large-diameter suture has a greater tensile strength, and studies evaluating strengths must compare sutures of equal diameters.
      • Muller D.A.
      • Snedeker J.G.
      • Meyer D.C.
      Two-month longitudinal study of mechanical properties of absorbable sutures used in orthopedic surgery.
      A knotted suture has one-third the tensile strength of an unknotted suture. Therefore, clinically relevant studies measure the effective tensile strength: the strengths of looped and knotted sutures.

      Breaking strength retention

      Breaking strength retention is a measure of the percentage of a suture’s original tensile strength at different time points. The majority of strength is lost within the first 60 days.
      • Muller D.A.
      • Snedeker J.G.
      • Meyer D.C.
      Two-month longitudinal study of mechanical properties of absorbable sutures used in orthopedic surgery.
      The maximum breaking strength begins to decline immediately after placement due to mechanical stress and tissue fluid influences.
      • Muller D.A.
      • Snedeker J.G.
      • Meyer D.C.
      Two-month longitudinal study of mechanical properties of absorbable sutures used in orthopedic surgery.
      The suture is weakened by handling and other factors (Table 3).
      • Muller D.A.
      • Snedeker J.G.
      • Meyer D.C.
      Two-month longitudinal study of mechanical properties of absorbable sutures used in orthopedic surgery.
      Dyes such as gentian violet added to a suture provide better visualization and slightly longer strength retention compared to undyed counterparts.
      • Yag-Howard C.
      Sutures, needles, and tissue adhesives: a review for dermatologic surgery.
      Although large-diameter sutures have higher tensile strengths than smaller-diameter sutures, they lose relative strength at similar rates. However, the initial tensile strength is an important factor. Poliglecaprone (Monocryl), for example, retains adequate tensile strength for the first week of healing due to a high initial tensile strength.

      Bending stiffness, memory, and plasticity

      Bending stiffness measures how a material handles: the force required to bend sutures to desired angles. Large-diameter sutures have more stiffness than small-diameter sutures. Monocryl and PDS II have the least stiffness and best handling properties.
      • Lear W.
      Instruments and materials.
      Memory, as a result of bending stiffness and correlated with elasticity, is the suture’s ability to return to its prior configuration (form and length) after being stretched.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      ,
      • Tajirian A.L.
      • Goldberg D.J.
      A review of sutures and other skin closure materials.
      Often, memory refers to the retention of its coiled shape from packaging.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      Excessive memory is undesirable for handling and knotting. However, high memory is beneficial in edematous tissues, where sutures should accommodate swelling and retain their configurations.
      • Tajirian A.L.
      • Goldberg D.J.
      A review of sutures and other skin closure materials.
      Plasticity is the ability to take on a new shape through applied stress.
      • Patel K.A.
      • Thomas W.E.G.
      Sutures, ligatures and staples.
      Plasticity is the reciprocal of memory (high plasticity = low memory), and therefore sutures with high plasticity often have limited memory and are able to remain in whichever shape the are placed. Plasticity allows for better handling and knotting (eg, silk has high plasticity and nearly no memory, and therefore excellent handling and knotting properties). However, highly plastic materials may take on unwanted shapes, such as kinking of steel sutures, making suturing and tying more difficult.

      Capillarity

      Capillarity refers to the ability to transport fluid through a measured length of suture in a specific time frame.
      • Lear W.
      Instruments and materials.
      High capillarity may increase the infection risk due to the propensity to absorb bacteria-contaminated fluid. The ability for a suture to potentiate infection can be measured by contaminating a suture with a known quantity of bacteria and measuring the bacterial growth after several days. Monofilaments have less capillarity and much lower bacterial growth than braided sutures.
      • Lear W.
      Instruments and materials.
      Therefore, some surgeons avoid braided sutures in deep wounds at risk for contamination.

      Tissue drag

      Tissue drag is the force required to overcome resistance of the suture’s pull through tissue. Lower drag results in less tissue damage. Suture coating (eg, beeswax, silicone, polytetrafluoroethylene, or stearates) may minimize the coefficient of friction and tissue drag, thereby decreasing capillarity and the associated infection risk.
      • Yag-Howard C.
      Sutures, needles, and tissue adhesives: a review for dermatologic surgery.
      A monofilament suture has a smooth surface with lower tissue drag than a braided or twisted suture.

