Abstract
Background
Soft tissue injuries are frequently repaired using various suture material. The ideal suture should have the biomechanical properties of low displacement, high maximum load to failure, and high stiffness to avoid deformation. Since tendon healing occurs over a period of months, it is important for the surgeon to select the proper suture with certain biomechanical properties. Therefore, the purpose of this study is to qualitative summarize the published literature on biomechanical properties of different suture materials used in orthopaedic procedures.
Methods
Following PRISMA guidelines, PubMed and Cochrane databases were queried for original articles containing “biomechanic(s)” and “suture” keywords. Following screening for inclusion and exclusion, final articles were reviewed for relevant data and collected for qualitative analysis. Data collected from each study included the tissue type repaired, suture material, and biomechanical properties, such as elongation, maximum load to failure, stiffness, and method of failure.
Results
17 articles met final inclusion criteria. Two studies found No.2 Fiberwire™ to have the lowest elongation and 4 studies found No. 2 Ultrabraid™ to have the greatest. 12 studies reported Maximum load to failure was highest in No. 2 Fiberwire™, No. 2 Ultrabraid™, and FiberTape™ while No. 2 Ethibond ™ had the lowest in 5 studies. 3 of the 5 studies that evaluated No. 2 Fiberwire™ found it to have the highest stiffness. No. 2 Ethibond™, No. 2 Orthocord™, and No. 2 PDS™ were reported as the least stiff sutures in 2 studies each.
Conclusion
Fiberwire™, FiberTape™, and Ultrabraid™ demonstrated the highest load to failure while Ethibond™ consistently was the weakest. Fiberwire™ was found to have the lowest elongation while Ultrabraid™ had the highest. Fiberwire™ was also noted to be the stiffest while PDS, Ethibond™, and Orthocord™ were found to be the least stiff. Final treatment decisions on which suture to utilize to optimize repair integrity and healing are complex, and rarely solely dependent upon the biomechanical properties of the materials used.
Level of evidence
Systematic Review, Level IV.
Keywords: Suture, Biomechanics, Elongation, Maximum load, Stiffness
1. Introduction
Surgical repair of soft-tissue injuries is indicated for a variety of pathologies. Tendon ruptures such as the Achilles, quadriceps, triceps, and rotator cuff are frequently repaired utilizing a variety of different suture materials. Other soft-tissue structures such as the menisci and labrum are intra-articular and are frequently repaired with implants utilizing sutures but pose unique challenges with sutures contacting the articular cartilage (see Table 1, Table 2, Table 3).
Table 1.
Elongation of suture materials. Values displayed as mean millimeters (standard deviation).
| Elongation | Bisson (2008) | Bisson (2010) | Matthews (2020) | Rose (2011) | Feucht (2015) | Taha (2020) | Nakama (2019) | Hurwit (2010) | Martin (2014) |
|---|---|---|---|---|---|---|---|---|---|
| LigaFiber | 0.55 | ||||||||
| No. 2 PDS | 0.6 (0.2) | ||||||||
| Fiber Tape | 1.90 (1.15) | 0.98 | 1.0 (0.2) | 0.66 (0.14) | |||||
| No. 2 Orthocord | 1.04 (0.18) | 1.59 (0.31) | 0.83 (0.18) | 0.73 (0.11) | |||||
| No. 2 Fiberwire | 0.95 (0.40) | 1.45 (0.41) | 0.8 (0.3) | 0.90 (0.13) | 0.87 (.04) | ||||
| No. 2 Ethibond | 0.98 (0.29) | 0.8 (0.1) | 2.06 (0.05) | 2.17 (.11) | |||||
| 2–0 Fiberwire | 0.95 (0.17) | ||||||||
| OrthoFiber | 0.96 | ||||||||
| No. 0 Fiberwire | 1.09 (0.17) | ||||||||
| Tiger Wire | 1.09 (0.29) | ||||||||
| Labral Tape | 1.20 (0.33) | ||||||||
| No. 5 FiberWire | 1.3 | ||||||||
| Ultra-tape | 1.36 (0.18) | 2.49 (0.62) | 2.36 (0.47) | ||||||
| Tiger Tape | 1.39 (0.29) | ||||||||
| No. 2 MagnumWire | 1.43 (0.25) | 3.19 (.25) | |||||||
| No. 2 Ultrabraid | 1.48 (0.30) | 1.91 (0.34) | 4.18 (0.85) | 2.76 (0.44) | |||||
| 3–0 V-Loc | 2.65 (0.56)_ | ||||||||
| No. 0 Ethibond | 2.69 (0.57) | ||||||||
| Stratafix | 2.71 (0.59) | ||||||||
| No. 2 ForceFiber | 3.43 (0.28) | ||||||||
| Nylon | 3.75 |
Table 2.
