Review Article

Suture materials — Current and emerging trends

Christopher Dennis,1 Swaminathan Sethu,2 Sunita Nayak,1,3 Loganathan Mohan,4

Yosry (Yos) Morsi,5 Geetha Manivasagam1
1
Centre for Biomaterials Science and Technology, School of Mechanical and Building Sciences, VIT University, Vellore,
Tamil Nadu 632014, India
2
GROW Research Laboratory, Narayana Nethralaya Foundation, Bangalore, Karnataka 560099, India
3
School of Bio Sciences and Technology, VIT University, Vellore, Tamil Nadu 632014, India
4
Surface Engineering Division, CSIR - National Aerospace Laboratories, Bangalore, Karnataka 560017, India
5
Biomechanical and Tissue Engineering Labs, Faculty of Science, Engineering and Technology,
Swinburne University of Technology, Australia

Received 28 September 2015; revised 7 January 2016; accepted 5 February 2016

Published online 4 April 2016 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jbm.a.35683

Abstract: Surgical sutures are used to facilitate closure and
healing of surgical- or trauma-induced wounds by upholding
tissues together to facilitate healing process. There is a wide
range of suture materials for medical purpose and the main
types include absorbable and nonabsorbable. Recently, there
is a growth in the development of classes of suture materials
based on their properties and capabilities to improve tissue
sutures, and smart sutures including elastic, and electronic
sutures. These newer strategies expand the versatility of
sutures from being used as just a physical entity approximat-
ing opposing tissues to a more biologically active component
enabling delivery of drugs and cells to the desired site with
immense application potential in both therapeutics and diag-
nostics. V
C 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A:

approximation and wound closure. This review outlines and 104A: 1544–1559, 2016.
discusses the current and emerging trends in suture technol-
ogy including knotless barbed sutures, antimicrobial sutures, Key Words: sutures, antimicrobial sutures, drug-eluting
bio-active sutures such as drug-eluting and stem cells seeded sutures, barbed sutures, smart sutures

How to cite this article: Dennis C, Sethu S, Nayak S, Mohan L, Morsi Y(Y), Manivasagam G. 2016. Suture materials — Current
and emerging trends. J Biomed Mater Res Part A 2016:104A:1544–1559.

INTRODUCTION lowing surgical procedures or trauma by and large still

It is well recognised that sutures have been an effective and
critical part of surgeries and trauma management.1 The pri-
mary purpose of sutures is to hold apposing tissues
together to facilitate and hasten healing process with mini-
mal or no scar formation following an injury or surgical
procedure.2 A variety of materials such as gold, silver, iron
and steel wires, dried animal gut, animal hair (e.g., horse
hair), silk, tree bark, and plant fibers (e.g., linen, cotton)
were used as suture materials in the past, while some of
them are still in use today. The recent past has witnessed
the use of various synthetic biomaterials such as polydioxa-
none, poly (lactic-co-glycolic acid) as suture materials.3
However, despite the availability of a wide range of suture
materials, there is no single suture material that would be
suitable for all types of surgical and medical requirements.4
Regardless of the advancements and innovations in materi-
als technology and surgical techniques, wound closures fol-
involves the use of sutures. Some suture materials which
have been available for decades are still being used rou-
tinely.1 There is a substantial growth in the surgical sutures
segment of the health care industry, with a market share of
up to $649 million for absorbable and nonabsorbable suture
products.5 However, a recent global forecast reveals slower
growth for the sutures market due to lack of novel products
in wound care.5 Demands for sutures materials are on the
rise due to an increase in number of surgical procedures
performed worldwide, regardless of the availability of
sutures substitute such as surgical staples, glues, and strips
in the market. These products do on occasions fall short of
the stability and flexibility rendered by sutures in wound
management.6
The choice of a suture material in wound management
largely depend on factors such as the number of tissue
layers involved in wound closure, tension across the wound,

Correspondence to: G. Manivasagam; e-mail: geethamanivasagam@vit.ac.in

1544 C 2016 WILEY PERIODICALS, INC.

V

FIGURE 1. Overview of types of sutures based on physical and structural characteristics of suture materials. (Note: Citations for facts stated in
the Fig. 1 Refs. 10–35).
depth of suture placement, presence of oedema, expected
time of suture removal, possess adequate strength, and elicit
minimal or no inflammatory reactions.7 Sutures must also
possess significant pliability and flexibility for better han-
dling characteristics during suturing. In addition, ease in
knot placement, high knot security, free from irritating, or
infectious substances are also highly sought after fea-
tures.1,8,9 Suture materials available for routine use fulfil
most of the primary requirements, but not all. Hence, cur-
rent efforts are centred on developing suture materials
which has all the desired features along with the additional
capabilities such as the potential to deliver drugs and cells
to facilitate and/or augment wound healing.
Newer suture materials and design have expanded the
range of biomedical applications of sutures. The recent
advancements and emerging trends in suture technology
have immense potential in clinical/surgical applications
involving specialized procedures and wound management.
This article intends to provide an overview of currently avail-
able sutures, the characteristic features, and properties of
suture materials with emphasis on emerging trends such as
sutures with bioactive molecules (drugs, antimicrobials, and
stem cells) and smart sutures. A comprehensive literature
search for studies or reports on different types of sutures
published until the end of September 2015 using electronic
databases such as PubMed, Scopus and www.clinicaltrials.gov
was performed. The search terms used in these databases
include “sutures,” “suture materials,” “antimicrobial sutures,”
“antibacterial sutures,” “surgical site infection”, “drug eluting
sutures,” “stem cells sutures,” “bioactive sutures,” “barbed
sutures,” “bioactive barbed sutures,” and “elastic sutures”.
These terms were either used alone or in different combina-
JOURNAL OF BIOMEDICAL MATERIALS RESEARCH A | JUN 2016 VOL 104A, ISSUE 6
REVIEW ARTICLE
tions. Searched articles were limited to those published in
English only. The articles were then compiled and studied for
their relevance along with supportive evidence. In addition,
relevant articles that were cited in the reference lists of the
retrieved and chosen articles were also included. Any study
or report with lack evidence supporting the findings stated
in the publications was excluded from the review.
PHYSICAL AND STRUCTURAL CHARACTERISTICS OF
SUTURE MATERIALS
The principle features and properties that contribute toward
the function of different sutures are filament structure, size,
degradation property, tensile strength, surface texture, stiff-
ness, and flexibility of the materials (summarized schemati-
cally in Fig. 1). The ability of sutures to resist tissues
induced stress and repair capability directly corresponds to
the size and tensile property of the suturing material.1 The
tensile strength of the suture material should balance the
tensile strength of the tissue for better healing process. It is
known that tensile strength of suture materials varies with
its size and is measured by the quantity of weight (kg)
needed to sever the suture material.9 The tensile strength of
the suture material also depends on the number of fila-
ments (monofilament or multifilament).7 Multifilament
sutures tender high mechanical property with significant
flexibility and pliability than monofilament sutures.1
Based on surface design, sutures are categorised into
smooth (standard) and barbed sutures which are suitable
for specific surgical needs such as external or deep wound
closures. Barbed sutures have sharp projections or barbs on
the surface of suture material which helps in anchoring the
sutures to tissues linearly. Smooth suture materials
1545
TABLE I. Absorbable Sutures Used for Clinical Applications
Total Mass
Type of sutures Size Total T.S Absorption
(Brand name) Pattern Material (USP) loss (Days) (Days) Refs

