Strength Retention of Chromic Gut and Synthetic
Absorbable Sutures in a Nonhealing
Synovial Wound
MARKWALTON,M.Sc., PH.D.
The rate at which absorbable sutures lose their
mechanical strength in a slow healing wound is
clinically important, particularly because the fac-
tors inhibiting normal healing are not always ap-
parent at the time of closure. Sutures of chromic
catgut and two monofilament absorbable synthetic
suture materials (polydioxanone and polyglycon-
ate) were used to close a synovial incision in the
knees of sheep. A corticosteroid was applied
around the wound resulting in minimal tissue heal-
ing when the sutures were retrieved up to six
weeks later. The failure load and maximum tensile
strength of the retrieved sutures were measured.
The mechanical degradation of the materials fol-
lowed a pattern similar to that in normally healing
wounds except that the early fragmentation of
chromic gut and polydioxanone occurred far less
frequently and neither weakened further after
three weeks. Polyglyconate was significantly the
strongest material up to three weeks but thereafter
continued to weaken. The strength of absorbable
sutures was retained longer than in a healing lesion
probably because of the absence of the phagocytic
cells of an inflammatory tissue.
In orthopedic practice there are many situa-
tions in which the healing potential of wound
tissues is limited or absent. Local infection,
aseptic wound contamination, interposition
of tissue or implanted materials, tissue necro-
sis, steroid therapy, impaired blood supply,
From the Department of Orthopedic Surgery, Univer-
sity of Otago Medical School, Dunedin, New Zealand.
Supported by the New Zealand Medical Research
Council and the American Cyanamid Company.
Reprint requests to Mark Walton, Ph.D., Department
of Orthopaedic Surgery, Dunedin Hospital, Private Bag,
Dunedin, New Zealand.
Received: November 28. 1989.
294
radiotherapy, and systemic factors such as
malnutrition can affect the ability of a tissue
to heal. One or several of these factors may be
present in a wound but unapparent at the
time of wound closure. The role of sutures
has added importance in the nonhealing
wound because they are required to carry the
mechanical loads associated with maintain-
ing closure for a longer period of time. Ab-
sorbable sutures are commonly used in
wound closure, so clearly it is important to
test their strength retention in nonhealing
wounds.
In a previous experimental study, the
strength of three materials (chromic gut,
polydioxanone, and polytrimethylene car-
bonate, subsequently renamed polyglycon-
ate) in the form of No. 2-0 absorbable su-
tures, was measured up to six weeks after
closing a surgical incision through healthy sy-
novial tissue in sheep knee Joints.4 There is
some doubt concerning the validity of extrap-
olating the results obtained from that study
to predict suture performance in a nonhea-
ling wound, because the two situations have
different physiologic environments. In nor-
mal wound healing, a rampant localized in-
flammatory reaction develops, whereas this
reaction is absent when healing does not oc-
cur. Therefore, the previous study was re-
peated, but the strength retention of the su-
tures was measured after the wound had been
treated with a local application of corticoste-
roid, which inhibits an inflammatory reac-
Number 267
June. 1991
tion and thereby severely curtails the ability
of the tissues to heal.’
MATERIALS AND METHODS
The surgical method has been described
p r e v i ~ u s l y Briefly,
.~ adult cross-bred ewes were
anesthetized by induction with thiopental fol-
lowed by maintenance using halothane in a ni-
trous oxide/oxygen mixture. One knee was shaved
and a medial parapatellar incision using sterile
techniques was made to the depth of the joint cap-
sule. Care was taken to make a single straight inci-
sion through the capsule and synovial tissue.
A No. 2-0 suture of the test material was sewn
across the wound using a mattress stitch. Before
tightening, 1 ml of triamcinolone (Kenacort-A 40,
E. R. Squibb & Sons, Princeton, New Jersey) was
injected into the joint cavity using a syringe. Some
of the steroid was encouraged to spill out of the
wound and onto adjacent tissues but not on the
skin or subcutaneous tissue. The wound was
closed with sufficient tension to make it water-
tight. Rather than tying a distal knot, the leading
end of the thread was brought forward and a single
knot was tied proximally, thus aiding later re-
trieval. The remaining length of test suture was
retained for mechanical testing.
