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Inflammatory synovial fluid and absorbable suture strength.

The effect of inflammatory synovial fluid upon several absorbable sutures commonly used for meniscus repair was studied by implanting lengths of these sutures into unstable, arthritic rabbit knees and, after varying lengths of time (1-6 weeks), testing their breaking strength. Both polyglactin-910 (Vicryl) and polyglycolic-acid (Dexon) sutures retained only minimal breaking strength 3 weeks after implantation. Chromic gut sutures demonstrated a steady reduction in breaking strength until they retained only 6% of their original strength at 5 weeks and none at 6 weeks. Polydioxanone (PDS) sutures began to lose breaking strength at 2 weeks and retained only 40% of their original strength 5 weeks after implantation. The rate of loss in polydioxanone breaking strength was faster in inflammatory synovial fluid than previously reported in the normal synovial joint. Braided polyester sutures (Mersiline) showed no loss of breaking strength over the duration of this test. While the choice of suture is only one variable influencing the outcome of a meniscus repair, this study demonstrates that only polydioxanone and green braided polyester sutures retain any strength 6 weeks after implantation (the time of immobilization commonly recommended for meniscal repairs). Complete meniscal healing can require several months. In the absence of compelling evidence to the contrary, the use of nonabsorbable suture materials for meniscal repair seems the most appropriate choice.

Absorption↗

Computerized topography of selective versus all-suture release to manage high astigmatism after cataract surgery.

PURPOSE: To compare the efficacy of selective suture release (SSR) with all-suture release (ASR) in controlling corneal astigmatism after cataract surgery. SETTING: Sight Saver's Cornea Training Centre, L.V. Prasad Eye Institute, Hyderabad, India. METHODS: This prospective, randomized study evaluated the effect on astigmatism of two techniques of suture release in 30 patients with more than 3.00 diopters (D) of corneal astigmatism after cataract surgery. All patients had interrupted sutures with well-healed wounds. Fifteen patients had ASR irrespective of the location of the steep meridian. In the other 15, only the suture located in the steep meridian was selectively released. The pattern of decay of astigmatism after suture release was studied using computerized videokeratography. RESULTS: Mean pretreatment corneal cylinder was 6.30 D +/- 2.72 (SD) in the ASR group and 6.95 +/- 1.67 D in the SSR group. In the ASR group, corneal cylinder dropped to 3.70 +/- 1.15 D immediately after suture release and further decreased to 1.82 +/- 0.66 D at 1 week (P < .001). In the SSR group, astigmatism swung erratically to the adjoining sutures and decreased unpredictably at an average of 1.32 +/- 2.00 D with each suture release. CONCLUSION: The ASR technique was more predictable and less cumbersome than the SSR method.

Aged↗

Complement activation by vascular sutures both alone and in combination with synthetic vascular prostheses.

Polymer surfaces activate complement pathways resulting in platelet and leucocyte deposition as well as possible release of growth factors. A consequence of these interactions may be early graft failure or intimal hyperplasia leading to late graft failure. C5a generation in human plasma by vascular sutures, both alone and in combination with synthetic vascular prostheses was measured by radioimmunoassay to determine the influence of suture materials on C5a activation. Prolene and ePTFE suture material caused significant activation of C5a (p less than 0.01), while Novafil did not. Both Dacron and ePTFE graft material caused significant activation (p less than 0.01) of C5a. The addition of the suture materials to the ePTFE did not increase the C5a levels above the ePTFE material alone. In contrast, the addition of either Prolene or Novafil suture to Dacron material elevated C5a levels significantly over Dacron alone (p less than 0.01). The combination of Dacron material with ePTFE suture did not increase C5a levels over Dacron alone. The pattern of C5a activation by Prolene, ePTFE and Novafil sutures parallels the relative degree of in-vivo platelet accumulation on these suture materials as previously reported by our group. Since these experiments demonstrate that vascular suture material influences human complement activation, it may be that this interaction contributes to either early or late graft failure by enhancing platelet reactivity or neointimal proliferation, respectively.

Blood Vessel Prosthesis↗

A simple suture shuttle in rotator cuff repairs: a technical note.

