Physical and functional comparison of Coated VICRYL* Plus Antibacterial Suture (coated polyglactin 910 suture with triclosan) with Coated VICRYL* Suture (coated polyglactin 910 suture)

Update on Suture Techniques in Corneal Transplantation: A Systematic Review

Effective suturing remains key to achieving successful outcomes in corneal surgery, especially anterior lamellar keratoplasty and full thickness transplantation. Limitations in the technique may result in complications such as wound leak, infection, or high astigmatism post corneal graft. By using a systematic approach, this study reviews articles and conducts content analysis based on update 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria). The aim of this paper is to summarize the state of the art of corneal suturing techniques for every type of corneal transplant and patient age and also their outcomes regarding astigmatism and complications. Future developments for corneal transplantation will be also discussed. This is important because especially the young surgeon must have knowledge of the implications of every suture performed in order to achieve consistent and predictable post-operative outcomes and also be aware of all the possible complications.

Mechanical properties of Triclosan sutures

To avoid infections and wound healing disorders, Triclosan coated sutures have been invented. Little is known of these sutures regarding their tensile properties. Three different Triclosan coated sutures (Vicryl 1 plus, PDS 0 plus, Monocryl 3-0 plus) were tested at several time points over 42 days regarding load to failure, strain, and stiffness compared to their non-coated versions (Vicryl 1, PDS 0, Monocryl 3-0). Four different measurement points were made. Suture loops were fixed in a material testing machine over two metal bars which were moved apart creating a stress to the fiber. Unpaired, two-tailed t-test were performed for each group (untreated and treated) while level of significance was defined at a level of p < 0.05. Vicryl 1 was significantly stronger on day 14 than Vicryl 1 plus (p = 0.033). On day 28, significant changes were found in PDS 0 which was weaker compared to PDS 0 plus (p = 0.039) and Vicryl 1 which was stronger than Vicryl 1 plus (p = 0.032). We have seen that Vicryl 1 plus sutures are significantly weaker according to loading to failure after 14 and 28 days, which might cause incisional hernias. PDS 0 sutures are used to reconstruct tendons, therefore a longer durableness might be of interest as re-ruptures of tendons are problematic. Our in vitro findings support, the use of Triclosan coated PDS plus sutures and Vicryl sutures as they show a longer resistance. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1777-1782, 2018.

Non-incisional eyelid everting suture technique for treating lower lid epiblepharon

Background

This study investigated surgical outcomes of full-thickness eyelid everting sutures for lower lid epiblepharon and influential factors leading to surgical failure.

Methods

A retrospective review was conducted of patients with lower lid epiblepharon who underwent surgical correction using the full-thickness eyelid everting suture technique. Lower lid epiblepharon was assessed preoperatively using a morphological classification (class I–IV) according to the horizontal skin fold height and a functional classification (grade 0–3) according to the severity of keratopathy. Four stitches with 5-0 coated polyglactin 910 sutures per eyelid were made, and all procedures were conducted under local anaesthesia in an office-based setting. To assess surgical outcomes, we evaluated undercorrection at 1 month and surgical failure at 6 months after the procedure. Several factors affecting surgical failure were also investigated

Results

Sixty-eight eyes of 41 patients were included. There were no eyes showing an undercorrection at 1 month. Keratopathy was significantly improved at 6 months postoperation (P<0.01). All patients showed good cosmesis without undesired creation of a lower lid crease and no significant complications. Sixty-one eyes (89.7%) showed surgical success. Three patients (7.3%) required additional incisional surgery due to recurring irritation. The rate of surgical failure was significantly different between the patient groups classified by preoperative severity of keratopathy (P=0.026) and lower lid horizontal skin fold height (P<0.001). Multiple logistic regression analysis revealed that the lower lid horizontal skin fold height was significantly correlated with surgical failure (OR 18.367, P=0.002).

Conclusion

Non-incisional eyelid everting sutures have utility for the correction of lower lid epiblepharon with advantages including its simplicity, being performed in office under local anaesthesia and minimal changes in appearance. We suggest mild to moderate epiblepharon with class I or II horizontal skin fold height and grade 1 or 2 keratopathy as the criteria for considering this suture procedure.

Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures

BACKGROUND

Despite several randomized trials, systematic reviews and meta-analyses that have demonstrated the effectiveness of antimicrobial (triclosan-coated or -impregnated) sutures (TCS), the clinical and economic impact of using these sutures compared with conventional non-antimicrobial-coated absorbable sutures (NCS) remains poorly documented.

METHODS

An independent systematic review and meta-analysis of all published evidence from January 2005 to September 2016 comparing TCS with NCS was conducted. Surgical-site infection (SSI) was the primary outcome. The results of the meta-analysis were used in a decision-tree deterministic and stochastic cost model, using the National Health Service (NHS England)-based cost of inpatient admissions for infections and differential costs of TCS versus NCS.

RESULTS

Thirty-four studies were included in the final assessment from an initial 163 identified citations; 20 of 34 studies were randomized, and 17 of 34 reported blinding of physicians and assessors. Using a random-effects model, the odds ratio for SSI in the TCS compared with NCS control groups was statistically significant (odds ratio 0·61, 95 per cent c.i. 0·52 to 0·73; P < 0·001). There was significant heterogeneity (I² = 49 per cent). Using random-effects event estimates of SSI for TCS and NCS for each individual wound type, the mean savings per surgical procedure from using antimicrobial sutures were significant: £91·25 (90 per cent c.i. 49·62 to 142·76) (€105·09 (57·15 to 164·41); exchange rate 15 November 2016) across all wound types.

CONCLUSION

The reviewed literature suggested that antimicrobial sutures may result in significant savings across various surgical wound types.

Biomechanical Outcomes of Bridge-enhanced Anterior Cruciate Ligament Repair Are Influenced by Sex in a Preclinical Model

BACKGROUND

Despite the well-established role of sex on the anterior cruciate ligament (ACL) injury risk, its effects on ACL surgical outcomes remain controversial. This is particularly critical when developing novel surgical techniques to treat the injury because there are limited data existing on how these procedures will respond in each sex. One such approach is bridge-enhanced ACL repair, in which primary suture repair of the ACL is augmented with a bioactive scaffold saturated with autologous blood. It has shown comparable biomechanical outcomes to ACL reconstruction in preclinical models.

QUESTIONS/PURPOSES

We asked (1) whether sex affects the biomechanical outcomes of bridge-enhanced ACL repair; and (2) if suture type (absorbable or nonabsorbable), used to repair the torn ACL, can minimize the potential sex discrepancies in outcomes after 15 weeks of healing in a large animal preclinical model.

METHODS

Seventeen (eight males, nine females) Yorkshire pigs (Parson's Farms, Hadley, MA, USA) underwent bilateral ACL transection and received bridge-enhanced ACL repair with an absorbable suture (n=17) on one side and with a nonabsorbable suture (n=17) on the other side. The leg receiving the absorbable suture was randomized within each animal. ACL structural properties and AP knee laxity for each knee were measured after 15 weeks of healing. Mixed linear models were used to compare the biomechanical outcomes between sexes and suture groups.

RESULTS

When treated with absorbable suture, females had a lower ACL linear stiffness (females, 11 N/mm [range, 8-42]; males, 31 N/mm [range, 12-56]; difference, 20 N/mm [95% confidence interval {CI}, 4-36]; p=0.032), ACL yield (females, 121 N [range, 56-316]; males, 224 N [range, 55-538]; difference, 103 N [95% CI, 6-200]; p=0.078), and maximum load (females, 128 N [range, 63-332]; males, 241 N [range, 82-538]; difference, 114 N [95% CI, 15-212]; p=0.052) than males after 15 weeks of healing. Female knees treated with absorbable suture had a lower linear stiffness (absorbable, 11 N/mm [range, 8-42]; nonabsorbable, 25 N/mm [range, 8-64]; difference, 14 [95% CI, 2-26] N; p=0.054), ACL yield (absorbable, 121 N [range, 56-316]; nonabsorbable, 230 N [range, 149-573]; difference, 109 N [95% CI, 56-162]; p=0.002), and maximum load (absorbable, 128 N [range, 63-332]; nonabsorbable, 235 N [range, 151-593]; difference, 107 N [95% CI, 51-163]; p=0.002) along with greater AP knee laxity at 30° (absorbable, 9 mm [range, 5-12]; nonabsorbable, 7 mm [range, 2-13]; difference, 2 mm [95% CI, 1-4]; p=0.034) than females treated with nonabsorbable suture. When repaired using nonabsorbable suture, the biomechanical outcomes were similar between female and male knees (p>0.10).

