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Suture Material

Suture Material

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Vol. 20, No. 2February 1998
Refereed Peer Review
FOCAL POINTKEY FACTS
#
Suture materials should bechosen with the goal of reducingpatient morbidity, not on thebasis of personal preferenceor cost alone.
Selecting SutureMaterials for Small Animal Surgery 
Texas A&M University 
Harry W. Boothe, Jr., DVM, MS
N
ew information about surgical sutures has made it possible for veteri-narians to make better-informed decisions about the selection and useof suture material. Also, veterinarians now have a broader range of materials to choose from. Veterinary surgeons should base their choice of su-ture material on the characteristics of the material and how it interacts with tis-sue, not just on personal preferences or cost. This article reviews the character-istics of suture materials and provides guidelines for choosing the suturematerial that will minimize morbidity and maximize wound healing.
CHARACTERISTICS
Several physical properties of suture material are important to surgeons (e.g.,initial tensile strength, relative knot security, handling characteristics). Impor-tant features of the suture–tissue interaction include tissue reactivity, rate of loss of tensile strength, and degradation mechanism.
Physical Properties
Tensile Strength 
Most suture materials are stronger fresh from the package than they will beafter having been implanted in tissue. Size for size, poliglecaprone 25 has thehighest initial tensile strength of absorbable suture materials and surgical(chromic) gut has the lowest (Table I). Stainless steel is the strongest nonab-sorbable suture material, whereas silk is the weakest (Table I).Sutures must be strong enough to withstand disruptive forces across a wounduntil the wound gains sufficient tensile strength. When choosing the type andsize of suture material to use in a wound, the surgeon must choose a material whose physical properties closely match the mechanical properties of the tissuebeing sutured (Figure 1). Mechanical properties of suture materials and theirrelationship to those of tissue need further characterization for many species.The mechanical properties of polypropylene and nylon (particularly elonga-tion) are similar to those of skin.
1
Table II presents guidelines for selecting the proper size of suture material.
2
The properties of suture material (including the reliability of knots) improve as
CE
V
I
Poliglecaprone 25 has thehighest initial tensile strengthof absorbable suture materials,and surgical gut has the lowest.
I
Synthetic absorbablemonofilament suturematerials have advantagesover multifilament absorbablematerials.
I
Ending knots of a continuouspattern require at leastfive throws to be secure(polydioxanone requiresseven).
I
Excessively tight sutures increasepatient morbidity and decreasewound strength.
I
Minimally reactive suturematerials, swaged needles,and smaller suture sizes arepreferable to more reactivematerials, eyed needles, andlarger suture sizes.
 
diameter increases.
3
However, larger-diameter suturescause greater tissue reaction.
3
The size of material cho-sen usually represents a compromise between maximalmechanical support and minimal tissue reactivity.
3
Sometimes, the need for mechanical support (e.g.,for body-wall closure or tension sutures) is more criticalthan the need to minimize tissue reaction. When one isclosing a body wall with a continuous pattern of polypropylene suture, a suture diameter one size largerthan that usually selected is recommended.
4
In othersituations (e.g., closure of visceral wounds or subcuta-neous tissue), the need tominimize tissue reactionpredominates.Because larger-diametersuture materials providemore-secure knots, a veteri-narian may be tempted touse excessively large suturematerials routinely. Howev-er, veterinarians should re-sist this temptation becausethe larger materials cause ex-cessive tissue reaction.
Knot Security 
The number of throws(there are two throws in a square knot) needed to tie asecure knot depends on the suture material and the su-ture pattern
5
(Table III). To make a secure knot in aninterrupted suture pattern takes at least three throws when polyglactin 910, polyglycolic acid, surgical gut, orpolypropylene suture material is used but at least fourthrows when polydioxanone or nylon is used. Whenstarting a continuous pattern using polydioxanone, sur-gical gut, or nylon, the surgeon should add one throwmore than would be needed for an interrupted pattern.The ending knots of a con-tinuous pattern tend to bethe least secure and requireat least five throws—or moreif polyglactin 910, nylon, orpolydioxanone is used
5
(Table III).For some suture materialsthat were developed recently (e.g., poliglecaprone 25 andpolyglyconate) or that havebeen used frequently in vet-erinary patients (e.g., poly-merized caprolactum andstainless steel), the numberof throws necessary to createsecure knots has not beenevaluated. The knot security 
Small Animal
The Compendium 
February 1998
MECHANICAL SUPPORT
I
TISSUE REACTION
I
ENDING KNOTS
TABLE IA Ranking of the Physical Characteristics of Suture Materials
Relative Knot Security 
Effective Strength 
Suture MaterialInitial Tensile Strengt
Ranking(%
Stiffness 
 Absorbable
Poliglecaprone 25156Polydioxanone324Polyglactin 910441Polyglycolic acid 53665Polyglyconate213Surgical gut66632
Nonabsorbable
Nylon44663Polyester26515Polymerized caprolactum33794Polypropylene52892Silk65576Stainless steel11921
1 = highest, 6 = lowest.
Figure 1—
Relationship between loss of tensile strength by se-lected absorbable sutures and gain in strength of various tis-sues as a result of healing (From Bucknall TE, Ellis H:
Wound Healing for Surgeons.
London, Baillière Tindall, 1984,pp 77, 81. Modified with permission.)
 