In rotator cuff repairs, it is often necessary to pass 2 tails of 2 sutures through 1 transosseous hole to maximize the number of sutures per hole. We report on a simple technique with a double-loop suture thread that allows the passing of more than 1 suture limb through the same hole. This simple device, the simple suture shuttle, used in cuff repairs in combination with the modified Mason-Allen suture technique, significantly reduces the difficulty of passing more than 1 suture tail through a single bone tunnel. By reducing the number of bone tunnels, the weakening of a bone that might not be very strong is kept to a minimum. The Simple Suture Shuttle can also be used to pass more sutures through a given number of transosseous holes.

Humans↗

Species-dependent premature degradation of absorbable suture materials caused by infection--impact on the choice of thread in vascular surgery.

BACKGROUND: In case of infection after vascular reconstruction, preference is often given to absorbable suture material with the aim of preventing persistence of infection. We have investigated the functional deficit of absorbable sutures on incubation with various different bacteria. MATERIAL AND METHODS: Four suture materials Dexon bicolor, Vicryl, Maxon and PDS II--were placed in contact with reference bacterial cultures (Staphylococcus aureus, Pseudomonas aeroginosa, E. coli, coagulase-negative staphylococci and Proteus mirabilis). The bacteria were incubated for 7 days at 37 degrees C, together with the suture material. A logarithmic phase (Group A) and a static phase (Group B) were simulated. The linear tensile strength (LTS) of the suture material was measured (Instron Tensiometer). RESULTS: In the case of Staphylococcus aureus, a significant decrease in LTS was established for Dexon bicolor (group A: 31%, group B: 22%), and Vicryl (53% and 43%), but not for the monofilament threads. With regard to the other bacteria, a considerably more dramatic effect was observed: in both groups the braided sutures had completely disintegrated after 7 days. The monofilament sutures also revealed a significant loss of function (Maxon: 88%, PDS II 66%). CONCLUSIONS: The absorbable sutures revealed a premature, species-dependent loss of function due to the presence of the bacteria. On the basis of our results, the use of absorbable threads for vessel sutures in case of infection cannot be recommended, with the exception of monofilament material in a monocultural Staphylococcus aureus infection.

Absorbable Implants↗

Effects of suture tension and surgical approach during unilateral arytenoid lateralization on the rima glottidis in the canine larynx.

OBJECTIVES: To evaluate the effect of abduction suture tension and cricothyroid (CT) joint disarticulation on the area, height, and width of the rima glottidis (RG) during unilateral arytenoid lateralization. STUDY DESIGN: Experimental study. ANIMALS: Nine canine cadaver larynges. METHODS: Left arytenoid lateralization was performed with high or low abduction suture tension. RG area, height, and width were measured by computerized planimetric analysis with the epiglottis in an open and closed position. The experiment was performed with the CT joint intact and disarticulated. The effects of suture tension, CT disarticulation, and their interaction on RG area with the epiglottis closed or open were evaluated by repeated measures analysis of variance (ANOVA). RESULTS: RG area increased by 82% and 129% (P <.0001) with low and high suture tension, respectively. The aperture not covered by the epiglottis in a closed position was 467% larger with high suture tension than with low tension (P <.0001). CT disarticulation had no significant effect on RG geometry with either low or high suture tension (P =.4970). CONCLUSIONS: Low suture tension increased RG area when the epiglottis was in an open position without increasing RG aperture when the epiglottis was closed. Suture tension had a significant effect on RG opening when the epiglottis was closed. CT disarticulation did not modify the geometry of the RG. CLINICAL RELEVANCE: Use of a low-suture tension should be considered during arytenoid lateralization because it has the potential to reduce the risk of aspiration pneumonia.

Animals↗

A through-the-scope device for suturing and tissue approximation under EUS control.

BACKGROUND: The ability to place sutures under EUS control might allow development of a new type of transluminal endosurgery. The aim of this study was to develop endoscopic methods for suturing to variable predetermined depths in the wall of the GI tract and to allow fixation of adjacent hollow organs under EUS control. METHODS: A suturing device was constructed for suturing under EUS control to any desired depth. Sutures can also be placed into hollow or solid organs within 5 cm of the endoscope tip. The device allows multiple sutures to be placed without withdrawing the endoscope. Stitching, knot-tying, and thread-cutting are achieved through a 2.8-mm accessory channel. RESULTS: Multiple (>100) sutures were placed in predetermined gut wall layers in pigs. Sutures were placed in the gallbladder (n = 7) and small intestine (n = 8) to fix the gallbladder/small intestine to the stomach and allow traction for the insertion of stents and other devices through the 2 lumens. CONCLUSION: A new method for stitching under flexible EUS control is described. This technology was used to place sutures at precise depths in the GI tract. It allowed fixation of other organs to the accessible GI tract for various purposes including delivery of stents and devices for creating anastomoses.

