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• W3157867583 abstract "The use of suture to close wounds and bring tissues together is nearly as old as surgery itself. From surgery’s early days of cotton and dried gut, the evolution of medicine and technology have produced an explosion of suture options such that there now exist more than 5000 types, sizes, and varieties [10]. Most of us are largely ignorant of major suture characteristics beyond whether it is nonabsorbable or absorbable, braided or monofilament, and generally seems to do what we want it to do clinically [16]. However, new sutures have been developed over the last few years that have changed surgical practice. Barbed and bidirectional suture for facia and skin approximation can decrease operative time and overall costs, with most authors reporting equivalent clinical healing and complication rates [1, 4]. The development of so-called high–tensile strength sutures has also been widely adopted into practice. Indeed, these sutures are now so ubiquitous for a variety of indications, from rotator cuff and other tendon repairs to ligament reconstructions, that we scarcely notice them—they just are. The tensile strength and stabilizing potential of these sutures is such that their use has been expanded to include the treatment of a variety of fracture and dislocation types (with or without accompanying anchors, washers, or buttons) in lieu of metal wires and implants [6, 7]. Problems like foreign body reactions to the Kevlar or silicone components of the high–tensile strength sutures have been reported [14] but at much lower rates than reported for early-generation synthetic tendon grafts [2]. Other considerations include the bacterial adherence potential and infection risk associated with these permanent, nonabsorbable implants [13]; fortunately, most procedures in which high–tensile strength sutures are required are clean. We’ve reached the point that the actual tensile strength of these high–tensile strength sutures is no longer a question, and in some cases, can be part of the problem. First, it is possible to sustain a friction burn (“rope burn”) or laceration to either one’s surgical gloves or hands with high–tensile strength sutures when aggressively tightening without the aid of instruments I know both have happened to me. The concept is not dissimilar from that of excessively rigid locking plates causing nonunions [5, 11], a problem that is remedied by permitting motion via far-cortical locking or active locked plating, as I’ve written about in this column before [17]. I am not suggesting that we make the sutures weaker or more prone to breakage, but we have strengthened one link in the reconstructive chain to such a point that we must now look at how to strengthen the others or improve the suture/tissue interface such that the same end is achieved. For example, if high–tensile strength sutures rarely exceed tensile ceilings under physiologic conditions and it can cut me, it must be prone to cutting through living tissue, right? Turns out, that is correct—the vast majority of rotator cuff tendon repair failures occur not through breakage or anchor pull-out; they fail, both in vivo and in vitro, through tendon cut-through [3, 8]. Next, we theoretically want to make these sutures tight … but not too tight. In reality, though, because we want to maximize the tendon, ligament, or bone opposition, we may be prone to tying these knots pretty much as tightly as we can. While tendons and ligaments are relatively avascular at baseline, it stands to reason that some perfusion is required to permit healing. The absolute degree of ischemia created may depend both on the tension at which the knot is secured as well as the stitch or repair technique utilized [12]. One promising advance in this area relates to so-called laxity-minimizing high–tensile strength sutures. The first such suture, Dynacord™ (DePuy Synthes, Mitek Sports Medicine), contains a silicone and salt core that effectively hydrates in vivo, resulting in both demonstrable axial shortening and radial expansion. Theoretically, this can minimize both suture laxity and knot slippage. These same properties might also broaden and improve tissue purchase, preventing creep of either suture or tissue. Two biomechanical studies support these suppositions. The first study utilized an in vivo ovine model and compared laxity-minimizing high–tensile strength sutures with in “industry standard” competitor at both 5 days and 6 weeks. The authors found the new suture to cause no adverse reactions in the test animals and had approximately one-half of the gap formation of the conventional ones [9]. The second study utilized a laboratory ovine model and noted less tendon cut-through with laxity-minimizing high–tensile strength sutures (2.69 ± 1.02 mm versus 3.72 ± 1.14 mm; p = 0.012) and further noted that this finding was present in 13 of 14 tested specimens [15]. But we still need confirmatory studies that prove that these differences improve repair integrity or patient-reported outcomes in humans. Meanwhile, biomechanical studies still seem fixated on which high–tensile strength sutures are strongest and stiffest (they are probably all strong and stiff enough), but at least consider creep under both static and dynamic loads in their analyses [18]. Further, this column is not intended as a Dynacord™ advertisement. I’m pretty sure I’ve never used it, and one could just as easily imagine an alternate suture with broad, grippy, noncrushing, and nonlacerating tissue purchase that can simply stretch and recoil to maintain repair opposition and minimize gapping. One could also imagine either adverse reactions developing around this suture, as we have seen with other synthetic sutures and ligaments [2, 14], or the additional tissue compression upon rehydration applying too much additional tension when utilized in vivo, leading to strangulation. What’s exciting here is the concept: A laxity-minimizing high–tensile strength suture that represents a promising new approach to soft tissue repair and warrants further study. We need to critically consider tissue purchase, perfusion, cut-through, and creep in future studies. We should seek to make our repairs and reconstructions both strong and, like a master yogi or Gumby himself, flexible. Namaste." @default.
• W3157867583 created "2021-05-10" @default.
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• W3157867583 date "2021-05-05" @default.
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• W3157867583 title "From Bench to Bedside: Semper Gumby—Like Living Tissue, Let’s Stay Flexible" @default.
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