Load to failure of suture materials. Values displayed as mean Newtons (standard deviation).
| Max Load to Failure | Bisson (2008) | Bisson (2010) | Matthews (2020) | Gomide (2019) | Rose (2011) | Liu (2017) | Feucht (2015) | Najibi (2010) | Barber (2009) | Wust (2006) | Nakama (2019) | Petri (2012) | Martin (2014) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2–0 Ethibond | 39.9 (14.9) | ||||||||||||
| Stratafix | 42.3 (7.2) | ||||||||||||
| No. 2 PDS | 133.2 (35.4) | 170 (15) | 42.8 (16.7) | ||||||||||
| 3–0 V-Loc | 50.7 (8.8) | ||||||||||||
| No. 2 Fiberwire | 165 (49) | 168 (73) | 240.17 | 145 (14) | 169.0 (43.4) | 282 (30) | 259.70 (85.81) | 307 (22) | 50.9 (22.4) | ||||
| No. 0 Ethibond | 73 (5) | 169.47 (58.18) | |||||||||||
| 2–0 Vicryl | 76 (3) | ||||||||||||
| No. 2 Ethibond | 133 (15) | 97.98 | 146.1 (20.6) | 134 (9) | 143.92 (16.57) | 137 (5) | |||||||
| No. 0 Vicryl | 105 (6) | ||||||||||||
| 2–0 Fiberwire | 124.55 (14.69) | ||||||||||||
| No. 1 Vicryl | 130 (9) | ||||||||||||
| No. 2 Ticron | 136 (3) | ||||||||||||
| No. 0 Fiberwire | 148.44 (15.41) | ||||||||||||
| No. 2 Orthocord | 152 (56) | 228.13 (29.55) | 221.80 (81.79) | 282 (13) | |||||||||
| Ultra-tape | 198.94 (39.23) | 172.03 (80.40) | |||||||||||
| No. 2 Ultrabraid | 181 (55) | 218.91 (45.69) | 233.95 (62.11) | 313 (7) | 184.35 (30.15) | ||||||||
| FiberTape | 184 (83) | 724.6 (84.9) | 218 (28) | 195.6 (62.1) | |||||||||
| No. 2 Magnum Wire | 190.09 (61.44) | 237.78 (64.51) | |||||||||||
| No. 5 Ethibond | 207.38 | 247 (10) | |||||||||||
| No. 2 Hi-Fi | 213.39 | 240.42 (62.50) | |||||||||||
| No. 5 TiCron | 226 (12) | ||||||||||||
| No. 2 MaxBraid | 237.90 (71.55) | ||||||||||||
| No. 2 ForceFiber | 246.25 (60.52) | ||||||||||||
| Tiger Wire | 251.03 (25.8) | ||||||||||||
| Labral Tape | 271.34 (48.48) | ||||||||||||
| Herculine | 276 (18) | ||||||||||||
| Tiger Tape | 287.43 (41.15) | ||||||||||||
| Nylon | 402.9 (5.2) | ||||||||||||
| No. 5 Fiberwire | 773.9 (11.0) | 620 (29) | |||||||||||
| OrthoFiber | 867.4 (25.4) | ||||||||||||
| Ligafiber | 1210.2 (65.6) |
Table 3.
