in Tensile Strength and Knot Security of Surgical Sutures in Vivo

John B. Herrmann, MD, Worcester, Mass

Changes

Changes in tensile strength and knot security of commonly used surgical suture materials during the postoperative period were evaluated by implanting sterile suture loops
in the subcutaneous tissue of rats and rabbits. Tensile strength testing after varying periods of implantation showed that of the materials studied, only Dacron maintained its initial knot security and tensile strength. Silk and cotton showed moderate loss of strength even in two weeks. Of the absorbable sutures, polyglycolic acid sutures were superior in tensile strength and markedly superior in knot security as compared to catgut. Both materials showed progressive loss of strength reaching minimal values at about three weeks.

breaking strength and knot security in the early postoperative period. The materials studied were those in most common use today, including the new synthetic absorbable suture, poly glycolic acid (PGA).
Methods

cross-sectional area. Cross-sectional area was calculated from the diameter of the suture measured with a precision microme

introduction of a variety of suture materials in recent years has given surgeons the opportu nity to select the most appropriate suture for each specific surgical ap plication. Thorough knowledge of the properties of the various suture mate rials available is essential in making these decisions. In a previous report1 the in vitro tensile strength and knot security of currently available mate rials has been presented. Perhaps of more importance to the surgeon and his patients are the changes that may occur in these important suture prop erties during the postoperative pe riod. The following experiments were designed to evaluate the changes in

The

new

Young adult Sprague-Dawley strain white rats and New Zealand strain white rabbits were used in the following experi ments. All animals were individually caged and fed a standard laboratory diet with water ad lib. Sterile sutures intended for general op erating room use were obtained commer cially. Sterile suture loops for implantation were prepared by tying the suture around an 8.2-mm diameter sterile glass rod using three squared throws on the knot. Suture loops were implanted subcutaneously in the abdominal wall of experimental ani mals through a small midline incision with use of ether anesthesia and aseptic oper technique. loops were carefully dis surrounding tissue and immediately placed in a Petri dish on a saline-soaked sponge to prevent drying. Testing was performed on a commercial recording tensiometer. Suture loops were placed individually over right-angle rods clamped in the jaws of the tensiometer
room

ter. Effective tensile strength is knot se curity level divided by cross-sectional area. Percent loss of tensile strength is calcu lated on the basis of preimplantation ten sile strength. The methods outlined above have been presented in detail in a previous publication.' Experiment 1.Suture loops of size 2-0 Dacron, silk, cotton, PGA, plain catgut,

and medium chromic catgut were im planted in each of 40 rats. Animals were killed in groups of ten at 3, 7, 10, and 14 days. Suture loops were tested as previ ously outlined. Experiment 2.Suture loops of sizes 0 and 3-0 PGA and medium chromic catgut from the two major manufacturers (a total of six loops in each animal) were implanted in 60 rats and ten rabbits. The rats were killed at 5, 10, 15, 20, 25, and 30 days. The rabbits were all killed at ten days. The su tures were tested as previously described.

ating

At sacrifice, the sected free from

Results

for publication Dec 1, 1972. Department of Surgery, Georgetown University School of Medicine, and the Surgical Service, Washington Veterans Administration Hospital, Washington, DC. Reprint requests to Department of Surgery, Worcester City Hospital, 26 Queen St, Worcester, Mass 01610 (Dr. Herrmann).
From the

Accepted

that were then distracted at a rate of 1.0 cm/min until disruption or knot slippage occurred. If the knot began to slip, the ten siometer was momentarily stopped, and a clamp applied to the "rabbit ears" beyond the knot to prevent further slipping. The breaking strength of the loop was defined as the maximum force applied to the loop at the point of disruption. Knot security level is defined as the force applied to the loop at the point of knot slippage or disrup tion (if slippage did not occur). Tensile strength is breaking strength divided by

strength of the suture loops following implantation are shown in Fig 1. Da cron retains its strength, but all other materials, including silk and cotton, show loss of strength over the twoweek period studied. Plain catgut had negligible strength by 14 days. The PGA sutures were superior in strength to chromic catgut at all in tervals studied and were equal in strength to comparably sized silk and cotton sutures at 14 days. Conversion of breaking strength values to actual tensile strength

Experiment 1.Changes in breaking

values based on cross-sectional area accentuated the differences noted above (Fig 2) because of the larger

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Size 2-0 Suture Loops Subcutaneous Implants

5-

Fig 1.Changes in knot pull breaking strength of size 2-0 suture loops over a twoweek period following subcutaneous im plantation in rats.