Standard sutures
1,3,7
Plain Surgical Gut Plain (Twisted) Collagen 3 – 7/0 14-21 70
1,3,7
Chromic Surgical Gut Chromic Collagen 3 – 7/0 14-21 90-120
(Twisted)
1,3,7
CoatedTMPolyglactin 910 Braided Copolymer of lactide 3 – 10/0 28 56-70
(Vicryl , PolysorbTM) Monofilament and glycolide
Coated Vicryl PlusTM Braided Copolymer of lactide and 2 – 5/0 28 56-70 1,3

(polyglactin 910) Monofilament glycolide and coated

with triclosan
1,3
Rapid absorbing coated Braided Copolymer of lactide 1 – 8/0 14 40-50
Polyglactin 910 and glycolide
(Vicryl RapidTM)
3,7
Polyglytone 6211 Monofilament Synthetic polyester-glycolide, 1 – 6/0 21 56
(CaprosynTM) caprolctone, trimethylene
carbonate and lactide
1,3
Poliglecaprone 25 Monofilament Copolymer of glycolide and 1 – 6/0 21 91-119
(MonocrylTM) epsilon-caprolactone
Monocryl PlusTM Monofilament Copolymer of glycolide and 1 – 6/0 21 91-119 51

Antibacterial epsilon-caprolactone
(poliglecaprone 25) (Coated with triclosan)
Suture
3,7
Coated Polyglycolide Braided Homopolymer of glycolide 2 – 6/0 28 60-90
(Dexon IITM)
3,7
Polyglycomer 631 Monofilament Synthetic polyester-glycolide, 1 – 6/0 28 90-110
(BiosynTM) dioxanone and trimethylene
carbonate
3,7
Polyglyconate Monofilament Copolymer of glycolide and 2 – 7/0 56 180
(MaxonTM) trimethylene carbonate
1,3
Polydioxanone Monofilament Polyester polymer 2 – 9/0 90 183-238
(PDS IITM) (Poly (p-dioxanone))
PDSTM Plus Monofilament Polyester polymer 1 – 6/0 90 182-238 51

Antibacterial (Poly (p-dioxanone)) and

(polydioxanone) coated with triclosan
Sutures
R 52
TephaFlexV Monofilament Poly (4-hydroxybutyric acid) 2 – 5/0 84 546
Barbed sutures
Bidirectional (QuillTM SRS)
3,36,53–55
Barbed Poliglecaprone 25 Monofilament Copolymer of glycolide and 2 – 3/0 21 90-120
(MonodermTM ) epsilon-caprolactone
(PGA-PCL)
3,36,56–63
Barbed Polydioxanone Monofilament Polyester polymer 2 – 4/0 90 180
(PDO)
Unidirectional
V-Loc 90TM Absorbable Monofilament Glycolide, dioxanone and 2/0 – 4/0 28 90-110 3,64–66

device trimethylene carbonate

V-Loc 180TM Absorbable Monofilament Copolymer of glycolide and 0 – 4/0 56 180 3,64,66–73

device trimethylene carbonate

SRS - Self-retaining sutures, USP - United States Pharmacopoeia, T.S - Tensile strength, TM - Trademark. Biosyn, Caprosyn, Polysorb,
Dexon II, Maxon, V-Loc 90 and V-Loc 180 - Covidien AG, Mansfield, MA; Monocryl, Monocryl Plus, PDS II, PDS Plus, Vicryl, Vicryl Plus and Vicryl
Rapide - Ethicon, Inc., Somerville, NJ; TephaFLEX : Tepha Inc, Lexington, MA; Quill TM SRS: Monoderm, PDO - Angiotech Pharmaceuticals,
VR

Vancouver, Canada.

conversely are held in position around the tissue through
knots. It is well known that knots are exceptionally strong
and reliable to endure tendon and bone related forces. How-
ever, the presence of knots may have adverse effects on the
tissues and placing a knot might be difficult in deep surgical
regions, especially during minimally invasive surgical proce-
dures.3 By eliminating the need to knot, barbed sutures has
widened its applications in complex reconstructive surgical
procedures.36 Further, multifilament barbed sutures termed
as “intertwined,” with improved mechanical property offers
more flexibility and pliability, ideal for deep wound
closures.37
Barbs geometry and design need to be tailored for its
use on various types of tissues to achieve good mechanical
anchoring of sutures within the tissues.38 Experimental
results by Ingle et al.39,40 concluded the biomechanical