Superficial layers were closed with No. 2-0 su-
tures of polyglactin 910 (Vicryl, Ethicon, Somer-
ville, New Jersey) or polyglycolic acid (Dexon,
Davis & Geck, Manati, Puerto Rico). After recov-
ery from anesthesia, the animals were kept over-
night in canvas slings that allowed them to stand
or supported them if required. They were then re-
turned to open fields. The sutures were retrieved
from groups of six animals at one, two, three, four,
and six weeks and wrapped in saline-dampened
swabs for up to two hours at room temperature
until mechanically tested.
This surgical procedure was repeated in groups
of 30 animals for chromic gut (Ethicon, Somer-
ville, New Jersey) green polyglyconate (Maxon,
Davis & Geck; formerly called polytrimethylene
carbonate) and violet polydioxanone (PDS, Eth-
icon).
Each type of suture material was from the same
batch obtained from commercially available
stocks and was verified to be within the period
before expiration of the storage date. All sutures
were handled in an identical manner.
At least three diameter measurements were
taken along the length of each suture sample using
a Nikon Measurescope with digital counter (To-
kyo, Japan). Each sample was cut into three
lengths, which in turn were clamped between 2.5-
cm-sided, rubber-faced jaws of an Instron 1193
materials testing machine (High Wycombe, En-
gland). Crosshead speed was set at 200 mm per
Suture Strength in Nonhealing Wounds 295
minute and a record was made of the applied load
when the suture failed in tension. Analyses ofvari-
ance were calculated to determine statistical signifi-
cance between values.
RESULTS
A total of 90 knee wounds were closed. Of
these, two became infected and six healed de-
spite the steroid treatment. The procedure
was therefore repeated on an additional eight
animals.
The skin always healed normally. How-
ever, there was minimal healing beneath the
skin, with the soft tissues appearing pale with
the absence of visible blood vessels. There
was no indication of an inflammatory re-
sponse in or around the wound. In most
cases, even at six weeks the configuration of
the tissues and sutures was not much differ-
ent from that at operation, with the sutures
still in their implanted positions. By the third
and fourth weeks, the polyglactin 9 10 and
polyglycolic acid sutures were either very
weak but intact or extensively fragmented. At
six weeks only knots were present. Conse-
quently, from four weeks there was dehis-
cence of the tissues superficial to the synovial
wound, though occasionally they were joined
by a thin membrane.
Normally, the synovial wound parted as
the test suture was unthreaded. In some, lim-
ited vascularization was accompanied by frag-
ile edematous repair tissue, which could be
easily parted using forceps. All test sutures
could be readily pulled through the tissue and
retrieved.
Polydioxanone displayed signs of degrada-
tion as early as two weeks with the appear-
ance of short lengths along which the violet
dye was absent; these were the same locations
where the material fractured during mechan-
ical testing. Over subsequent periods the
polydioxanone had frequently hardened so
that great care had to be taken to extract the
brittle sutures to avoid breakages. Six of the
30 polydioxanone sutures had broken in at
least one place before retrieval. With the ex-
ception of one specimen that was fragmented
at four weeks, polyglyconate sutures were re-

296 Walton
trieved intact at all time intervals, although
they were very weak at six weeks. Chromic
gut was readily retrieved intact from all speci-
mens, although a few threads were frayed or
thinned at three weeks.
Clinically, the most relevant parameter is
the load required to break the suture. How-
ever, a weaker material may have a higher
failure load than a stronger one because it is
manufactured as a thicker strand (yet still
within the United States Pharmacopoeia
(USP) standard). Thus, for each material, it is
necessary not only to measure the tensile
load at which the material fails but also to
calculate the tensile breaking strength, i. e.,
the failure load in relation to the cross-sec-
tional area of the thread.