CONCLUSIONS

Females had significantly worse biomechanical outcomes than males when the repairs were performed using absorbable sutures. However, the use of nonabsorbable sutures ameliorated these differences between males and females.

CLINICAL RELEVANCE

The current findings highlight the critical role of sex on the biomechanical outcomes of bridge-enhanced ACL repair in a relevant large animal model. Better understanding of the mechanisms responsible for these observations using preclinical models and concomitant clinical studies in human patients may allow for additional development of sex-specific surgical and rehabilitative strategies with potentially improved outcomes in women.

Meta-analysis of prevention of surgical site infections following incision closure with triclosan-coated sutures: robustness to new evidence

BACKGROUND

A systematic literature review (SLR) and meta-analysis of surgical site infections (SSIs) after surgical incision closure with triclosan-coated sutures (TS) compared with non-antibacterial coated sutures (NTS) published previously by the authors suggested that fewer SSIs occurred in the TS study arm. However, the results were vulnerable to the removal of one key randomized controlled trial (RCT) because of insufficient data. Furthermore, recently published RCTs highlighted the need for an update of the SLR to challenge the robustness of results.

METHODS

The protocol for the new SLR included more stringent tests of robustness than used initially and the meta-analysis was updated with the results of two new RCTs as well as the count of patients and SSIs by U.S. Centers for Disease Control and Prevention (CDC) incision class.

RESULTS

The updated SLR included 15 RCTs with 4,800 patients. No publication bias was suggested in the analysis. The predominant effect estimated a relative risk of 0.67 (95% CI: 0.54-0.84, p=0.00053) with an overall lower frequency of SSI in the TS arm than in the NTS arm. RESULTS were robust to sensitivity analysis.

CONCLUSIONS

The two additional peer-reviewed double-blind RCTs of this update confirmed the predominant effect found in the authors' previous meta-analysis and established the robustness of conclusions that were lacking previously. This SLR and meta-analysis showed that the use of triclosan antimicrobial sutures reduced the incidence of SSI after clean, clean-contaminated, and contaminated surgery. The two additional peer-reviewed double blind RCTs reinforced the evidence level of this SLR (CEBM level 1a).

[Surgical site infections in vaginal prolapse surgery]

INTRODUCTION

Vaginal prolapse surgery is at high risk of surgical site infections (SSI) because it's a "clean-contaminated surgery" and it's frequently associated with implantation of meshes.

OBJECTIVES

To evaluate the rate of SSI and associated risk factors in vaginal prolapse surgery with mesh support.

METHODS

In a retrospective unicenter study, two groups of patients were operated by vaginal route for a pelvic floor reconstructive surgery with mesh support. Colporraphy was made by classic surgical sutures non-coated (Monosyn(®) 3/0, B-Braun) in the first group, and surgical sutures coated with triclosan in the second group. We collected risk factors of SSIs using the procedure of the CCLIN and analyzed the occurrence of SSIs with a statistical comparative univariate analysis.

RESULTS

Study included 78 patients in the first group and 72 in the second group. SSIs total rate was 2.6 % (4 of 150), as part of 3 in the group with surgical sutures non-coated and one in the group with surgical sutures coated with triclosan (P=0.62).

CONCLUSION

In our study, SSIs rate in vaginal prolapse surgery was twice higher than classic gynecologic surgery. As the interest of using a surgical suture coated with triclosan to reduce SSI has not been demonstrated statistically, we can't recommend it.

Systematic review and meta-analysis of triclosan-coated sutures for the prevention of surgical-site infection

Background

Surgical-site infections (SSIs) increase morbidity and mortality in surgical patients and represent an economic burden to healthcare systems. Experiments have shown that triclosan-coated sutures (TCS) are beneficial in the prevention of SSI, although the results from individual randomized controlled trials (RCTs) are inconclusive. A meta-analysis of available RCTs was performed to evaluate the efficacy of TCS in the prevention of SSI.