1546 DENNIS ET AL. SUTURE MATERIALS

 REVIEW ARTICLE

TABLE II. Nonabsorbable Sutures used for Clinical Applications

Type of sutures (Brand name) Pattern Material References

Standard sutures
Silk (SofsilkTM, Perma-HandTM) Braided Protein – Fibroin 1,7

Nylon (Monosof TM, EthilonTM) Monofilament Long-chain of aliphatic polymers 1,7

Nylon 6 or Nylon 6,6

Nylon (SurgilonTM, NurolonTM) Braided Long-chain aliphatic polymers 1,7

Nylon 6 or Nylon 6,6

Polyester fiber (SurgidacTM, Braided Poly (ethylene terephthalate) 1,7

TiCronTM, MersileneTM) Monofilament

Polyester Fiber (Ethibond ExcelTM) Braided Poly (ethylene terephthalate) coated 1

with Polybutilate
1,7
Polypropylene Monofilament Isotactic crystalline stereoisomer of
(SurgiproTM II, ProleneTM) Polypropylene/polyethylene
FiberWireTM Braided Braided Braided Jacket of polyester and Long 34

Composite sutures Chain Ultra-high molecular weight

polyethylene (UHMWPE)
1
Poly (hexafluoro-propylene-VDF) Monofilament Poly (vinylidene fluoride) 1 poly (vinylidene
(PronovaTM) fluoride – cohexoafluoro-propylene)
Polybutester (NovafilTM) Monofilament Copolymer of butylenes terephthalate and 1,7

polytetramethylene ether glycol

1,7
Surgical Stainless steel Mono/Multi 316L Stainless Steel
filament
74
PremiCronV R Braided Poly (ethylene terephthalate) coated with silicone
75
Gore-Tex sutures ePTFE Monofilament Polytetrafluoroethylene (PTFE)
76
Polyurethane (AssuplusV R) Monofilament Polyurethane
Barbed sutures
Bidirectional (Quill TM SRS)
36
Nylon Monofilament Long-chain aliphatic polymers Nylon 6 or Nylon 6,6
36
Polypropylene Monofilament Isotactic crystalline stereoisomer of Polypropylene
Unidirectional
V-LocTM PBT Non-Absorbable Monofilament Polybutester 64,77

Device

SRS - Self-retaining sutures, TM - Trademark, CABG - Coronary Artery Bypass Graft, A/V Fistula - Arteriovenous Fistula, A/V Graft - Arterio-
venous Graft.
Monosof, Surgilon, Surgidac, Sofsilk, Surgipro, TiCron, Novafil and V-Loc PBT - Covidien AG, Mansfield, MA; Perma-Hand, Ethilon, Nuro-
lon, Mersilene, Ethibond Excel, Prolene and Pronova - Ethicon, Inc., Somerville, NJ; Quill TM SRS: Nylon, Polypropylene - Angiotech Pharmaceut-
icals, Vancouver, Canada, FiberWire - Arthrex, Florida, USA; W. L. Gore & Associates, Inc., Flagstaff, Arizona, USA, AssuplusV R , Assut Europe

S.p.A, Roma, Italy. PremiCronV R , B.Braun (Aesculap), Center Valley, Pennsylvania, USA.

anchoring of barbed sutures in soft skin tissue can be
achieved with a cut angle of 170 and a cut depth of
0.18 mm, while for tendons a cut angle of 150 and a cut
depth of 0.18 mm are necessary. Knotless barbed sutures
demonstrated comparable tensile strength to smooth
sutures on fascial repair without any adverse effects in por-
cine model.41 The choice of suture materials for face lifting
procedures to attain appropriate balance for tissue eleva-
tions depends on the configuration of barbed sutures such
as bidirectional or selected nonbarbed segments.42,43
Advancement in suture technology with barbed sutures has
shown to achieve improved cosmetic appeal and soft tissue
handling during surgical procedures.44,45 In recent time, the
practice of barbed suture has been efficiently used in vari-
ous specialities including general and plastic surgery, obstet-
rics and gynaecology, orthopaedics, urology, and other
surgeries.46–49 Innate design of sutures with barb front can
puncture the glove and pose a risk of infection for both the
surgeons and patients. However, a recent report has sug-
gested that there is less incidence of glove damage with the
use of barbed sutures.50 Nevertheless, precautions should
be followed to avoid any such incidences for effective and
safe use of barbed sutures.
Smooth and barbed sutures made of absorbable and
nonabsorbable materials and their various types available
for clinical use are listed in Tables I and II . Absorbable
sutures undergo degradation by losing 50% of their tensile
strength within 60 days in tissues, whereas, nonabsorbable
sutures can retain their tensile strength exceeding 60 days.1
Furthermore, naturally derived absorbable sutures are easily
broken down by enzymes (proteolytic enzyme) in the
human body and are absorbed within 70 days.1 Synthetic
absorbable sutures degrade by hydrolysis, where water mol-
ecules penetrate into the polymer threads and breakdown
the polymer chains of the suture.78 In contrast, nonabsorb-
able sutures show poor degradation in body tissues and
they are neither digested by enzymatic action in body nor
hydrolyzed and hence had to be physically removed.79
Regardless of the number of these absorbable and nonab-
sorbable sutures clinically available, the types of the