Stiffness of suture materials. Values displayed as mean millimeters (standard deviation).
| Stiffness: | Bisson (2008) | Bisson (2010) | Matthews (2020) | Rose (2011) | Yamagami (2006) | Feucht (2015) | Taha (2020) | Najibi (2010) | Hurwit (2014) |
|---|---|---|---|---|---|---|---|---|---|
| No. 2 Orthocord | 14.8 (2.5) | 75.28 (16.01) | 5.07 (0.74) | 24.4 (0.7) | |||||
| No. 2 Ultrabraid | 16.5 (3.8) | 88.05 (21.03) | 6.12 (0.81) | ||||||
| No. 2 Ethibond | 9.2 (2.3) | 11.3 (0.4) | 13.6 (0.8) | 7.40 (2.38) | 13 (2) | 16.3 (0.5) | |||
| No. 2 PDS | 8.1 (0.2) | 8.6 (1.2) | |||||||
| Nylon | 43.3 (0.9) | 9.4 (1.6) | |||||||
| 2–0 Vicryl | 10 (1) | ||||||||
| Ultra-tape | 125.82 (24.67) | 11.13 (1.12) | |||||||
| No. 0 Vicryl | 12 (1) | ||||||||
| No. 0 Ethibond | 12 (1) | ||||||||
| No. 1 Ethibond | 12(1) | ||||||||
| No. 2 Ticron | 14 (1) | ||||||||
| No. 1 Vicryl | 15 (1) | ||||||||
| No. 2 Fiberwire | 67 (13) | 26.9 (2.4) | 17.77 (3.07) | 35 (6) | 71.1 (2.1) | ||||
| No. 5 TiCron | 19 (5) | ||||||||
| Fibertape | 66 (11) | 114.7 (5.8) | 26.6 (6.8) | 23.94 (3.20) | |||||
| No. 5 Ethibond | 25 (2) | ||||||||
| No. 2 ForceFiber | 26.1 (1.4) | ||||||||
| No. 2 MagnumWire | 105.75 (16.89) | 34.0 (2.5) | |||||||
| 2–0 Fiberwire | 124.98 (17.02) | 50.9 (7.7) | |||||||
| No. 5 Fiberwire | 79.5 (3.9) | 62 (18) | |||||||
| OrthoFiber | 69.8 (9.1) | ||||||||
| No. 0 Fiberwire | 127.92 (16.23) | ||||||||
| Ligafiber | 161.4 (25.1) | ||||||||
| Tiger Tape | 173.35 (15.60) | ||||||||
| Tiger Wire | 186.49 (19.83) | ||||||||
| Labral Tape | 195.77 (49.06) |
The goal of any orthopaedic soft tissue repair is to obtain anatomically healed and biomechanically functional tissue. The biomechanics of various repair methods and techniques pertaining to orthopaedic procedures have been extensively studied.1, 2, 3, 4, 5, 6 The ideal suture for soft-tissue repairs should have a high load to failure to prevent detachment during the healing process, low displacement to prevent suture elongation resulting in non-anatomic healing, and high stiffness to avoid deformation under loading conditions.7 Since normal tendon healing can take several months and early mobilization has become an important part of the post-operative rehabilitation process to improve motion, correct suture selection is a crucial factor to allow for optimization of healing.8 Prior studies have demonstrated gap formation at repair sites can inhibit strength gains and result in higher re-ruptures.9 Therefore, it is imperative for surgeons to be aware of the biomechanical properties of sutures commonly used with regard to tensile load, gap formation, common modes of failure, as well as the most vulnerable location for failure when repairing different soft-tissue injuries. Furthermore, when repairing intra-articular structures, understanding the sutures’ impact on cartilage surfaces can help surgeons avoid abrasive material as many sutures are non-absorbable and permanently present within the joint.