Methods

A systematic search of PubMed, Embase, MEDLINE, Web of Science®, the Cochrane Central Register of Controlled Trials and internet-based trial registries for RCTs comparing the effect of TCS and conventional uncoated sutures on SSIs was conducted until June 2012. The primary outcome investigated was the incidence of SSI. Pooled relative risks with 95 per cent confidence interval (c.i.) were estimated with RevMan 5.1.6.

Results

Seventeen RCTs involving 3720 participants were included. No heterogeneity of statistical significance across studies was observed. TCS showed a significant advantage in reducing the rate of SSI by 30 per cent (relative risk 0·70, 95 per cent c.i. 0·57 to 0·85; P &lt; 0·001). Subgroup analyses revealed consistent results in favour of TCS in adult patients, abdominal procedures, and clean or clean-contaminated surgical wounds.

Conclusion

TCS demonstrated a significant beneficial effect in the prevention of SSI after surgery.

Effects of suture choice on biomechanics and physeal status after bioenhanced anterior cruciate ligament repair in skeletally immature patients: a large-animal study

PURPOSE

The objective of this study was to assess the effect of absorbable or nonabsorbable sutures in bioenhanced anterior cruciate ligament (ACL) repair in a skeletally immature pig model on suture tunnel and growth plate healing and biomechanical outcomes.

METHODS

Sixteen female skeletally immature Yorkshire pigs were randomly allocated to receive unilateral, bioenhanced ACL repair with an absorbable (Vicryl) or nonabsorbable (Ethibond) suture augmented by an extracellular matrix-based scaffold (MIACH). After 15 weeks of healing, micro-computed tomography was used to measure residual tunnel diameters and growth plate status, and biomechanical outcomes were assessed.

RESULTS

At 15 weeks postoperatively, there was a significant difference in tunnel diameter with significantly larger diameters in the nonabsorbable suture group (4.4 ± 0.3 mm; mean ± SD) than in the absorbable group (1.8 ± 0.5 mm; P < .001). The growth plate showed a significantly greater affected area in the nonabsorbable group (15.2 ± 3.4 mm(2)) than in the absorbable group (2.7 ± 0.8 mm(2), P < .001). There was no significant difference in the linear stiffness of the repairs (29.0 ± 14.8 N/mm for absorbable v 43.3 ± 28.3 N/mm for nonabsorbable sutures, P = .531), but load to failure was higher in the nonabsorbable suture group (211 ± 121.5 N) than in the absorbable suture group (173 ± 101.4 N, P = .002). There was no difference between the 2 groups in anteroposterior laxity at 30° (P = .5117), 60° (P = .3150), and 90° (P = .4297) of knee flexion.

CONCLUSIONS

The use of absorbable sutures for ACL repair resulted in decreased physeal plate damage after 15 weeks of healing; however, use of nonabsorbable sutures resulted in 20% stronger repairs.

CLINICAL RELEVANCE

Choice of suture type for ACL repair or repair of tibial avulsion fractures may depend on patient skeletal age and size, with absorbable sutures preferred in very young, small patients at higher risk with physeal damage and nonabsorbable sutures preferred in larger, prepubescent patients who may place higher loads on the repair.

Surgical site infections after abdominal closure in colorectal surgery using triclosan-coated absorbable suture (PDS Plus) vs. uncoated sutures (PDS II): a randomized multicenter study

BACKGROUND

Surgical site infections (SSI) are the third most common hospital-acquired infections and account for 14% to 16% of all such infections. In elective colorectal operations, the international SSI rate ranges from 4.7%-25%. In a previous retrospective study in this department, the SSI rate was unacceptably high (25%), and the promising different international evaluations of triclosan-coated suture materials encouraged us to create a multicenter randomized trial to improve our results. The main goal of this study was to compare triclosan-coated and uncoated absorbable suture (PDS Plus(®) with PDS II(®)) in elective colorectal operations.