JOURNAL OF BIOMEDICAL MATERIALS RESEARCH A | JUN 2016 VOL 104A, ISSUE 6 1547
commonly used sutures at present in clinical practice
appear to be limited.80 The available suture materials
almost fulfil all the primary requirements, but not all.
Improving on its versatility and adaptability would be valua-
ble with more options for the clinicians. The current efforts
are centred on developing suture materials with improved
physical and mechanical properties along with the addi-
tional capabilities such as to deliver drugs and cells to
improve wound healing.
RECENT AND EMERGING TRENDS
Recently, there has been a surge in the development of
novel sutures with additional properties such as those
modified with antimicrobial agents81–87 bioactive molecules
like DNA,88 drugs,89 antibodies,90 proteins,91–93 growth fac-
tors,94–99 and silver100 in an effort to customize and
improve the functional outcome of sutures. After several
years of research and development the first antibacterial
suture Vicryl Plus (triclosan coated polyglactin 910 suture)
was approved in 2002 by Food and Drug Administration
(FDA), United States to reduce the risk of surgical site infec-
tions. Furthermore, the use of triclosan coating was
extended to other suture materials to overcome bacterial
adherence and prevent or reduce surgical site infec-
tions.101–103 Sutures with bioactive substance can be thera-
peutically useful for wide range of procedures in a site-
specific manner and hasten the healing process.104 The fol-
lowing sections would describe the various emerging con-
cepts in suture technology (Fig. 2) such as drug eluting
sutures, cell seeded sutures and smart sutures to overcome
postoperative wound complications including surgical site
infections, biofilms, scars, inflammation, and pain. These
advances promise immense potential in tissue engineering,
regenerative medicine and minimal invasive surgeries.
Antimicrobial sutures
Infections due to bacterial attachment and proliferation on
the surfaces of devices or implants are major concerns dur-
FIGURE 2. Schematic representation of recent and emerging suture technologies. (Note: Citations for facts stated in the Fig. 2: Refs. 105–117.)
1548 DENNIS ET AL.
ing reconstructive procedures and use of implantable bio-
medical devices.118,119 Localized surgical site infections
(SSIs) are the most common postoperative complications
and it was estimated to occur in 5% of all proce-
dures.120–122 It has been estimated that nearly 750,000 to 1
million SSIs occur in the United States every year, causing
extensive morbidity and mortality.123 In general, surgical
site infections are categorized in three classes: superficial
incisional, deep incisional and organ/space or intracavitary
infections.124–126 Staphylococcus aureus, a class of gram pos-
itive bacteria, capable of colonizing on the surface of the
medical implants, were mainly liable for the incidence of
23% of surgical site infections.121 The bacterial growth on
surgical site resembles alike to the biofilm formation over
the sutures.127 Chitin (natural polysaccharide) with antimi-
crobial property can effectively accelerate wound healing
and provide protection from wound infections.128 Recently,
fabrication of diacetyl chitin based absorbable suture
retained  63% of its original strength for 14 days and
completes absorption of material was observed in 42 days
with higher wound breaking strength similar to Vicryl PlusV R
and rapid regeneration of tissues at incision site in rats.129
This novel multifilament suture material can aid its poten-
tial use for short and middle term wound healing for epithe-
lial and connective tissue.129 Another recent study reported
that oxidative plasma treatment over different suture mate-
rials though controlled etching resulting in distinct nanoto-
pographies that prevented the bacteria attachment on
suture surface.130 This strategy can be used in the develop-
ment of cost-effective sutures with antibacterial potential
without compromising on the desirable features of suture
materials. Although, a long course of antibiotics can treat
the bacterial infections, it is often ineffective and cause side-
effects with systemic complications including bacterial
resistance to antibiotic therapy. To overcome the antibiotic
resistance by a broad spectrum of microbes and postopera-
tive infection related complications at surgical site, studies
focused on to identify and alter organic and inorganic
SUTURE MATERIALS
 TABLE III. Newer Suture Technologies
Category Suture material Bioactives modification Clinical significance References

Antibacterial Triclosan coating removed from
sutures Vicryl plus (Poly (lactic-co-glycolic
acid)) sutures
Polyglycolic acid (Braided suture)
Polyglycolide
Poly (lactic-co-glycolic acid)
Chromium gut, Nylon (EthilonTM),
Silk, Poly (ethylene terephthalate)
(Ethibond Excel TM)
Polyamide sutures
Poly (glycolic acid)
Poly (lactic-co-glycolic acid)
Amphiphilic polymer: poly [(aminoethyl Bactericidal effect 131
methacrylate)-co-(butyl methacrylate)]
Chlorhexidine diacetate Antimicrobial efficacy up to 5 days with 132
good biocompatibility
Octanidine Biocompatible and antimicrobial efficacy 133
against S. aureus up to 9 days
Caffeic acid phenethyl ester (from natural Antimicrobial activity and inhibition of bac- 134
propolis) terial proliferation
Quaternary ammonium compound (K21: Bacterial growth inhibition of Porphyromo- 135
1-Octadecanamium, N,N’-[[3,3-bis[[[3- nas gingivalis (periodontal) and Entero-
(dimethyloctadecylammonio)propyl]19di- coccus faecalis (endodontic) virulent
hyroxysilyl]oxy]-1,1,5,5-tetrahydroxy-1,5- pathogens.
trisiloxanediyl]di-3,1 propanediyl]bis[N,N-
dimethyl-,chloride (1:4))
Silver nanoparticles 1 Sodium alginate Antimicrobial activity varied with capping 136
agent
Silver nanoparticles 1 Hyperbranched High efficacy against bacterial adhesion 137
polylysine and noncytotoxic
Silver nanoparticles Anti-bacterial and Anti-inflammatory 139
property

JOURNAL OF BIOMEDICAL MATERIALS RESEARCH A | JUN 2016 VOL 104A, ISSUE 6

Silk
Drug-eluting Silk
sutures
Braided silk sutures
Polypropylene sutures
Poly (lactic-co-glycolic acid)
Polyvinylidene difluoride
Poly (lactic-co-glycolic acid)
Poly (lactic-co-glycolic acid)
Poly (e – caprolactone)
Silver particles (0.5%)
Tetracycline hydrochloride
Levofloxacin hydrochloride
Vancomycin HCl (Immobilized/ loaded with
Glycidyl methacrylate and Acrylic acid)
Bupivacaine (Local Anaesthetic)
Tacrolimus (Immunosuppressive)
Ibuprofen (NSAID)
Dexamethasone (Anti-inflammatory)
Diclofenac 1 Hydrotalcite (nanohybrid)
Demonstrated excellent antibacterial effi- 138
cacy and reduced bacterial adhesion
against S.aureus and E. Coli without cyto-
toxic effect on fibroblast.
Antimicrobial efficacy and zone of inhibi- 142
tion was greater for E. coli than S.
aureus.
E.coli was more susceptible to the drug 140,143
than S.aureus up to 7 days
Antimicrobial activity: Reduction of S.aur- 144
eus adherence on suture surface and
inhibition of bacterial growth with good
biocompatibility
Prolonged analgesia at incision site for 7-10 141
days
Prevent the neointimal hyperplasia. 145
Relief from post-operative pain with drug 146
release for 6 days
Anti-inflammatory response at surgical site. 147
Tuneable release rate of composition 148
against inflammation (in-vivo) with good
tensile strength and can also alleviate the
post-operative pain.

1549
REVIEW ARTICLE
 References compositions of sutures to combat or prevent infections.

149,150

151,152
Table III summarizes the recent advances in antibacterial

153
154

155

156
suture technology.