S
O

XL

Days
80E E

7 After

10

14

Implantation
Size 2-0 Suture
-

Loops

Subcutaneous Implants
Dacron

-Silk
.

:60
<1)
C

to

Chromic Catgut PGA

-Plain

Catgut
Fig 2.Changes in tensile strength (breaking strength divided by cross-sec tional area).

-Cotton

5 40(
c

1 SE

20O)

10

Days After Implantation

Size 2-0 Suture Loops Subcutaneous Implants
-

Dacron Silk
Chromic PGA Plain

Catgut
Fig 3.Effect of failure level. implantation
on

Catgut

knot

Cotton

1 SE

10

Days After Implantation

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Size O -PGA -Chromic Catgut A -Chromic Catgut

Size 3-0 PGA --Chromic -Chromic

Catgut Catgut

10

Days

20 15 After Implantation

25

10

15

20

25

Days After Implantation

7

Fig 4.Comparison of breaking strength of two samples of chromic catgut and PGA sutures after implantation. Left, Size 0 ma terial; right, size 3-0 material.

D
K//d
10

Rat

Rabbit

Days

I
zi
Fig 5.Comparison of breaking strength of two samples of chromic catgut and PGA sutures (sizes 0 and 3-0) in the rat and rab > .05. bit at 10 days. Asterisk denotes
diameter of catgut. Determination of knot security level (Fig 3) showed that Dacron, silk, cotton, and PGA sutures retained ex cellent knot security with three squared throws on the knot following implantation. Plain and chromic cat gut, on the other hand, showed a marked loss of knot security even at three days. Experiment 2.This experiment was performed to extend the period of ob servation for the absorbable suture materials, to compare different sizes of these materials, to compare chro mic catgut from the two major manu facturers, and to extend observations into
a

IE
Catgut
Chromic A PGA

Li
Catgut A
Chromic
PGA

Catgut

Chromic

Chromic

Catgut

Size 0

Size 3-0

species. The results of loop breaking strength determina tions in the rat up to 30 days are shown in Fig 4. The PGA sutures re tain their strength superiority over comparable sizes of chromic catgut during the first 20 days. Polyglycolic
different

acid sutures appear to have a pre dictable rate of strength loss re gardless of size with an end point of about 25 days. Chromic catgut loses strength more rapidly in the early pe riod with the end point decreasing with smaller sizes of the suture. No significant difference was noted be tween the two sources of chromic cat gut used in this study.

No significant differences were noted in the loss of strength of chro mic catgut in the rat as compared to the rabbit at ten days. A slight, but significant, increased strength loss was noted for PGA in the rabbit as compared to the rat both in the 0 and 3-0 sizes (Fig 5).
Comment
to maintain

The purpose of

until the healing process has pro gressed to the point where artificial support is no longer necessary for the wound to resist normal stresses. Be yond this point, sutures serve no use-