of many suture materialshas been evaluated qualita-tively.
6,7
 All sutures losestrength when knotted;many lose at least a third of their initial tensile strength
7
(Table I). Relative knot se-curity expresses knot-hold-ing capacity as a percentageof initial tensile strength(Table I). The effectivestrength of the suture mate-rial depends on both theinitial tensile strength andthe relative knot security (see Effective Strength of Suture Materials).
Handling Characteristics 
The handling characteristics of suture materials arean important consideration. Stiffer (i.e., less pliable) su-ture materials are more difficult to handle.
8
 When us-ing a stiff suture material, the surgeon must take partic-ular care to ensure that the knots are secure.In general, monofilament sutures are stiffer than mul-tifilament sutures of the same composition, Also, larger-diameter sutures are stiffer than smaller-diameter su-tures.
8
Silk is so easy to han-dle that suture materials with excellent pliability aredescribed as “handling likesilk.” Poliglecaprone 25, arecently marketed absor-bable suture material, hasthe least stiffness (greatestpliability) of the absorbablesutures
9
(Table I). Althoughhandling characteristicsmay be the decisive factorin the choice of suture ma-terial for some surgical pro-cedures, a suture materialshould never be chosen sole-ly on the basis of its handlingcharacteristics.
Suture–Tissue Interaction
Suture materials influence patient morbidity primari-ly through their interaction with tissue. Many factorsaffect this interaction, including the amount (diameterand length) of suture material in the wound as well asthe placement technique. The impact of sutures on the wound is an important consideration in the selection of a suture material. Although much is known about theinfluence of sutures as foreign material in wounds, little is known about their effecton the wound microenvironment.
10
Tis-sue–suture interactions are complex, involv-ing humoral and cellular factors.
11
Sutures alter the healing process in con-taminated or infected wounds. The pres-ence of any suture in tissue increases the tis-sue’s susceptibility to infection. Thus, theveterinarian should avoid placing suture ina contaminated wound unless it is essentialfor positioning tissue.
12
Both the physical construction (monofil-ament versus multifilament) and the chemi-cal composition of the suture material affect whether a contaminated wound will be-come infected.
13–15
Monofilament sutures withstand contamination better than multi-filament sutures. The number of sutures inthe wound also influences whether a con-taminated wound will become infected. Su-ture size and length should be minimized inany wound but particularly in a contami-nated wound.Because of their monofilament construc-tion, polydioxanone, polyglyconate, and
The Compendium 
February 1998Small Animal
RELATIVE KNOT SECURITY
I
PLIABILITY
I
CONTAMINATED WOUNDS
TABLE IIGuide for Selecting SutureSize for Small Animal Surgery
Tissue or UseRecommended Siz
Skin4-0 to 2-0Subcutaneous tissue4-0 to 3-0Muscle3-0 to 2-0Fascia3-0 to 0Viscera5-0 to 3-0Ligation of small vessels4-0 to 3-0Ligation of large vessels2-0 to 1Tension sutures2-0 to 1
Data from Grier RL: Surgical sutures—Part II: Indicationsfor different suture materials and comparable costs.
Iowa State Univ Vet 
34:89–92, 1972.
TABLE IIINumber of Throws Needed to Create a Secure Knot
Continuous Pattern Interrupted Suture MaterialPatter
StartEn
 Absorbable
Poliglecaprone 25Polydioxanone457Polyglactin 910336Polyglycolic acid335PolyglyconateSurgical gut345
Nonabsorbable
Nylon456PolyesterPolymerized caprolactumPolypropylene335SilkStainless steelN/
N/A 
For many suture materials, the number of throws needed to create a secureknot has not been established.
Not applicable: Stainless steel should not be used in a continuous suturepattern.

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