Antimicrobial agent coated sutures. Triclosan-coated

absorbable suture materials with antimicrobial properties

Cells survived and metabolically active after

bolically active and survive in injured ten-

ing as well as tissue remodelling at rapid

suturing into wound model using human

chain (in-vitro) and enhance wound heal-

phase tend with delayed healing process

heart (Cell retention > 60%). Reduction in

Decrease in acute inflammatory reaction at

Abundant deposition of collagen alpha-1(I)

fibrosis and increased mechanical func-

were commercially launched to overcome or prevent post-

thickness of ventricular myocardium of

Cells deposited on repair site were meta-

early stage after tracheal resection and

Enhance repair strength for 7 to 10 days.

through release of different collagens.

Suture delivered hMSCs throughout the

operative infections.101–103 Triclosan is an antimicrobial

agent that is commercially used in several products such as
soaps, deodorants, shower gels and toothpastes due of its
Clinical significance

antimicrobial efficacy with low toxicity to humans.157 The

antimicrobial effect of triclosan coated polyglactin 910
suture (Vicryl Plus, Ethicon) was consistent over a wide
range of suture diameters and treatment conditions even
skin (ex vivo). after several passes through fascia and subcutaneous tissue
in porcine model.103 The zone of bacterial inhibition sur-
tion of heart.

anastomosis
don tissue.

rounding the knotted sutures using triclosan coated suture

material in in vitro colonization experiments showed an
antimicrobial effect over Staphylococcus aureus (S. aureus)
and Staphylococcus epidermidis (S. epidermidis).103 In vivo
studies on triclosan-coated sutures exhibited significant
inhibition of bacterial colonies on its surface near the
infected site without compromising the mechanical property
of the suture.158,159 Similarly, poliglecaprone 25 suture with
Pluripotent embryonic cells (Murine)

triclosan (Monocryl Plus, Ethicon) exhibited good antibacte-

rial efficacy post-implantation in animal models.101
Bioactives modification

Human Mesenchymal stem cells

Double-blind randomized study of triclosan-coated

(hMSCs) 1 Quantum dots

sutures on SSI in cardiac surgery patients reported that

Adipose-derived stem cells

Adipose-derived stem cells

Mesenchymal stem cells

Mesenchymal stem cells

2.4% and 3.5% patients were recorded for the incidence of

sternal infections and leg wound infections respectively,
(Porcine and Murine)

which is comparatively less than the infection rate reported

following the use of conventional sutures.160 Further,
randomized controlled trial in colorectal surgery with 410
participants involving 206 patients using triclosan-coated
sutures and 204 patients with conventional suture showed
reduced incidence of wound infection at the surgical site
following the use of triclosan-coated suture.161 Similarly,
triclosan-coated sutures reduced the sutures-related compli-
(low molecular weight), Poly (ethyl-

cations following breast surgery.162 A meta-analysis on sev-

ene terephthalate), Poly (lactic-co-
Fibrin or Combination of fibrin and

Polyglycolic acid, Polyglycolic acid

enteen randomized controlled trials involving 3720

participants reported a significant benefit in the reduction
Poly (ethylene terephthalate)

of SSIs by about 30% following the use of triclosan-coated

Poly (lactic-co-glycolic acid)

Poly (lactic-co-glycolic acid)

Suture material

Braided Polyblend sutures

sutures.163 Similarly, a reduction of approximately 35% in

collagen microthreads

VitaSuture: VitaThreads, LLC, Worcester, MA.

the incidence of SSI after vein harvesting in patients under-

gone coronary artery bypass grafting was reported when
triclosan-coated sutures were used.164,165 A comparative
(FibreWireTM)

glycolic acid)
(VitaSutures)

report by Brendan et al.166 on bacterial adherence to

absorbable and nonabsorbable sutures which includes
Vicryl, Silk, Monocryl, Vicryl Plus, and Prolene revealed pol-
yglycolic acid suture (Vicryl) had greatest bacterial adher-
ence than other sutures. A study reported that triclosan-
TABLE III. Continued

coated sutures, barbed and standard sutures revealed lower

seeded sutures

bacterial adherence.167 Triclosan-coated sutures effectively

reduced bacterial growth while having no effect on bacterial
adherence compared to standard sutures.167 It should also
Stem cells
Category

be noted that contradicting reports have also been made

indicating a lack of significant antimicrobial effect by
triclosan-coated sutures.168,169 An in vitro by Li et al.131