a surgical suture is approximation of tissues

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ful purpose and may, in fact, be the source of irritation or serve as a nidus for persistent infection. Thus, the ideal suture should persist and main tain tensile strength until the tissue has healed sufficiently, and then dis appear. Unfortunately, requirements of various tissues differ widely from a few days (muscle, skin, and subcuta neous tissue), weeks to months (fascia and tendon), to indefinite periods (vascular prostheses). No one suture will therefore be able to meet the cri teria for an "all-purpose" material even from this narrow point of view. Until recently, catgutboth plain and chromicizedhas been the only truly absorbable material available. It is made from collagen obtained from the intestinal submucosa of sheep and cattle. Although portions of the suture, particularly the knots, may become encapsulated and persist for long periods of time, the suture is generally broken down by proteolytic tissue enzymes and absorbed. This process may take six months or longer. Loss of strength occurs much more rapidly, however. The process of catgut absorption is accompanied by an inflammatory reaction that has been noted by many investigators.2 ' ' Another truly absorbable suture is now available. This material, poly glycolic acid, is a synthetic polyester polymerized from glycolic (hydroxyacetic) acid and is available as a braided suture. This material is ab sorbed by simple hydrolysis in 60 to 90 days without the inflammatory re action evoked by catgut. A distinction must be made be tween the rate of absorption of a su ture material and the rate of tensile strength loss of that material. The terms are not interchangeable. Al though the rate of absorption is of some importance with regard to late suture complications such as sinus tracts and granulomas, the rate of tensile strength loss is of much greater importance to the surgeon considering the primary function of a

suture-maintaining tissue approxi mation during healing.

tained from the two

turers.
ences were

study, only
material

Of the materials evaluated in this the synthetic polyester

Dacron retained tensile
even

major manufac Similarly, only minor differ

noted in the two different

during the relative short span of the experiment. Both silk and cotton, generally referred to

strength
as

experimental animals used in the present study. It is therefore unlikely

have been observed histologically. Nylon has also been reported to lose strength after prolonged implanta tion.4 In the clinical setting a disturb ing incidence of anastomotic false an eurysms has been noted following insertion of vascular prostheses using silk suture material. This has been at tributed to suture failure, and the re sults presented above would support this concept. It is apparent, therefore, that only permanent materials, such as Dacron, should be used for such ap

"nonabsorbable" materials lost strength during the initial two weeks of implantation (cotton, 40%; silk, 30%). This has been reported by other authors.4 Over longer intervals, actual fragmentation and loss of substance

that either the source of the material or the experimental animal accounts for the wide variation reported. The difference in experimental method re mains the most likely source of the difference. It is interesting that the in vivo human studies of Haxton*1 tend to support the lower range for chromic catgut (8 to 14 days). Of perhaps more significance is the marked loss of knot security exhib ited by both plain and chromic catgut in the presence of body fluids. This phenomenon was not evident in the other materials studied. Since all su tures are tied in clinical practice, maintenance of tissue approximation is dependent not only on suture strength but on knot security as well.

Considerable controversy has arisen regarding the rate of tensile strength loss of absorbable sutures. This has become of particular interest since the introduction of the syn thetic PGA suture to challenge cat gut, the traditional absorbable mate rial. The rapid loss of strength of plain catgut is well-known and con firmed by the present study. Previ ously published studies comparing chromic catgut and PGA sutures have shown that PGA loses most of its strength by 14 to 21 days. Results with chromic catgut have ranged from 14 days25 to two months.3 This disparity was one of the factors that
the present investigation. Our current study would indicate that chromic catgut has about the same period of strength retention as PGA. Although the source of catgut used in the previous studies was not speci fied, we were unable to detect any significant differences in material ob-

plications.

This investigation was supported Administration Research Funds.

by

Veterans

Trade Names of

Nonproprietary
acidDexon.

and

Drug

Polyglycolic

References
1. Herrmann JB: Tensile strength and knot security of surgical suture materials. Am Surg 37:209-217, 1971. 2. Herrmann JB, Kelly RJ, Higgins GA: Polyglycolic acid sutures: Laboratory and clinical evaluation of a new absorbable suture material. Arch Surg 100:486-490,1970. 3. Postlethwait RW: Polyglycolic acid surgical suture. Arch Surg 101:489-494, 1970. 4. Postlethwait RW, et al: Wound healing: II. An evaluation of surgical suture material. Surg Gynecol Obstet 108:555-566, 1959. 5. Katz AR, Turner RJ: Evaluation of tensile and absorption properties of polyglycolic acid sutures. Surg Gynecol Obstet

prompted

131:701-716,

tol, England, John Wright & Sons Ltd, 1970, p 65.

1970. 6. Haxton H: Surgical

Techniques. Bris-

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