Before they were implanted, chromic gut
and polydioxanone sutures could sustain sim-
ilar loads (4.76 kg and 4.90 kg, respectively;
Fig. 1). Subsequent weakening with increas-
ing implantation time was more rapid with
gut, but average values from three weeks on-
ward were similar in chromic gut and poly-
dioxanone (0.93 kg and 1.57 kg, respec-
tively). In comparison, polyglyconate had a
mean failure load of 6.94 kg, which was signif-
icantly stronger (p I 0.001) than the other
materials. This superior strength continued
up to three weeks, but then, unlike chromic
gut and polydioxanone, it continued to
Poiyglyconote
0Polydioxonone
0Chromic Gut
0 1 2 3 6 5
Weeks After Implant
FIG.I . Failure load of suture materials retrieved
after various intervals of implantation in a non-
healing synovial wound.
Clinical Orthopaedics
and Related Research
80 Polyglyconole
l o o r - Gul
A Chromic
Polydioxonone
Weeks After Implant
FIG.2. Retention of failure load.
weaken throughout the study period, reach-
ing a failure load of 0.20 kg at six weeks, mak-
ing it significantly weaker (pI 0.00 1) at that
stage than the other two materials (Fig. 2).
Polyglyconate maintained a more consistent
level of performance throughout the experi-
ment as demonstrated by standard errors that
were one third or less those of the other two
materials.
There was a considerable increase in the
diameter of the gut sutures from 0.381
-t 0.003 mm to 0.558 ~t 0.0 18 mm during the
first week. However, there was no subsequent
significant change from then on. Neither
polyglyconate sutures at 0.387 k 0.003 mm
nor polydioxanone at 0.357 0.002 mm*
changed significantly during the study pe-
riod.
Chromic gut was the weakest material, and
its strength fell rapidly over the first week be-
cause of its rapid decrease in failure load and
its considerable increase in diameter. The
tensile strength of the synthetic materials fell
in parallel over the first three weeks, though
polyglyconate was the stronger of the two
(Figs. 3 and 4). From then on, polydioxanone
retained a mean value of 14.5 kg/cm2,
6 whereas pol yglyconate continued to decline,
reaching 1.71 kg/cm2 at six weeks. At each
time interval the mean value of polydioxan-
one was calculated from a range of results,
and the standard errors of the mean were
Number 267
June, 1991
6oooL
5000
3000
1000
Weeks After Implant
FIG. 3. Tensile strength of suture materials re-
trieved after various intervals of implantation in a
nonhealing synovial wound.
consistently higher relative to those of chro-
mic gut and polyglyconate.
DISCUSSION
This study has shown that when a cortico-
steroid severely impedes wound healing in a
synovial wound of a sheep, chromic gut loses
strength rapidly over the first week but from
then on retains approximately 12%ofits origi-
nal strength. Polydioxanone and polyglycon-
ate synthetic absorbable sutures lose their
strength slowly for three weeks, after which
polydioxanone retains 15% of its original
strength, whereas polyglyconate continues its
steady decline for six weeks. Chromic gut
swells considerably; polydioxanone becomes
brittle and occasionally fractures, whereas
polyglyconate remains unaltered in its han-
dling characteristics. Despite these time-de-
pendent changes, the wound edges were
maintained in apposition by the various su-
tures over the six weeks of the experiment.
Sutures of all three tested materials were still
present in their original placement despite
the absence of any healing and the early post-
operative remobilization of the joint.
In an experiment that was identical except
that the wound was allowed to heal normally,
the sutures became embedded in inflamma-
tory tissue formed in reaction to the surgical
Suture Strength in Nonhealing Wounds 297
insuk4 In that environment, chromic gut
continued to lose strength after the first week,
probably because of phagocytosis, which
thinned the thread, causing it to break into
short lengths. The two synthetic materials re-
tained a higher tensile strength for longer, but
polydioxanone had lost color and broken
into multiple fragments by four weeks,
whereas polyglyconate survived intact to six
weeks. Yet even the chromic gut sutures held
the incised but otherwise healthy tissues to-
gether sufficiently for them to heal over the
first two weeks.
By comparison, in the present study, chro-
mic gut weakened in a similar manner but
not to such low values and survived intact.