To date, there are no recommendations regarding the choice of suture material for orthopaedic procedures involving soft tissue repairs. Despite extensive research on different repair constructs, there have been minimal investigations concerning the biomechanical properties of the suture material itself and the influence on the suture-specimen construct. Since suture material can significantly impact the healing and re-rupture rates of soft-tissue repairs, the purpose of this study was to provide a qualitative summary of the published literature on the biomechanical properties of different suture materials used in orthopaedic procedures.
2. Methods
The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist and guidelines were followed throughout the conduction of this systematic review.10 This systematic review did not require Institutional Review Board approval or funding.
Author (CC) conducted a search using the keywords “suture” and “biomechanics” across PubMed and Cochrane databases. Studies were screened by two independent reviewers (NC and CC) for inclusion criteria which included reporting biomechanical data regarding various suture types and reported biomechanical data in respect to orthopaedic procedures. References in articles were cross referenced to avoid missing articles that our original search did not produce. Articles were excluded if they were published abstracts, narrative reviews, not written in English, commentaries, focused on various suture techniques/methods, and not focused on orthopaedic procedures. Studies involving flexor tendon injuries of the hand were also excluded as these studies typically involve 4-0 or smaller sutures. The results of the literature search were assessed by 2 independent reviewers (CC and NC). A consensus decision was reached for each article between reviewers and discussion with other authors were conducted to resolve any disagreements regarding study eligibility.
The following data was collected from each includes study: study name, year published, tissue type repaired (Achilles, patellar tendon, menisci, rotator cuff) or xenograft, suture material, biomechanical properties (elongation, maximum load to failure, stiffness, and method of failure). No funding or support was received for any aspect of this work.
3. Results
The database query yielded an initial 1046 articles that were first screened by title as well as abstract. If both reviewers agreed that the article met criteria for further evaluation then the article was screened in its full text along with references to avoid looking over other potential inclusions. A total of 17 articles were deemed eligible for final data collection (Fig. 1).
Fig. 1.
PRISMA 2020 flow diagram for new systematic reviews. This figure depicts how the final selection of articles were included for analysis.
3.1. Elongation
Nine studies reported on suture elongation.11, 12, 13, 14, 15, 16, 17, 18, 19 The most frequently studied suture materials were No. 2 Fiberwire™ (Arthrex, Inc) (n = 5 studies), No. 2 Ethibond™ (Ethicon Inc) (n = 4 studies), No. 2 Ultrabraid™ (Smith & Nephew) (n = 4 studies), FiberTape™ (Arthrex, Inc) (n = 4 studies), Ultratape™ (Smith & Nephew) (n = 3 studies), No. 2 Orthocord™ (DePuy Synthes) (n = 2 studies), and No. 2 MagnumWire™ (Smith & Nephew) (n = 2 studies). Nylon (Ethicon Inc), TigerWire™ (Arthrex, Inc), TigerTape™ (Arthrex, Inc), No.0 Ethibond™ (Ethicon, Inc), No. 2 ForceFiber™ (Stryker Inc), No. 2 PDS™ (Ethicon Inc), LabralTape™ (Arthrex, Inc), 2-0 Fiberwire™ (Arthrex, Inc), No. 0 Fiberwire™ (Arthrex, Inc), OrthoFiber™ (Securos Surgical), No. 5 Fiberwire™ (Arthrex, Inc), 3-0 V-Loc (Covidien, Inc.), and Stratafix (Ethicon, Inc.) were each reported once.