      Skin Closure Alternatives: Staples, Skin Glue, and Adhesive Strips

      Staples

      Skin staples, used for rapid skin closure, are composed of stainless steel. They have the greatest tensile strength of all skin closure materials and are thus used in high-tension wounds (eg, scalp). They have low reactivity and a similar infection risk to those of most sutures.
      • Regula C.G.
      • Yag-Howard C.
      Suture products and techniques: what to use, where, and why.
      Studies demonstrate equivalent cosmetic outcomes when compared to nylon sutures, largely due to the excellent wound eversion that staples provide.
      • Regula C.G.
      • Yag-Howard C.
      Suture products and techniques: what to use, where, and why.
      ,
      • Batra J.
      • Bekal R.K.
      • Byadgi S.
      • Attresh G.
      • Sambyal S.
      • Vakade C.D.
      Comparison of skin staples and standard sutures for closing incisions after head and neck cancer surgery: a double-blind, randomized and prospective study.
      While staples are generally costlier than sutures, the rapidity with which wounds are closed using staples may be more cost-effective than suturing.
      • Regula C.G.
      • Yag-Howard C.
      Suture products and techniques: what to use, where, and why.
      ,
      • Batra J.
      • Bekal R.K.
      • Byadgi S.
      • Attresh G.
      • Sambyal S.
      • Vakade C.D.
      Comparison of skin staples and standard sutures for closing incisions after head and neck cancer surgery: a double-blind, randomized and prospective study.

      Skin glue

      Skin glue is a convenient alternative to sutures. Application is rapid and simple: it is applied to opposed wound edges (usually after buried sutures) in liquid form and solidifies, forming a chemical bond with the skin. Skin glue protects wounds from microbes and the environment. The glue dries rapidly and lasts approximately 1–2 weeks until it peels off.
      • Maloney J.
      • Rogers G.S.
      • Kapadia M.
      Surgical corner: a prospective randomized evaluation of cyanoacrylate glue devices in the closure of surgical wounds.
      Currently available skin glues include octyl cyanoacrylate (Dermabond), butylcyanoacrylate (LiquiBand), and N-butyl-2-cyanoacrylate (GlueSeal). GlueSeal is available in multiuse packaging. The butyl formations are more rigid and dry more quickly than octyl formations of cyanoacrylates (30 seconds compared with 60 seconds).
      • Maloney J.
      • Rogers G.S.
      • Kapadia M.
      Surgical corner: a prospective randomized evaluation of cyanoacrylate glue devices in the closure of surgical wounds.
      Advantages of skin glue over sutures include the speed and ease of application, liberty of showering without the burden of dressing applications, decreased infection risk, and lack of a need for suture removal. Additionally, the allergic contact dermatitis risk is minimal, allowing for application on patients with latex or adhesive allergies. The primary disadvantage is a poor cosmetic appearance if the skin glue seeps into a wound with improperly everted skin edges or without direct apposition, which may cause a wide-appearing scar. Therefore, meticulous subcutaneous closure is paramount. There is no significant cosmetic benefit to either wound closure method.
      • Sniezek P.J.
      • Walling H.W.
      • DeBloom III, J.R.
      • et al.
      A randomized controlled trial of high-viscosity 2-octyl cyanoacrylate tissue adhesive versus sutures in repairing facial wounds following Mohs micrographic surgery.
      • Tierney E.P.
      • Moy R.L.
      • Kouba D.J.
      Rapid absorbing gut suture versus 2-octylethylcyanoacrylate tissue adhesive in the epidermal closure of linear repairs.
      • Vanholder R.
      • Misotten A.
      • Roels H.
      • Matton G.
      Cyanoacrylate tissue adhesive for closing skin wounds: a double blind randomized comparison with sutures.
      Although it is outside the scope of a discussion on skin closure, it is worth mentioning that skin glue is commonly used in hand surgery for nail bed injuries. Octyl cyanoacrylate (Dermabond) nail bed repairs allow for a more expeditious procedure with similar cosmetic and functional results as compared to suture repair.
      • Strauss E.J.
      • Weil W.M.
      • Jordan C.
      • Paksima N.
      A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries.