1550 DENNIS ET AL. SUTURE MATERIALS


validated the bacteriostatic rather than bactericidal effects
of triclosan-coated sutures. Further, they also studied effi-
cacy of newer version of antimicrobial suture coated with
amphiphilic polymer poly [(aminoethyl methacrylate)-co-
(butyl methacrylate)] (PAMBM) inspired from antimicrobial
peptides.170,171 PAMBM-coated suture demonstrated signifi-
cant bactericidal activity and competency to kill S. aureus
rapidly, while the extensively used triclosan was bacterio-
static. Thus, concluded PAMBM was more effective antibac-
terial compound for sutures than triclosan. Further,
chlorhexidine-coated antimicrobial sutures demonstrated
considerable antimicrobial efficacy over 96 hours against S.
aureus using palmitic and lauric acid as carriers.132 Similar
to chlorhexidine, sutures coated with octenidine was experi-
mented and results were compared with chlorhexidine-
coated suture.133 Octenidine-palmitate coated suture
showed similar drug release at 96 hours, but the time span
of drug release kinetics was longer with slower release due
to lower solubility of palmitic acid in octenidine. The report
concluded octenidine-coated sutures to be better than chlo-
rhexidine based on their release kinetics, antimicrobial effi-
cacy and host cytotoxicity.133 Another study, suggested the
use of caffeic acid phenethyl ester loaded sutures to pre-
venting infections.134 The antimicrobial effect was due to
outer membrane damage and reactive oxygen species syn-
thesis in bacteria.134 Meanwhile, an in vitro study of quater-
nary ammonium compound (K21)-coated sutures and
dental floss showed dose-dependent antimicrobial activity
of bacterial species of direct relevance to infection and
bacteremia.135
Silver nanoparticles treated sutures. Silver nanoparticles
(AgNPs) are considered to be best candidates for coating
polymeric medical devices to enhance their antimicrobial
profile.172 The mechanism of action for silver’s antibacterial
effect involves generation of reactive oxygen species, which
directly affects DNA and cell membrane of microorgan-
isms.173 Moreover, bacterial resistance to AgNPs is very rare
and nanocluster of silver ions ranging between 1 nm to
100 nm in diameter offer a large surface area-to-volume
ratio which permits smaller amount to be used with less
risks of toxicity.174 At present, silver nanoparticles are used
in medical devices like urinary catheters and wound dress-
ings for burns.173 In recent time, AgNPs treated surgical
sutures to prevent bacterial adhesion on their surface has
gained interest to enhance infection free wound closure on
incision site.
A study reported that the capping concentration influ-
enced inter-particle repulsion of AgNPs thus affecting anti-
microbial activity. Further, it also revealed an increase in
antimicrobial activity of S. Aureus from 13% to 76% on
reducing the capping concentrations from 5 mM to 0.1 mM
respectively.136 In another report, AgNPs based bactericidal
coating on poly (lactic-co-glycolic acid; PLGA) suture was
generated by laser ablation technique.175 However, ultra-
short pulse lasers generated particles in ultrapure form
with no chemical precursors as contaminants with notable
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REVIEW ARTICLE
particles dimension and distribution to coat over the
sutures.176,177
Recently, a long-term active antimicrobial coating for
surgical sutures with silver nanoparticles and hyper-
branched polylysine was developed.137 The poly (glycolic
acid) based suture was coated by dipping method and the
coated surface exerted high efficacy against S. aureus
exceeding more than 99.5% reduction of bacterial adhesion
with no cytotoxicity to fibroblast cells than the uncoated
suture. In another study, AgNPs (0.5%) coating over the
sutures showed efficient antimicrobial activity and reduced
bacterial adhesion of S.aureus and E. coli.138 In another
study, AgNPs-coated suture showed both antibacterial as
well as anti-inflammatory effects.139 Further, the in vivo
study in mice explored intestinal anastomosis healing with
significant increase in deposition of collagen and notable
mechanical property over the anastomotic tissue.
Conflicting reports on efficacy and development of bac-
terial resistance with regards to the currently available anti-
bacterial triclosan-coated sutures has made it is necessary
to develop newer antibacterial sutures to combat SSIs. With
familiar nano-silver based products as creams and wound
dressings for treating the burns and other infection dis-
eases, development of antimicrobial suture either through
coating or loading into fibers can foster its application for
wound closure.178–181 Advancement of suture fabrication
with antimicrobial nanofibers into filaments of suture at the
same time retaining its mechanical strength and properties
can decrease the need for antimicrobial coating into
sutures.182,183 Novel approach through combination of anti-
microbial agents and/or nanostructured surface with dis-
tinctive material geometries to overcome the bacterial
adherence and biofilm formation can be effective to reduce
the infection rate on wound closure.
Drug-eluting sutures
Depending on the type of therapeutic agent used, drug-
eluting sutures can alleviate postoperative complications
such as surgical site infections and expedite wound heal-
ing.140 It also can reduce the need for supplemental drugs
which can have decreased potency or availability at the site
of the procedure following a systemic administration. Sus-
tained release of drugs at a specific site can allow therapeu-
tically relevant concentration locally for prolonged duration
without exceeding toxic limit in the systemic circulation.
Drug-eluting sutures are developed using various proce-
dures including coating the suture surface by dip
method184,185, grafting,186 or by electrospinning pro-
cess.141,187 The challenge in fabricating a drug-eluting
suture is to obtain the required concentration and potency
of the drug without compromising on the much important
mechanical properties of the suture and this can be
achieved by augmenting polymer degradation and controlled
drug release strategies.
Braided sutures are prone for bacterial adherence and
the propensity of bacteria to remain trapped in the braided
filament is rather high. Braided silk sutures have a greater
risk for surgical site infection as they are more susceptible
1551
to bacterial attachment.140 Tetracycline-coated silk suture
exhibited greater antimicrobial activity against E. coli than S.