Bisson et al. used a simple stitch configuration in bovine infraspinatus specimens to assess elongation. They found no significant difference between Ethibond™ (0.98 ± 0.29 mm), no. 2 Fiberwire™ (0.95 ± 0.40 mm), or Orthocord™ (1.04 ± 0.18 mm) but did show significantly (p < 0.05) greater elongation for Ultrabraid™ (1.48 ± 0.30 mm).11 In a later study with a similar design, Bisson et al. found no significant difference in elongation between No. 2 Fiberwire™ (1.454 ± 0.41 mm) and 2.0 FiberTape™ (1.90 ± 1.15 mm) with respect to elongation (p = 0.192).12
Several other authors performed biomechanical testing on isolated suture materials. Rose et al. found elongation to be the lowest for LigaFiba (0.549 mm) followed by OrthoFiber™ (0.952 mm), FiberTape™ (0.976 mm), and No 5. Fiberwire™ (1.32 mm). Monofilament sutures had the highest cyclic elongation (3.75 mm).14 Taha et al. found the lowest elongation with FiberTape™ (0.66 ± 0.14 mm) and the highest with No. 2 Ultrabraid™ (4.18 ± 0.85 mm).15 Hurwit et al. found Orthocord™ (0.73 ± 0.11 mm) to have the lowest elongation, followed by No 2. Fiberwire™ (0.87 ± 0.04 mm), No. 2 Ethibond™ (2.17 ± 0.11 mm), and MagnumWire™ (3.19 ± 0.25 mm). No 2. Force Fiber (3.43 ± 0.28 mm) had the greatest elongation.16
Matthews et al. evaluated several different suture materials using a simple stitch configuration in porcine menisci. In their study, they found No. 2 Ultrabraid™ (1.91 mm ± 0.34 mm) to have the greatest elongation which was significantly greater than all other suture materials (p < 0.05) except Magnum Wire (1.43 mm ± 0.25 mm, p = 0.14) and Orthocord™ (1.59 mm ± 0.31 mm, p = 0.46). 2-0 Fiberwire™ (0.95 ± 0.17 mm) demonstrated the lowest elongation but was not significantly different than No. 0 Fiberwire™ (1.09 ± 0.17 mm, p = 0.79), TigerWire™ (1.09 ± 0.29 mm, p = 0.85), TigerTape™ (1.39 mm ± 0.29 mm, p = 0.08), and LabralTape™ (1.20 ± 0.33 mm, p = 0.41).13
Feucht et al. also used porcine menisci but in their study, 2.0 FiberTape™ (1.0 ± 0.2 mm) had the greatest elongation followed by No. 2 Ethibond™ (0.8 ± 0.1 mm) and No. 2 Fiberwire™ (0.8 ± 0.3 mm). No. 2 PDS™ (0. ± 0.2 mm) demonstrated the least elongation.15
Nakama et al. used male cadaveric knees to assess displacement in the setting of simple suture fixation. Nakama found Ultratape™ (2.36 ± 0.47 mm) to have less elongation than No. 2 Ultrabraid™ (2.76 ± 0.44 mm) and No. 0 Ethibond™ (2.69 ± 0.57 mm).17
3.2. Load to failure
13 studies reported outcomes with regards to the maximum load to failure.11, 12, 13, 14, 15,17,19, 20, 21, 22, 23, 24, 25 The most frequently studied suture materials were No. 2 Fiberwire™ (n = 9 studies), No. 2 Ethibond™ (n = 7 studies), No. 2 Ultrabraid™ (n = 5 studies), No. 2 Orthocord™ (n = 4 studies), FiberTape™ (n = 4 studies) and No. 2 PDS™ (n = 3 studies).
