By confocal microscopy a qualitatively greater amount of bacteria adhered to Vicryl* as compared with PDS* (Fig. 5). A brighter green signal was seen in the grooves throughout the length of the Vicryl suture, whereas few bacteria were seen throughout the length of the PDS suture. Confocal microscopy of the Quill suture showed adherence patterns similar to those of the PDS suture.
Previous research has shown the superiority of monofilament sutures in contaminated wounds [1-3, 10, 13, 14, 20, 25]. Barbed monofilament suture is being used more frequently as a result of its efficiency, cost savings, and improved or comparable wound closure outcomes [5, 7, 15-17, 19, 21, 23, 24, 26, 28]. The use of barbed monofilament suture for closure in a TKA has shown superiority in tightness of closure and failure analysis [16, 24]. However, the barbed nature of this monofilament suture has the theoretical concern of the barbs acting as a place for bacteria to hide, resulting in higher infection rates if contaminated wounds are closed with barbed monofilament suture. We therefore determined (1) the adherence of bacteria to each of five suture types including a barbed monofilament suture; (2) the ability to culture bacteria after gentle washing of each suture type; and (3) the pattern of bacterial adherence.
There are several limitations of this study. First, these in vitro data may not translate directly to the in vivo setting. Although we have attempted to simulate incubation of the sutures with bacteria, this scenario would not necessarily be replicated in vivo. Second, this study does not control for numerous factors that would be present in vivo, such as the properties of specific bacteria, presence of gross tissue infection or biofilm formation at the site, an active immune system, and the flow of fluids over the sutures. Third, we chose to use MRSA for our study as it is the most common isolate at our institution (66% of all Staphylococcus cultures). One study suggested coagulase negative Staphylococcus aureus to be the most common bacteria isolated from wounds . Different bacteria could have different adherence properties and could affect our findings. Further studies comparing the adherence patterns of different bacteria are needed. Fourth, we chose to use planktonic bacteria rather than a biofilm. Bacteria in a biofilm, a common finding in infected total joint arthroplasties, likely would show increased adherence and that could alter our findings.
Barbed monofilament suture appears to have comparable performance to monofilament suture in a contaminated wound model. The barbed monofilament suture, Quill, showed less bacterial adherence than Vicryl and Vicryl Plus, both absorbable braided sutures. Antibacterial-coated sutures effectively prevented bacterial growth, although adherence to the suture was unchanged compared with nonantibacterial-coated sutures. Although in vivo models will be needed to confirm use of this in vitro model in the clinical setting, our observations suggest barbed monofilament suture might be substituted for monofilament suture, at the surgeon’s discretion, without fear of increased risk of infection.
1. Alexander, JW., Kaplan, JZ. and Altemeier, WA. Role of suture materials in the development of wound infection. Ann Surg.
1967; 165: 192-199. 10.1097/00000658-196702000-00005
2. Ananthakrishnan, N., Rao, RS. and Shivam, S. Bacterial adherence to cotton and silk sutures. Natl Med J India.
1992; 5: 217-218.
3. Edlich, RF., Panek, PH., Rodeheaver, GT., Turnbull, VG., Kurtz, LD. and Edgerton, MT. Physical and chemical configuration of sutures in the development of surgical infection. Ann Surg.
1973; 177: 679-688. 10.1097/00000658-197306000-00006
4. Edmiston, CE., Seabrook, GR., Goheen, MP., Krepel, CJ., Johnson, CP., Lewis, BD., Brown, KR. and Towne, JB. Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination? J Am Coll Surg.
2006; 203: 481-489. 10.1016/j.jamcollsurg.2006.06.026
5. Einarsson, JI., Vellinga, TT., Twijnstra, AR., Chavan, NR., Suzuki, Y. and Greenberg, JA. Bidirectional barbed suture: an evaluation of safety and clinical outcomes. JSLS.
2010; 14: 381-385. 10.4293/108680810X12924466007566
6. Elek, SD. and Conen, PE. The virulence of staphylococcus pyogenes for man: a study of the problems of wound infection. Br J Exp Pathol.
1957; 38: 573-586.
7. Jandali, S., Nelson, JA., Bergey, MR., Sonnad, SS. and Serletti, JM. Evaluating the use of a barbed suture for skin closure during autologous breast reconstruction. J Reconstr Microsurg.
2011; 27: 277-286. 10.1055/s-0031-1275491
8. Jones, RD., Jampani, HB., Newman, JL. and Lee, AS. Triclosan: a review of effectiveness and safety in health care settings. Am J Infect Control.
2000; 28: 184-196. 10.1016/S0196-6553(00)90027-0
9. Kathju, S., Nistico, L., Hall-Stoodley, L., Post, JC., Ehrlich, GD. and Stoodley, P. Chronic surgical site infection due to suture-associated polymicrobial biofilm. Surg Infect (Larchmt).