aureus and the antimicrobial efficacy increased with drug
concentration.142 Further, braided silk sutures coated with
mixture of levofloxacin hydrochloride and poly (e-caprolac-
tone) showed similar result to tetracycline with more sus-
ceptibility to E. coli than S. aureus with acceptable in-vitro
cytotoxicity of porcine endothelial cells and higher average
knot-pull tensile strength than the standard USP require-
ment.140 Static and dynamic suture-to-suture friction, and
bending stiffness were altered during antibacterial treat-
ment.143 Ophthalmic drug-eluting sutures containing levo-
floxacin loaded poly (L- lactic acid) and polyethylene glycol
made from biocompatible polymers with hydrophilic poly-
mer (microfiber) for use in ocular surgery inhibited the bac-
terial growth (S. epidermidis) and infection rate in rats.188
Vancomycin grafted onto polypropylene suture with acrylic
polymer by ionic interaction with acrylic acid moieties but
not by covalent immobilization through glycidyl groups of
glycidyl methacrylate reported sustained release of the
drug.144
Casalini et al.189 investigated a theoretical model of a
bioresorbable (poly – e – caprolactone) suture with an
active lidocaine and their release kinetics in tissues. The
study reported that increasing the diffusion coefficient and
half-life of the drug improved the potency of the drug elut-
ing from the suture material. Meanwhile, release of lido-
caine from suture extended the analgesic effects on tissue
for nearly 75 h on anaesthetized tissue thus reducing the
post-operative pain.189 Recently, Weldon et al.141 developed
a local anaesthetic (bupivacaine)—eluting PLGA-based
suture material through electrospinning process at varying
concentration of anaesthetic. The electrospun drug-eluting
suture exhibited desirable mechanical property along with
significant drug diffusion into the tissues at the incision site
in rats. The drug-release kinetics was directly proportional
to the concentration of drug loaded on to the suture mate-
rial. This drug-eluting suture was reported to be clinically
useful as it offered postoperative analgesia for 7–10 days
and with maximum degree of analgesia for  3 days. The
tissue reaction to the fabricated local anaesthetic-eluting
sutures was similar to that of commercially available FDA
approved PLGA sutures with no evidence of any adverse
reactions.141 Design of core—sheath architecture based
yarns from electrospinning process can yield mechanically
strong and flexible suture threads which favors incorpora-
tion of bioactive molecules/dyes and these yarns can be
extended into multifilament sutures through braiding pro-
cess for versatile use.190
An in vivo study reported the inhibition of neointimal
hyperplasia, inflammatory response and granulation tissue
formation with a drug-eluting suture coated with tacrolimus
in porcine model.145 The controlled release of drugs pre-
vented neointimal hyperplasia at the anastomotic suture
site by direct diffusion of drugs into all the layers of blood
vessel wall—intima, media, and adventitia. This strategy can
possibly be effective in both coronary artery bypass graft
surgery and peripheral vascular bypass surgery.145 Zurita
1552 DENNIS ET AL.
et al.184 investigated drug (Ibuprofen—a Non-Steroidal Anti-
inflammatory Drug) loading and their release profile in poly
(p-dioxaonone) monofilament surgical sutures. With release
period of longer than 120 hrs, the drug coated monofila-
ment poly (p-dioxaonone) suture material reported to affect
mechanical property of suture slightly due to swelling and
diffusion process. Lee et al.146 reported surgical sutures
assembled with polymeric sheets loaded with ibuprofen ren-
dered sustained pain-relief post-operatively without com-
promising on the mechanical property of the sutures.
Immobilization of polyethyleneimine coated with dexameth-
asone and poly (lactic-co-glycolic acid) particles on absorb-
able suture surface showed controlled release of drug for 4
weeks without affecting mechanical property of the suture
material.147 Melt spun bioactive sutures containing nanohy-
brid of diclofenac with hydrotalcite revealed effective
release profile with excellent mechanical property than com-
pared with diclofenac with poly (e – caprolactone) fibers.148
The potential of drug-eluting sutures can be broadened
by fabricating sutures with multiple-drugs, in combination
that can exhibit synergistic and/or additive effect on the
desired site with limited payload.105–109 The fabrications
can be extended to produce drug-eluting braided sutures
with high tensile strength, flexibility and better handling
characteristics along with sustained release of drugs.141,191
Conversely, complications such as delayed wound healing,
severe scar formation and skin irritations in barbed
sutures192–194 warrants for more clinical studies and the
need for modifications with bioactives can widen its func-
tionality and reduce the adverse effects.110,195 Bioactive
barbed sutures with wide range of bioactive molecules and
its possible combinations can be deposited within the
barbed angles or elongated body of monofilament and mul-
tifilament barbed sutures to broaden its function and thera-
peutic.111 Recent progress in drug-eluting surgical sutures
and their clinical relevance is listed in Table III.
Stem cells seeded sutures
Biodegradable scaffolds are widely used in tissue engineer-
ing and regenerative medicine as a carrier to transplant and
differentiate stem cells to various tissues.196 Recent studies
revealed that sutures coated with growth factors or stem
cells could be used as a mode of delivery for these biologi-
cal components to the desired site.94,149 Sutures with bioac-
tive surface provide desirable tensile property and
degradation rate for rapid tissue regeneration after implan-
tation. The primary objective of stem cells seeded suture is
to increase the number of these cells at the injured site to
accelerate the tissue regeneration and repair.149 Although,
suture-based cell delivery appears to be a feasible approach
to transplant stem cells into the soft tissues of the body,
retaining the desired mechanical, and physical properties of
such sutures would be a major challenge.197 Recent
advancements in stem cells seeded sutures and their clinical
significance are listed in Table. III
An in vitro study by Yao et al.151 developed a bioactive
suture by seeding pluripotent stem cells onto a braided
suture material which proved to be beneficial in the
SUTURE MATERIALS