Animals↗

Polypropylene suture stresses after closure of longitudinal arteriotomy.

This study was performed (1) to determine the load on polypropylene (Prolene) sutures when used to close a longitudinal carotid arteriotomy and (2) to compare that load with the tensile strength of the suture material. Laboratory methods were used to determine the stress caused by pressure, the surgeon's knot, and that resulting from longitudinal extension of the sutured vessel. Results showed that the stress from the surgeon's knot accounts for more than 95% of total load on the suture, the remainder resulting from pressure and geometry. At 100 mm Hg in a 10 mm carotid artery at in situ length, 5-0 Prolene suture is loaded to 22%, 6-0 to 32%, and 7-0 to 42% of their respective breaking stresses. When the cervical spine is hyperextended, the carotid artery is stretched up to 6%. When the sutured pressurized vessel is extended 6%, 5-0 Prolene suture is loaded to 51%, 6-0 to 52%, and 7-0 to 75% of breaking stresses. These data suggest that 5-0 and 6-0 Prolene sutures should be used in preference to 7-0 sutures to close a carotid arteriotomy.

Animals↗

Initial evaluation of absorbable polydioxanone suture for peripheral vascular surgery.

The long-term integrity of an autogenous vascular anastomosis is primarily dependent on the strength of tissue healing; therefore permanent mechanical support of an autogenous anastomosis with sutures is unnecessary. In this study we evaluated monofilament absorbable polydioxanone as an alternative to polypropylene for suturing autogenous vascular tissue during adult peripheral vascular operations. We used polydioxanone suture for 21 vascular procedures in 20 patients. We evaluated suture handling characteristics during operation and then followed patients with clinical assessments and serial duplex scans to monitor for pseudoaneurysms, anastomotic narrowing, and vessel patency. Indications for surgery included limb salvage (67%), dialysis access (23%), traumatic arteriovenous fistula and claudication (5% each). The operative procedures included infrainguinal bypass (57%), arteriovenous fistula formation (24%), thromboembolectomy (14%), and arteriovenous fistula repair (5%). Polydioxanone sutures were placed in 39 separate test sites (35 arterial, 4 venous). No deaths occurred during operation. Polydioxanone suture was found to have handling characteristics similar to polypropylene. During mean patient follow-up of 7.2 +/- 0.6 months, we found no cases of anastomotic narrowing or pseudoaneurysms. Actuarial test site patency at 1, 3, and 6 months was 97%, 97%, and 86%, respectively. Polydioxanone suture has handling properties that are acceptable for use in vascular applications, and it provides adequate mechanical support for sutured vessels to heal. A randomized trial comparing polydioxanone with polypropylene suture will be necessary to determine whether the lack of permanent foreign material in vascular anastomoses can improve long-term patency.

Anastomosis, Surgical↗

Geometry of laparoscopic suturing and knotting techniques.