Bisson et al., utilizing a simple stitch configuration in bovine infraspinatus specimens found No. 2 Ultrabraid™ (181 ± 55 N) to have the highest load to failure, followed by No. 2 Fiberwire™ (165 ± 49 N), No. 2 Orthocord™ (152 ± 56 N), and No. 2 Ethibond™ (133 ± 15 N).11 Overall, there were no statistically significant differences between the suture materials.10 In their later study, Bisson et al. compared FiberTape™ and Fiberwire™, and found that the maximum load to failure in FiberTape™ (184 ± 83 N) was significantly greater than No. 2 Fiberwire™ (168 ± 73 N) (p = 0.046).12 Liu et al. found similar results using a simple stitch in bovine infraspinatus tendons with FiberTape™ (218 ± 28 N) having the highest load to failure which was significantly greater than the No. 2 Fiberwire™ (145 ± 14 N) (p = 0.04).21
Petri et al. used various sutures and different knot tying techniques in human cadaver hamstring tendons. The mean maximum load to failure in all knot types was highest in No. 2 Fiberwire™ (50.9 ± 22.4 N) followed by No. 2 PDS™ (42.8 ± 16.7 N). No. 2 Ethibond™ (39.9 ± 14.9 N) had the lowest mean maximum load to failure.24
Matthews et al. in their porcine menisci study found that TigerTape™ (287.43 ± 41.15 N) demonstrated the highest load to failure which was significantly greater than all other suture materials (p < 0.05) except TigerWire™ (251.03 ± 25.8 N, p = 0.51)) and LabralTape™ (271.34 ± 48.48 N, p = 0.99). The lowest maximum load to failure was observed with 2-0 Fiberwire™ (124.55 ± 14.69) which was significantly less than the other sutures (p < 0.05) except Magnum Wire (190.09 ± 61.44 N, p = 0.07) and No. 0 Fiberwire™ (148.44 ± 15.41 N, p = 0.49).13 Feucht et al. in their porcine study found FiberTape™ (195.6 ± 62.1 N) to have the highest load to failure, followed by No. 2 Fiberwire™ (169.0 ± 43.4 N), and No. 2 Ethibond™ (146.1 ± 20.6 N). No. 2 PDS™ (133.2 ± 35.4 N) had the lowest maximum load to failure.15
Nakama et al. used human cadaver medial menisci and performed a two-tunnel transtibial pull-out meniscal root repair with the given sutures. Although there were no statistically significant differences seen between sutures, No. 2 Ultrabraid™ (184.35 ± 30.15 N) recorded the highest load to failure followed by Ultratape™ (172.03 ± 80.40 N) while No. 0 Ethibond™ (169.47 ± 58.18 N) recorded the lowest.17
Load to failure was also tested with isolated sutures by several authors. Gomide et al. in their biomechanical study found No. 2 Fiberwire™ (240.17 N) had the highest maximum load to failure, followed by No. 2 HiFi (213.39 N) and No. 5 Ethibond™ (207.38 N). No. 2 Ethibond™ (97.8 N) had the lowest maximum load to failure.20
Rose et al. found LigaFiba (1210.2 ± 65.6 N) had the highest load to failure, followed by OrthoFiber™ (867.4 ± 25.4 N), No. 5 Fiberwire™ (773.9 ± 11.0 N), and FiberTape™ (724.6 ± 84.9 N). Monofilament had the lowest maximum load to failure (402.9 ± 5.2 N).14 Najibi et al. found statistically significant differences for all 11 sutures tested (p < 0.001) with No. 5 Fiberwire™ having the highest load to failure (620 ± 29 N), followed by No. 2 Fiberwire™ (282 ± 30 N), and No. 5 Ethibond™ (247 ± 10 N). No. 0 Ethibond™ (73 ± 5 N) had the lowest load to failure similar to Gomide et al.22
In the Barber et al. study, the maximum load to failure was also seen in No. 2 Fiberwire™ (259.70 ± 85.81 N) which was significantly greater than the other sutures (p < 0.05). No 2 Ethibond™ (143.92 ± 16.57 N) had the lowest maximum load to failure.23
Lastly, Wüst et al. found the highest load to failure in No. 2 Ultrabraid™ (313 ± 7 N) and No. 2 Fiberwire™ (307 ± 22). The lowest load to failure was observed in No. 2 Ethibond™ (137 ± 5 N) and No. 2 PDS™ (170 ± 15 N).25
3.3. Stiffness
9 studies reported outcomes with regard to stiffness.11, 12, 13, 14, 15, 16,18,22,26 The most frequently studied suture materials were No. 2 Ethibond™ (n = 6 studies), No. 2 Fiberwire™ (n = 5 studies), No. 2 Orthocord™ (n = 4 studies), FiberTape™ (n = 4 studies), and No. 2 Ultrabraid™ (n = 3 studies).