      Adhesive strips

      Adhesive strips (eg, Steri-Strips, 3M) are another option for wound closure. Most commonly, strips are placed on the skin surface perpendicular to the incision following subcutaneous suture placement.
      • Custis T.
      • Armstrong A.W.
      • King T.H.
      • Sharon V.R.
      • Eisen D.B.
      Effect of adhesive strips and dermal sutures vs dermal sutures only on wound closure: a randomized clinical trial.
      Adhesive strips last 1–2 weeks, with a longer durability if the surrounding environment is dry, has low mobility, and has minimal edema/swelling, and if a liquid adhesive is applied prior to strip application.
      • Yag-Howard C.
      Sutures, needles, and tissue adhesives: a review for dermatologic surgery.
      However, adhesive strips have not demonstrated improved scar cosmetics compared to subcuticular sutures without adhesive strips.
      • Custis T.
      • Armstrong A.W.
      • King T.H.
      • Sharon V.R.
      • Eisen D.B.
      Effect of adhesive strips and dermal sutures vs dermal sutures only on wound closure: a randomized clinical trial.
      Common liquid adhesives include gum mastic (Mastisol) and benzoin tincture. Gum mastic liquid provides superior adhesive qualities with lower risks for contact dermatitis and associated skin discoloration.
      • Lesesne C.B.
      The postoperative use of wound adhesives. Gum mastic versus benzoin, USP.
      The common complications of adhesive strips include allergic contact dermatitis and blistering from skin shear tension in the setting of edema.
      Alternative uses for adhesive strips are largely in the role of skin reinforcement. For example, the strips may be applied perpendicular or parallel to the incision and simple sutures passed through the strip and the skin, reinforcing the strength of the skin, with the primary advantage of the parallel method being even tensile forces along the length of the incision.

      Cost Analysis

      The costs associated with absorbable and nonabsorbable sutures commonly used in hand surgery are detailed in Tables 8 and 9, respectively. The price data were obtained from a single institution’s actual purchases in the year 2019. While no definitive conclusions may be drawn, as suture prices vary across institutions, this analysis offers some insight into the matter. Both the suture material and needle must be considered in a cost analysis. Proprietary needle points, such as the reverse cutting “Plastic Surgery” point, are markedly more expensive than a generic reverse cutting “For Skin” needle point. Tables 8 and 9 indicate that hand surgery needles cost approximately twice as much as For Skin needles and that barbed sutures are approximately 5 times the price of their nonbarbed counterparts (ie, Stratafix versus Monocryl, respectively). Additionally, Arthrex sutures are significantly more expensive than most other sutures shown in Table 8 and Table 9. Interestingly, antibiotic-coated (triclosan) sutures are marginally more expensive (10%–14%) than their noncoated counterparts: an expense that should be evaluated against the cost of managing a surgical site infection.
      Table 8Cost of Absorbable Sutures Commonly Used in Hand Surgery
      Absorbable SuturePrice, USDSuture Size, USPNeedle PointCompanyComposition
      Chromic gut$4.775-0P-3EthiconIntestinal beef serosa or sheep submucosa with chromic salts
      Plain gut$4.675-0P-3EthiconIntestinal beef serosa or sheep submucosa
      Monocryl$4.523-0PS-2EthiconPolyglicaprone 25
      Monocryl PLUS$5.063-0PS-2EthiconPolyglicaprone 25 and triclosan
      Vicryl$1.323-0RB-1EthiconPolyglactin 910
      Vicryl PLUS$1.523-0RB-1EthiconPolyglactin 910 and triclosan
      Vicryl$3.094-0PS-2EthiconPolyglactin 910
      Vicryl RAPIDE$5.214-0PS-2EthiconPolyglactin 910
      Stratafix Spiral Monocryl PLUS$29.993-0PS-1EthiconPolyglicaprone 25 and triclosan
      Stratafix Spiral$21.444-0FS-2EthiconPolyglycolic acid and polycaprolactone
      USD, US dollar.
      Table 9Cost of Nonabsorbable Sutures Commonly Used in Hand Surgery∗
      Nonabsorbable SuturePrice, USDSuture Size, USPNeedle PointCompanyComposition
      Prolene$4.444-0PS-2EthiconPolypropylene
      Perma-Hand Slk$1.294-0FS-2EthiconSilk
      Perma-Hand Slk$2.764-0PS-2EthiconSilk
      Supramid (looped)$13.504-0TaperS JacksonPolyamide
      Supramid (double arm)$12.504-0P-1, P-3S JacksonPolyamide
      Ethibond$1.302-0CT-2EthiconHigh-molecular-weight, long-chain polyesters
      Ethibond$3.094-0PS-2EthiconHigh-molecular-weight, long-chain polyesters
      Fiberwire$22.004-0TaperArthrexLong-chain UHMWPE core, polyester, and UHMWPE jacket
      Fiberloop$50.004-0TaperArthrexLong-chain UHMWPE core, polyester, and UHMWPE jacket
      Gore-tex$24.672-0CV-3WL GorePolypropylene
      UHMWPE, ultra-high-molecular-weight polyester; USD, US dollar.