BACKGROUND: Spatial limitation, together with a fixed trocar position, restricted handling, and movement of the instruments, is inevitably associated with reconstructive laparoscopy and retroperitoneoscopy. This problem includes not only suturing technique and instruments but also geometric factors of endoscopic reconstruction, such as optimal distances between the working trocars, length of instruments, and angles between the instruments and the object. We present an experimental access to determine the specific impact of these factors on reconstructive laparoscopy. MATERIALS AND METHODS: In an in vitro model, end-to-end anastomoses of porcine intestine were performed using a standardized intracorporeal suturing technique. Suturing was performed without and after training in reconstructive surgery with variation of the following geometric factors: (1) the distance between the working trocars (between 6 and 12 cm); (2) the position of the object (lateral right, medially, lateral left); (3) the camera position (medially, lateral right, lateral left); (4) the angle between the instruments and a horizontal line (15 degrees , 55 degrees, 90 degrees); (5) the intracorporeal length of instruments (between 10 and 25 cm); and (6) narrowed space available for the instruments (between 4 and 25 cm). RESULTS: Continual training decreased the time required for suturing between 30% to 50%. Training decreased the time required for nonsuturing activities between 50% and 70% but the time required for suturing activities only between 20% and 45%. If the space between instruments and camera was limited, shifting the camera into a lateral position simplified the procedure of intracorporeal suturing. Angles of <55 degrees between instruments and the horizontal line simplified laparoscopic suturing, as did angles of <45 degrees between the instruments. In cases of maximally narrowed space (diameter of 4 cm), a suture filament length of <10 cm decreased the time required by 30%. CONCLUSION: We suggest an isosceles triangle between the instruments with an angle between 25 degrees and 45 degrees and an angle of <55 degrees between the instruments and the horizontal line as the optimal geometry for intracorporeal suturing. These data should be considered when planning a reconstructive laparoscopic procedure (i.e., alignment of trocars, table position). However, further studies are required to confirm these preliminary results.

Anastomosis, Surgical↗

A comparison of the effect of pH on the biodegradation of two synthetic absorbable sutures.

The differences in hydrolytic degradation of two size 2-0 synthetic absorbable sutures, Polyglycolic acid (Dexon) and Poly(glycolide-lactide) (Vicryl), in the buffer media of three different pH levels ranging from 5.25 to 10.09, were compared in terms of the percentage retention of tensile strength. It was found that Vicryl sutures, in general, exhibited better retention of tensile strength than Dexon sutures within the studied pH range and extent of hydrolysis. When comparing Vicryl with Dexon sutures, the former was only slightly better than Dexon sutures, in the case of an acid environment. The former, however, retained better strength than the latter in a physiological pH (7.44) and under high-alkaline conditions (10.09). Among the three pH levels tested, Vicryl sutures retained the highest tensile strength in a physiological pH and showed a faster loss of tensile strength in both acidic and high-alkaline conditions. Dexon sutures, however, exhibited better retention of tensile strength in the acidic medium than in an alkaline medium. This pH dependent hydrolysis of Dexon and Vicryl sutures should command surgeons' attention in their selection of synthetic absorbable suture materials for particular needs.

Biodegradation, Environmental↗

Frontal bone advancement and compensatory craniofacial growth changes in rabbits with experimental coronal suture immobilization.

Recent clinical advances in the surgical correction of coronal suture synostosis involve the overcorrection of a frontal bone segment to allow for unrestricted expansion of the developing neurocapsular matrix. However, the effects of such large-scale calvarial repositioning on subsequent brain mass growth trajectories and compensatory cranio-facial growth changes is unclear. This study was designed to investigate this relationship in an experimental rabbit model of bilateral coronal suture synostosis. Amalgam markers were placed across the frontonasal, coronal, and anterior lambdoid sutures in thirty-one 1.5-week-old rabbits. Twenty-one animals underwent bilateral coronal suture immobilization using methyl-methacrylate. Ten animals were left untreated and served as sham controls. At 6 weeks of age, the coronal suture was released by frontal bone craniotomy or frontal bone craniotomy with a 6-mm frontal bone advancement. Lateral head radiographs were taken at 1.5, 6, 7, 9, 12, and 18 weeks of age. Results revealed that by 6 weeks of age, animals with coronal suture immobilization exhibited growth disturbances across the various sutures resulting in altered craniofacial and cranial vault shape compared to control animals. Following coronal suture release, animals that underwent craniotomy showed rapid restenosis, which resulted in significantly altered cranial vault shape and cranial orthocephalization by 18 weeks of age. Animals that underwent frontal bone advancement exhibited normal overall craniofacial growth by 18 weeks of age compared with control animals but did exhibit regional compensatory growth disturbances at the frontonasal and anterior lambdoid sutures, possibly related to neural tissue distension.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of Variance↗

In the absence of periosteum, transplanted fetal and neonatal rat coronal sutures resist osseous obliteration.