Polydioxanone lost strength faster after two
weeks but had increased longevity because of
a lower incidence of fragmentation. The rate
of loss of strength of polyglyconate was al-
most identical in both types of wounds.
Fragmentation of chromic gut and poly-
dioxanone occurred far less frequently than
in the comparable healing wound. The chro-
mic gut was not absorbed because of the ab-
sence of macrophages that would have been
present had inflammatory tissue formed. The
readiness with which the chromic gut suture
pulled out of the nonhealing wound was in
complete contrast to retrieval from early in-
flammatory tissue when it was difficult and
later impossible to retrieve the thread be-
FIG.4. Retention of tensile strength.

298 Walton
TABLE 1. Comparison of Results From Nonimplanted Lengths of Sutures
With a Previous Study4
C’huracteristics Chromic Gut
Failure load (kg)
Healing 4.810 f 0.140
Nonhealing 4.760 +- 0.220
Diameter (mm)
Healing 0.396 f 0.008
Nonhealing 0.381 f 0.003
Tensile strength (kg/cm2)
Healing 4032.000 f 158.000
Nonhealing 4194.000 f 202.000
cause of its partial r e ~ o r p t i o nIt. ~would also
appear that the absence of inflammatory tis-
sue influences polydioxanone degradation
because it fragments far less frequently in the
nonhealing wound.
The synthetic suture materials degrade in
two steps. First, hydrolysis depolymerizes
their long molecular chains to much shorter
polymers and second, the shorter polymers
then undergo phagocytosis.’ The early loss of
strength of polydioxanone during the first
three weeks must therefore have been due to
hydrolysis. The second phase of phagocytosis
that caused fragmentation in the healing
wound did not occur in the steroid-treated
wounds because of the absence of phagocytic
cells. The polyglyconate lost strength in a
near linear manner, suggesting a steady chem-
ical degradation with no cellular involve-
ment.
There was little difference between the val-
ues in this and the previous study for failure
load and tensile strength of chromic gut and
polydioxanone from the packet (Table 1).
However, the tensile strength of polyglycon-
ate was much higher because of a slightly in-
creased failure load and marked decrease in
diameter. This would suggest that there has
been a change in polymer formulation or
manufacture during the interval between the
two studies.
Visual assessment suggested that the poly-
glactin 910 and polyglycolic acid sutures in
Clinical Orthopaedics
and Related Research
Polygiyconate Polydioxanone
6.680 f 0.160 4.890 3: 0.050
6.940 f 0.130 4.900 31 0.030
0.406 f 0.000 0.357 3: 0.004
0.387 -t 0.003 0.357 3: 0.002
4933.000 t 150.000 478 1.000 3: 87.000
5916.000 +- 117.000 4907.000 f 66.000
the superficial tissues absorbed over the same
time period as they had in the normally heal-
ing synovial wound.4 Therefore, their disso-
lution appears to be only by hydrolysis, so the
presence or absence of macrophages has little
influence on this process. This observation
has been previously recorded for polyglactin
9 Though the braided form of these two
suture materials gives them superior han-
dling characteristics, their longevity within
tissues of the experimental model was clearly
inferior to the two monofilament suture ma-
terials. The monofilament synthetic sutures
should, therefore, be the preferred choice of
the surgeon if delayed healing is suspected.
ACKNOWLEDGMENT
The author thanks Mrs. Jacqui Thomson for her tech-
nical assistance.
REFERENCES
I . Bhussry, B. E., and Rao, S.: Histochemical response
to experimental skin injury in rats. Biochem. Phar-
macol. 17[Suppl.]:51, 1968.
2. Katz, A. R., and Turner, R. J.: Evaluation of tensile
and absorption properties of polyglycolic acid su-
tures. Surg. Gynecol. Obstet. I3 I :70 I . 1970.
3. Salthouse, T. N., and Matalaga, B. F.: Polyglactin
910 suture absorption and the role of cellular en-
zymes. Surg. Gynecol. Obstet. 142544, 1976.
4. Walton, M.: Strength retention of chromic gut and
monofilament synthetic absorbable suture materials
in joint tissues. Clin. Orthop. 242:303. 1989.