Bisson et al., in their bovine infraspinatus study, found No. 2 Ultrabraid™ (16.5 ± 3.8 N/mm) had the highest stiffness and was significantly greater than the other sutures (p < 0.05) except No. 2 Orthocord™ (14.8 ± 2.5 N/mm). No. 2 Ethibond™ (9.2 ± 2.3 N/mm) recorded the lowest stiffness.11 In their later study, Bisson et al. found FiberTape™ (218 ± 20 N/mm) had a higher stiffness than 2.0 Fibewire™ (85 ± 12 N/mm). In the bovine model, FiberTape™ (66 ± 11 N/mm) had a similar stiffness to Fiberwire™ (67 ± 13 N/mm).12
Yamagami et al. used gastrocnemius tendons of 24-week-old cattle in the setting of simple suture fixation. 2-0 Fiberwire™ (50.9 ± 7.7 N/mm) had the highest stiffness followed by No. 2 Ethibond™ (11.3 ± 0.4 N/mm) and Nylon (9.4 ± 1.6 N/mm). No. 2 PDS™ (8.1 ± 0.2 N/mm) had the lowest stiffness.26
Matthews et al. used porcine menisci in the setting of simple suture fixation and found LabralTape™ (195.77 ± 49.06 N/mm) demonstrated the highest stiffness and was significantly greater than all sutures (p < 0.05) except TigerTape™ (173.35 ± 15.60 N/mm, p = 0.19) and TigerWire™ (186.49 ± 19.83 N/mm, p = 0.45). Orthocord™ (75.28 ± 16.01 N/mm) had the lowest stiffness and was significantly lower than the other suture materials (p < 0.05) except Ultrabraid™ (88.05 ± 21.03 N/mm, p = 0.97).12 Feucht et al. in their porcine menisci study reported the highest stiffness in No. 2 Fiberwire™ (26.9 ± 2.4 N/mm) and FiberTape™ (26.6 ± 6 N/mm). No. 2 Ethibond™ (13.6 ± 0.8 N/mm) and No.2 PDS™ (8.6 ± 1.2 N/mm) had the lowest stiffness.15
Several studies performed biomechanical testing on isolated sutures. Rose et al. in their study found LigaFiber (161.4 ± 25.1 N/mm) had the highest stiffness and was statistically greater than the other suture materials. FiberTape™ (114.7 ± 5.8 N/m), No. 5 Fiberwire™ (79.5 ± 3.9 N/mm), and OrthoFiber™ (69.8 ± 9.1 N/mm) performed similar but were significantly greater than Monofilament (43.3 ± 0.9 N/mm, p < 0.05), which had the lowest stiffness.14 Taha et al. in their isolated suture study found FiberTape™ (23.9 ± 3.2 N/mm) had the highest stiffness followed by No. 2 Fiberwire™ (17.77 ± 3.07 N/mm), Ultratape™ (11.13 ± 1.12 N/mm), and No. 2 Ethibond™ (7.40 ± 2.38 N/mm). No. 2 Orthocord™ (5.07 ± 0.74) and No. 2 Ultrabraid™ (6.12 ± 0.81) had the lowest stiffness.16 Najibi et al. found No.5 Fiberwire™ (62 ± 18 N/mm) to have the highest stiffness, followed by No. 2 Fiberwire™ (35 ± 6 N/mm), and No. 5 Ethibond™ (25 ± 2 N/mm). 2-0 Vicryl (10 ± 1 N/mm) and No. 0 Vicryl (12 ± 1 N/mm) had the lowest stiffness.22 Hurwit et al. had similar results with No. 2 Fiberwire™ (71.1 ± 2.1 N/mm) having the highest stiffness, followed by No. 2 MagnumWire™ (34.0 ± 2.5 N/mm), No. 2 Force Fiber (26.1 ± 1.4 N/mm), and No. 2 Orthocord™ (24.4 ± 0.7 N/mm). No. 2 Ethibond™ (16.3 ± 0.5 N/mm) had the lowest stiffness. The differences in stiffness between the suture materials were all statistically significant (p < 0.001).18
4. Discussion
The goal of orthopaedic soft tissue repairs such as the meniscus or rotator cuff is to obtain anatomically healed and biomechanically functional tissue. Despite extensive studies evaluating various repair methods and suture techniques, there has been minimal investigation of whether suture design or material influences the biomechanical properties between the suture-specimen construct. The purpose of this study is to provide a qualitative summary of the published literature on the biomechanical properties of different suture materials used in orthopaedic procedures.