Normal craniofacial development depends on expansion of the cranial vault by growth at the sutures. Inappropriate development of the sutures leads to global disruption of patterns of craniofacial growth. Tissue interactions between dura mater and suture matrix play a critical role in the phenotypic maintenance of cranial sutures. However, the function of the periosteum in this process remains under-reported and controversial. To examine the contribution of periosteum in maintaining the patency of coronal sutures, fetal and neonatal rat coronal sutures were transplanted to surgically created defects in adult rat host parietal bones. These sutures were examined for their ability to persist in the host milieu in the presence and absence of both donor and host periosteum. This study established that removal of both host and transplant periosteum, unlike removal of dura mater, did not lead to obliteration of either fetal or neonatal sutures. Thus, periosteum and dura mater are nonequivalent tissues with respect to influence on suture patency.

Animals↗

Extrinsic tension results in FGF-2 release, membrane permeability change, and intracellular Ca++ increase in immature cranial sutures.

There are numerous studies cataloging the temporal profiles of the various growth factors during the morphogenesis of cranial sutures. There are also many clearly documented mutations of the receptors of some of these growth factors such as fibroblast growth factor (FGF)R-2 and FGFR-3 in clinical craniosynostosis. It is obvious, and often concluded, that growth factors play a role or are involved in craniofacial development. However, precisely what that role is, what causes the changes in the growth factor levels, and why these changes occur in the particular temporal and spatial patterns observed remains elusive. Using simple physics, we applied a plasma membrane disruption model and the principles of complex adaptive systems to arrive at a conjecture of calvarial morphogenesis. The purpose of this article is to introduce the concept of complex adaptive systems, to propose our conjecture, and to provide experimental proof of some key steps in this conjecture: tension induces rapid and demonstrable physiological responses in some cells within the immature cranial sutures. These responses include increases of intracellular Ca++, plasma membrane permeability, and the release of growth factors, e.g., FGF-2. Paired coronal sutures from 1-week-old Sprague-Dawley rat pups were subjected to either 0.59 N of tensile force or no force for 5 minutes in a protein-free medium. FGF-2 levels in the media were measured by slot blot analysis. Western blot analysis was used to determine FGF-2 levels in the sutures. To determine cell membrane permeability changes, fluorescein-conjugated dextran, with a molecular weight of 10 kd, was added to the media during the 5 minutes with or without tensile force. Laser confocal microscopy was used to compare the amount of entry of this impermeant tracer and the pattern of permeability change at the tissue level. To determine the intracellular pCa++, the sutures were first loaded with a calcium indictor, FURA-2 AM, and then subjected isotonically to 0.059 N of tension. The intracellular pCa++ was expressed as ratio of Ca++-bound FURA-2 to Ca++-free FURA-2. The experimental findings were as follows: 1) Sutures, in response to tension, release FGF-2. 2) Sutures contain higher levels of FGF-2 when strained. 3) There is an increase in the sutural cell membrane permeability as a result of tensile strain. 4) The cells along the leading edges of the ossification fronts (at the insertion sites of Sharpey's fibers) demonstrated the maximum permeability increase. 5) There was an immediate (within seconds) increase in intracellular Ca++. and 6) This increase in intracellular Ca++ caused by tension was reversible and independent of the extracellular Ca++ ion availability. In summary, these data support, in part, the conjecture that growth of the brain places strain on the cells within the immature sutures, which causes the iteration of a set of cellular subroutines. These subroutines integrate to generate the emergent property of directed cranial expansion with dissipation of the initiating strains.

Adaptation, Physiological↗

Study of corneal topographic patterns with single continuous suturing techniques in penetrating keratoplasty.

PURPOSE: To study the corneal topographic patterns following three different types of single continuous suturing techniques in penetrating keratoplasty. METHODS: One hundred forty-eight maps obtained from 40 patients who underwent penetrating keratoplasty with single continuous suturing were retrospectively analyzed at a tertiary eye care center. The videokeratograph maps were obtained on the Eye Sys System 2000 at 1, 3, and 6 months after surgery. Suture adjustment was done for cases with astigmatism greater than 3 diopters, and maps were also obtained after suture adjustment. The maps were classified according to the corneal profile and the astigmatic pattern seen in the topographic maps. RESULTS: Combined prolate patterns were seen most frequently, and their proportion was significantly higher at 1 month ( p= 0.009), 3 months ( p= 0.0004), and 6 months ( p= 0.0008). The simulated keratometric astigmatism was significantly higher in the prolate group compared with the other groups at 1 month ( p= 0.0021). However, all the topographic patterns showed comparable magnitude of astigmatism after suture adjustment and at 3 and 6 months. The antitorque suturing technique showed a higher proportion of prolate maps compared with the other suturing techniques. CONCLUSIONS: Prolate patterns of the cornea are the most frequently seen patterns after single continuous suturing, which is the normal physiological pattern of the cornea. The initial astigmatism is higher in the prolate pattern, which can be successfully reduced with suture adjustment.