METHODS

This was an internet-based study involving seven surgical centers. All the elective colorectal operations were performed by experienced surgeons. For abdominal fascia closure, running looped PDS was applied; triclosan-coated or uncoated PDS was chosen by computer randomization. Pre-operative and peri-operative variables such as gender, body mass index, neoadjuvant therapy, type II diabetes mellitus, amount of wound dressing material used, nursing days, and microbiological results were recorded. After the operation, the patient's data and risk factors were collected in a password-protected online database.

RESULTS

From 485 patients randomized, SSI was documented in 47 patients (12.5%), 23 (12.2%) in the group having triclosan-coated sutures (n=188) and 24 (12.2%) in the uncoated suture group (n=197), a non-significant difference. Of all SSIs, 13 (27.7%) were diagnosed only after discharge, being recognized in the outpatient setting, with four patients in the triclosan suture group (8.5%) and nine in the uncoated suture group (19.2%) being affected with no significant differences in the demographic data. Microbiological examinations, in addition to the same colon flora in both groups, revealed two gram-positive infections in the uncoated suture group. The hospital stay and costs of dressings were significantly higher in patients having SSIs.

CONCLUSION

Compared with the previous retrospective studies of this department, the implementation of looped PDS decreased the incidence of SSI by one-half, whether the suture was triclosan-coated or not. It seems that patient factors are less important than operative factors in the occurrence of SSI, and there were no differences between elective colon and rectal operations in the development of incisional infections. No beneficial effect of triclosan against gram-positive bacteria, which has been reported in the literature, could be confirmed in our study. We could not show an effect against gram-negative enteric microorganisms. Higher additional costs and longer hospital stay with SSI were confirmed.

Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial

OBJECT

Implantation of cerebrospinal fluid (CSF) shunting devices is associated with a 5-15% risk of infection as cited in contemporary pediatric neurosurgical literature. Shunt infections typically require complete removal of the device and prolonged antibiotic treatment followed by shunt replacement. Moreover, shunt infections are commonly associated with prolonged hospital stays, potential comorbidity, and the increased risk of neurological compromise due to ventriculitis or surgical complications. The authors prospectively evaluated the incidence of CSF shunt infection following shunt procedures performed using either antimicrobial suture (AMS) or conventional suture.

METHODS

In a single-center, prospective, double-blinded, randomized controlled trial, the authors enrolled 61 patients, among whom 84 CSF shunt procedures were performed over 21 months. Randomization to the study (AMS) or control (placebo) group was stratified to minimize the effect of known shunt infection risk factors on the findings. Antibacterial shunt components were not used. The primary outcome measure was the incidence of shunt infection within 6 months of surgery.

RESULTS

The shunt infection rate in the study group was 2 (4.3%) of 46 procedures and 8 (21%) of 38 procedures in the control group (p = 0.038). There were no statistically significant differences in shunt infection risk factors between the groups (procedure type and time, age < 6 months, weight < 4 kg, recent history of shunt infection). No suture-related adverse events were reported in either group.

CONCLUSIONS

These results support the suggestion that the use of AMS for CSF shunt surgery wound closure is safe, effective, and may be associated with a reduced risk of postoperative shunt infection. A larger randomized controlled trial is needed to confirm this association.

Bioactive Sutures

With the first wave of bioactive sutures already in the marketplace, research is ongoing in the development of future products. Such sutures could potentially have not only antimicrobial activity but also anesthetic and antineoplastic functions. Some clinical trials have already been completed in Russia. This technology is likely to become commonplace. This article reviews the progress made to date in the development of this technology.

Surgical Site Infections

This article examines the epidemiology and risk factors for the development of surgical site infections (SSIs), the importance of appropriate administration of prophylactic antibiotics, nonpharmacologic strategies, and the role of new "active" devices in reducing SSIs. A review of the pertinent English-language literature shows that many factors contribute to the risk of a patient developing an SSI. These include the patient's health status, preparation of the patient before surgery, and the use of appropriate antibiotic prophylaxis. Careful preparation of the patient and care after surgery is especially important. The use of new "active" antibacterial devices may reduce risk further. Surgeons can minimize the risk to the patient of the development of SSI through strict adherence to established surgical guidelines for perioperative care.