mechanical repair of tendons. The suture coated with poly-
L-lysine facilitated high level of cell adhesion than the
fibronectin-coated sutures and in vitro analysis of cells-
impregnated suture revealed that the cells were alive and
metabolically active to re-colonize the acellular zone in the
injured tendon tissues as they passed through rabbit’s ten-
don.151,152 Another study on rat Achilles tendon revealed
that bone marrow-derived mesenchymal stem cells on
sutures provide clinical advantage in tendon repair process
during the early phase of tendon healing on first two weeks
after surgery.153
Recently, a novel stem cells-seeded biological suture
material for use in cardiac surgery/tissue was developed.149
The human mesenchymal stem cell-seeded suture material
was developed by loading with quantum dot nanoparticles
to track the seeded cells within the myocardium.149 It was
found that the cell-seeded biological suture was able to
deliver the stem cells to the heart more efficiently than the
conventional manner (injection), illustrating a greater effi-
ciency in transplantation of stem cells in soft tissues in
rats,149 and reduction in fibrosis with increased mechanical
function of heart was reported.150 In another study, biosu-
ture developed from adipose-derived stem cells (ASCs) sup-
pressed local acute inflammation in the tracheal
anastomosis.154 The study reported that tissues with ASCs-
embedded sutures had abundant macrophages early on in
the damaged tissues and there almost no neutrophils. Previ-
ous reports on the use of stem cells coated biosutures in
colonic anastomosis showed no effect in anastomotic heal-
ing,198 whereas, colonic anastomosis with peritoneal instal-
lation of icodextrin 4% (adhesion-free environment) the
biosutures displayed more resistance than conventional
sutures.199 More recently, Reckhenrich et al.155 reported
biodegradable suture filled with ASCs showed equal distri-
bution of cells across the filament with improved viability
and increase metabolic activity of cells with release of cyto-
kines from in vitro wound healing assay. Furthermore,
sutures modified with mesenchymal stem cells showed
abundant deposition of collagen alpha-1(I) chain with rapid
recovery on wound healing.156
Sutures with growth factors and/or stem cells can be
used as a substitute to scaffolds in tissue engineering and
regenerative medicine. Sutures as a carrier in cell therapy
have advanced its clinical benefits with increased mechani-
cal function of heart, tendon repair, tracheal anastomosis
and wound healing with rapid recovery and tissue regenera-
tion in short duration. Significant high repairing strength,
resistance to gap formation and rapid healing with
enhanced clinical outcomes on tendon repair can expand its
use for critical orthopaedic injuries.152,200 Stem cell modi-
fied metallic sutures through nanocoatings with shape-
memory alloy (Nitinol) can broaden its clinical use for
orthopaedic application.112,113
Smart sutures
Shape-memory and elastic sutures. Development of smart
sutures from shape memory polymers can replace the con-
ventional sutures through self-tightening knots for deep
JOURNAL OF BIOMEDICAL MATERIALS RESEARCH A | JUN 2016 VOL 104A, ISSUE 6
REVIEW ARTICLE
wound closures by reducing the complexity for surgeons,
especially during key-hole surgeries. Shape-memory poly-
mers (SMPs) are capable to revert from deformed state
(temporary shape) to original state (permanent) by external
stimulation of energy such as heat, light, solution, magnetic,
or electric field.201 Smart sutures are pre-stretched filament
of smart material (temporary shape) above the critical tem-
perature and set to temporary shape by cooling below its
critical temperature. The suture is loosely connected on
wounds at controlled stress, on stimulus above the critical
point of temperature the suture regains to original state
and shape with defined tension across the surrounding tis-
sues.202,203 This facilitates the suture to change its shape
with rise in temperature either under body conditions or
using external source. Smart sutures exert great flexibility
and pliability with significant mechanical property to form
self-tightening knot for effective wound closure. Barbed
sutures on the whole or sections such as the barbs or
suture body can be produced from shape memory polymers
for intended tissue adherence and favorable clinical out-
come.111 This widens their application in cardiovascular,
orthopaedic, obstetrics surgery, and so forth, reducing the
complexity of knotting in confined space particularly in min-
imally invasive surgery.202 Moreover, incorporation of thera-
peutic, prophylactic and diagnostic agents within polymer
compositions of smart sutures can advance its function in
medical field.204–206
Implantation of nonelastic sutures may cause tissue
necrosis and slacking of sutures resulting in failure of
wound healing and can also tear out of the tissues during
early postoperative period especially during coughs.114
Newly developed thermoplastic polyurethane elastic sutures
are feasible and safe for midline laparotomy wound closure
with promising tensile characteristics to prevent post-
operative complications like burst abdomen after abdominal
surgery.114 Elastic sutures showed significant material
strength with mean elastic elongation of 56% after 10
cycles.114 The elastic suture material showed significantly
fewer inflammatory cells and improved collagen I/III ratio
compared to polypropylene sutures after 21 days in rab-
bits.114 Shape-memory polymers derived polyurethane
sutures with more elasticity and tensile strength, and with
self-tightening knots will expand its applications in clinical
use.207
Electronic sutures. Electronic sutures with the capability to
monitor, sense, and actuate typical biological responses in
the body would be very useful in improving localized tissue
health monitoring. Kim et al.208 reported on the develop-
ment of a smart electronic suture ( 1 mm wide and  3
mm thickness) with ultrathin, flexible silicon sensors inte-
grated on polymer or silk strips for wound monitoring. The
suture material was patterned in serpentine shape and the
design includes two temperature sensors of silicone and
platinum nanomembrane along with microheater made
from gold.208 Electronic suture can accurately measure the
elevated temperature which can be used to identify the
infection status and also helps in the maintenance of ideal
1553
temperature to support healing process with microheaters
at the wound site.208 The fabricated electronic suture was
highly flexible and pliable facilitating effortless threading
into surgical needles with considerable pull strength and
knotted without degradation of device in mouse.
With minimally invasive surgery and advancement in
suture technology gaining momentum, electronic sutures
with additional sensors to monitor pH, wound exudates, bac-
teria, oxygen, and enzymes along with temperature monitor-
ing system can facilitate accurate monitoring and improved
healing of acute and chronic wounds.115,116 Although several
potential markers have been identified for wound healing,
only few wound markers such as pH, oxygen, uric acid, hae-
moglobin, infection (including temperature and odor), and
protease activity are used for sensor application at present to
monitor and manage the wound site.115 In addition, integra-
tion of force sensors with feedback control tool in sutures
can help determine threshold of tension during the pulling
force applied by the surgeon to close the incision site in dif-
ferent tissues.117 This would enable the control and modula-
tion of high or low tensions in sutures at wound closure sites
thereby reducing the effect of disproportionate tension medi-
ated negative effects on wound healing.117 Smart barbed
sutures with sensing elements can broaden its application to
monitor and heal wound infections and can be useful in mini-
mally invasive procedures.
CONCLUSION
Surgical sutures play a vital role as a medical device in wound
management and recent advancements have expanded its
applicability and efficacy. Major progress in this front can be
attributed toward the technological advancements in materi-
als science. Polymers hold a significant potential with their
high flexibility giving rise to diverse suture materials with
excellent physical and mechanical properties. In addition, bio-
degradable polymers that can be easily broken down and
excreted or resorbed without removal or surgical reconsider-
ation have proven to be beneficial. These materials are also
well known for ability as carriers for drugs, stem cells, pro-
teins, peptides, antibodies, DNA, nanoparticles, and so forth,
to the desired site thereby enhancing the therapeutic poten-
tial of sutures. The principle function and efficacy of sutures
depends on the physico-mechanical properties and it is vital
to retain these characteristics while they are modified or
coated with bioactive agents and sensors. In addition, to bet-
ter handling qualities and desired modifications, it should
also be noncarcinogenic, nontoxic, free of allergens, and
importantly it should not evoke any adverse response in the
host tissues. To meet these requirements, it is necessary to
conduct detailed pre-clinical studies and evaluate the safety
and efficacy in human trials on these emerging sutures. The
next generation of suture materials, an outcome of multidisci-
plinary efforts has immense potential to impact surgical out-
comes and wound management.
ACKNOWLEDGMENT
We thank Dr. Pradeep M Poonnoose, Department of Orthopae-
dics, Christian Medical College, Vellore, Dr. Reji Rajan Varghese
1554 DENNIS ET AL.
from Department of Biomedical Engineering, Cochin Medical Col-
lege and Dr. A. Nagendra Kumar from Department of Forensic
Medicine, Government Vellore Medical College, India for their
support and guidance toward the preparation of this article.
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