Astigmatism↗

Continuous versus interrupted suturing of traumatic lacerations: a time, cost, and complication rate comparison.

BACKGROUND: The most frequently used techniques in the repair of traumatic lacerations are interrupted and continuous suturing. METHODS: We performed a prospective study of interrupted and continuous suturing techniques evaluating suturing rates, suture economy, and complication rates in the repair of 101 traumatic lacerations. RESULTS: Continuous closure was accomplished at a statistically faster rate (mean, 0.276 cm/min) than interrupted closure (mean, 0.175 cm/min; p = 0.004). Less suture material was used in the continuous closures (0.321 suture packets/cm) than in interrupted closures (0.508 suture packets/cm; p = 0.03). No statistically significant difference existed in the complication rate between the two closure methods (continuous, 1 of 44; interrupted, 1 of 57; p = 0.59). CONCLUSION: Although suturing technique should be selected primarily on the basis of wound characteristics and surgeon preference, continuous suturing warrants consideration for the closure of traumatic lacerations because of its time/material economy and the lack increased complication rates.

Cost-Benefit Analysis↗

Comparison of suture and nasal packing in rabbit noses.

OBJECTIVES/HYPOTHESIS: The study aimed to detect the changes in adult rabbit nasal septal tissues after application of nasal pack or trans-septal suture as performed during septoplasty. STUDY DESIGN: Randomized double-blind animal study. METHODS: Thirty-three adult albino Vienna rabbits were assigned into the following groups: control, suture, and nasal pack. The mucoperichondrium at one side of the nasal septum was elevated and then put into place again over the cartilage and fixed with either a nasal pack or an absorbable trans-septal suture. The nasal packs were removed 48 hours after insertion. Rabbits were killed 6 weeks after the procedure. The nasal septa were stained with hematoxylin and eosin and examined by means of light microscopy for mucosal changes (inflammation or damage) and for thicknesses of the mucosa, the perichondrium, and the cartilage. RESULTS: Both intranasal packs and sutures caused significant mucosal inflammation and damage when compared with the control group (chi test, P <.05). The mucosal thickness did not change, but the perichondrial thickness for both the nasal pack group and the suture group increased (Mann-Whitney U test, P <.05). Also, the septal cartilage thickness was not significantly different between the suture and the nasal pack groups, but the suture group had a thinner septal cartilage than the control group (Mann-Whitney U test, P <.05). CONCLUSION: The septal suture is an efficient and useful method for clinching the septal flaps over the septal cartilage. In addition, it has nearly the same effects as nasal packs on the histological appearance of the nasal septum and does not cause discomfort for the patient. The septal suture can be a preferred alternative to intranasal packing.

Animals↗

Impairment of motor recovery after late nerve suture: experimental study in the rabbit. Part 2: morphological findings.

To study motor recovery after increasingly late nerve suture, we severed 75 rabbit peroneal nerves and reanastomosed them by microsurgical epineural technique after a delay of up to 12 months. Functional, electromyographic, and morphological parameters were used to evaluate the quality of motor function 6 months after suture. This second part of the study deals with the results of the morphological examinations (nerve, motor end-plate, and muscle). In examining the histological picture of the peroneal nerve, individual variations in its neurotization distal to the suture were more obvious than were variations with increasing presuture denervation periods. Histological and histochemical changes within the muscle increased significantly with later nerve suture. Important alterations at the motor end-plate were observed in the very late suture group. From the findings of both parts of the present study, the following conclusions can be drawn. The normal anatomical (histochemical) picture of the muscle is not restored after a nerve suture, not even after primary suture. The important degenerative muscular changes after very late nerve suture are not due to alterations within the nerve alone; structural changes in the motor end-plates and muscle fibers are equally important. These findings seem to be relevant when discussing the indication for nerve suture in patients with a long-standing nerve injury.

Animals↗