      What’s Next: Technological Advances and Future Developments in Musculoskeletal Suturing

      Advances in suture materials are trending toward augmented tissue healing: providing mechanical strength during the healing process, with the ultimate goal of replacing the suture material with newly formed tissue. The suture material may be tailored to specific tissue types (by disease and age) to promote maximal regeneration.
      • Abhari R.E.
      • Martins J.A.
      • Morris H.L.
      • Mouthuy P.A.
      • Carr A.
      Synthetic sutures: clinical evaluation and future developments.
      At the fiber level, sutures may be manufactured on a submicron scale to mimic the native collagen fibril architecture, which varies with health and age. On the surface, biophysical cues, such as grooves, patterned dots, and ridges, may be microfabricated to mimic natural structures present in the matrix to stimulate native cell populations to secrete, deposit, and remodel native extracellular matrices.
      • Alshomer F.
      • Madhavan A.
      • Pathan O.
      • Song W.
      Bioactive sutures: a review of advances in surgical suture functionalisation.
      Another advancement includes suture porosity for cell-driven repair through a scaffold effect based on pore size, balanced against tensile strength. Additional developments may include drug-eluting sutures for controlled release of chemicals through a biodegradable polymer system, such as antibiotics, local anesthetics for pain relief, and anti-inflammatories.
      • Alshomer F.
      • Madhavan A.
      • Pathan O.
      • Song W.
      Bioactive sutures: a review of advances in surgical suture functionalisation.
      Finally, sutures coated with mesenchymal stem cells or gene-activating protein sequences may promote and expedite tissue healing.
      • Alshomer F.
      • Madhavan A.
      • Pathan O.
      • Song W.
      Bioactive sutures: a review of advances in surgical suture functionalisation.

      Appendix A.

      Table E1Brief History of Sutures∗
      DateRegionCategoryAdvancement(s)
      ∼500 B.C.IndiaSuture material propertiesSusruta used sutures of flax, hemp, bark, fiber, or hair
      150Roman EmpireTendon repairGalen of Pergamon sutured severed tendons of gladiators
      • First to mention catgut
      1867EnglandSterilization; suture material propertiesJoseph Lister, the father of antisepsis:
      • Realized sterile sutures may be safely implanted
      • Developed a method for sterilizing and storing catgut by soaking in mixture of carbolic acid and olive oil
      • Realized chromic acid, used to tan leather, delays absorption of catgut to allow tissues a longer time to heal
      1890GermanyNeedle material propertiesMetallurgist Adolf Martens invented martensitic steel: hardened steel crystalline structure of supersaturated carbon that is high in hardness and toughness
      1906USAStandardizationFDA founded: uses USP standards. Additionally, ensures public safety through its own sterility and packaging standards
      1937USAStandardizationUSP (founded: 1820), established standards for suture naming, diameter, tensile strength, labeling, and sterility
      1915ScotlandSuture material propertiesGeorge Merson invented eyeless needle
      • “Swaged needle”: suture inserted into butt of needle
      • Reduced tissue damage: single versus double strand
      • Mr Merson’s company became Ethicon Ltd
      1956USAMechanical propertiesUnidirectional barbed sutures invented
      1960ScotlandSterilizationGamma irradiation allows sterilization in final packaging
      1972USAMechanical propertiesBidirectional barbed sutures invented
      FDA, Food and Drug Administration; USA, United States of America.

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