2009; 10: 457-461. 10.1089/sur.2008.062
10. Katz, S., Izhar, M. and Mirelman, D. Bacterial adherence to surgical sutures: a possible factor in suture induced infection. Ann Surg.
1981; 194: 35-41. 10.1097/00000658-198107000-00007
11. Krizek, TJ. and Robson, MC. Evolution of quantitative bacteriology in wound management. Am J Surg.
1975; 130: 579-584. 10.1016/0002-9610(75)90516-4
12. Masini, BD., Stinner, DJ., Waterman, SM. and Wenke, JC. Bacterial adherence to high-tensile strength sutures. Arthroscopy.
2011; 27: 834-838. 10.1016/j.arthro.2011.02.003
13. Masini, BD., Stinner, DJ., Waterman, SM. and Wenke, JC. Bacterial adherence to suture materials. J Surg Educ.
2011; 68: 101-104. 10.1016/j.jsurg.2010.09.015
14. Mehta, PH., Dunn, KA., Bradfield, JF. and Austin, PE. Contaminated wounds: infection rates with subcutaneous sutures. Ann Emerg Med.
1996; 27: 43-48. 10.1016/S0196-0644(96)70295-0
15. Murtha, AP., Kaplan, AL., Paglia, MJ., Mills, BB., Feldstein, ML. and Ruff, GL. Evaluation of a novel technique for wound closure using a barbed suture. Plast Reconstr Surg.
2006; 117: 1769-1780. 10.1097/01.prs.0000209971.08264.b0
16. Nett, M., Avelar, R., Sheehan, M. and Cushner, F. Water-tight knee arthrotomy closure: comparison of a novel single bidirectional barbed self-retaining running suture versus conventional interrupted sutures. J Knee Surg.
2011; 24: 55-59. 10.1055/s-0031-1275400
17. Parikh, PM., Davison, SP. and Higgins, JP. Barbed suture tenorrhaphy: an ex vivo biomechanical analysis. Plast Reconstr Surg.
2009; 124: 1551-1558. 10.1097/PRS.0b013e3181babb77
19. Rashid, RM., Sartori, M., White, LE., Villa, MT., Yoo, SS. and Alam, M. Breaking strength of barbed polypropylene sutures: rater-blinded, controlled comparison with nonbarbed sutures of various calibers. Arch Dermatol.
2007; 143: 869-872. 10.1001/archderm.143.7.869
20. Shambaugh, P. and Dunphy, J. Postoperative wound infections and the use of silk: an experimental study. Surgery.
1937; 1: 379-385.
21. Shermak, MA., Mallalieu, J. and Chang, D. Barbed suture impact on wound closure in body contouring surgery. Plast Reconstr Surg.
2010; 126: 1735-1741. 10.1097/PRS.0b013e3181ef8fa3
22. Shuman, EK., Urquhart, A. and Malani, PN. Management and prevention of prosthetic joint infection. Infect Dis Clin North Am.
2012; 26: 29-39. 10.1016/j.idc.2011.09.011
23. Sulamanidze, M. Evaluation of a novel technique for wound closure using a barbed suture. Plast Reconstr Surg
2007; 120: 349-50.
24. Vakil, JJ., O’Reilly, MP., Sutter, EG., Mears, SC., Belkoff, SM. and Khanuja, HS. Knee arthrotomy repair with a continuous barbed suture: a biomechanical study. J Arthroplasty.
2011; 26: 710-713. 10.1016/j.arth.2010.07.003
25. Varma, S., Ferguson, HL., Breen, H. and Lumb, WV. Comparison of seven suture materials in infected wounds: an experimental study. J Surg Res.
1974; 17: 165-170. 10.1016/0022-4804(74)90103-6
26. Villa, MT., White, LE., Alam, M., Yoo, SS. and Walton, RL. Barbed sutures: a review of the literature. Plast Reconstr Surg.
2008; 121: 102e-108e. 10.1097/01.prs.0000299452.24743.65
27. Zamora, N., Esteban, J., Kinnari, TJ., Celdran, A., Granizo, JJ. and Zafra, C. In-vitro evaluation of the adhesion to polypropylene sutures of non-pigmented, rapidly growing mycobacteria. Clin Microbiol Infect.
2007; 13: 902-907. 10.1111/j.1469-0691.2007.01769.x
28. Zaruby, J., Gingras, K., Taylor, J. and Maul, D. An in vivo comparison of barbed suture devices and conventional monofilament sutures for cosmetic skin closure: biomechanical wound strength and histology. Aesthet Surg J.
2011; 31: 232-240. 10.1177/1090820X10395010