The biomechanical categories that were included consisted of elongation, load to failure, stiffness, and cartilage abrasion. The ideal suture should exhibit a high load to failure to prevent breakage throughout the healing process, a low elongation to prevent non-anatomic healing, and a high stiffness to resist deformation under stress.7
Several studies compared elongation across a variety of suture materials and specimens. Minimizing suture elongation is a critical aspect to obtain anatomic healing, especially pertaining to meniscal tissue as prior studies have demonstrated elongation in excess of 3 mm has significant effects on meniscal function which is secondarily linked to increased articular cartilage loss and osteophyte formation13
Two studies found No.2 Fiberwire™ to have the lowest elongation.11,12 In the 3 other studies that reported No. 2 Fiberwire™ elongation, it was 2nd lowest twice and 3rd lowest once.15,16,18 No other suture material was found to have the lowest elongation more than once. When it comes to the greatest elongation, all 4 studies that investigated No. 2 Ultrabraid™ found that it fared worse in comparison.11,13,16,17 FiberTape™ was reported in 2 studies to have the greatest elongation.12,15 Interestingly, Taha et al. reported 2-0 Ultrabraid™ having the greatest elongation, while FiberTape™ was recorded having the lowest elongation.16
Along with elongation, the capability of a suture to withstand larger loads can minimize repair failure and potentially allow for earlier range of motion. The integrity of a suture is dependent on its ability to withstand force and ultimately breakage. This corresponds to both the size of the suture and number of filaments (monofilament or multifilament).14
When comparing maximum load to failure, 3 suture types were most often reported as being able to handle the most load (No. 2 Fiberwire™, No. 2 Ultrabraid™, and FiberTape™). Looking further, it was noted that No. 2 Ultrabraid™ and FiberTape™ were compared to No. 2 Fiberwire™ in 6 studies.11,12,15,21,23,25 In 2 of those studies, No 2. Ultrabraid™ had a greater maximum load to failure,11,25 while 3 studies showed that FiberTape™ had a higher maximum load to failure.12,15,21 Only 1 study reported No. 2 Fiberwire™ having a higher maximum load than No. 2 Ultrabraid™.23 FiberTape™ and No. 2 Ultrabraid™ were never compared to each other. The lowest reporting suture type was No. 2 Ethibond™, recording the lowest maximum in 5 of the 7 studies reporting on that criterion.11,20,23, 24, 25 The main point to be drawn here is when deciding on a suture that requires being able to take high amounts of force without failing, No. 2 Ultrabraid™ and FiberTape™ showed capability to take on high amounts of force, while No. 2 Ethibond™ demonstrated the lowest maximum load to failure.
In addition to a high load to failure, the ideal suture should be stiff enough to resist stretching under loading conditions, but not too stiff to accommodate wound swelling and to avoid high shear forces between the suture and specimen which can result in suture pull out. Currently, there are no adequate stiffness threshold to optimize tissue healing.
Three types of sutures were reported as the least stiff twice (No. 2 Ethibond™, No. 2 Orthocord™, and No. 2 PDS™). No. 2 Ethibond™ was less stiff than No. 2 Orthocord™ in 2 out of 3 studies that compared them,11,18 however No. 2 PDS™ was less stiff than No. 2 Ethibond™ in the both studies that compared them.15,26 Although No. 2 PDS™ and No. 2 Orthocord™ were never compared, because No. 2 PDS™ was less stiff than No. 2 Ethibond™, a suture that was less stiff than No. 2 Orthocord™, it should be regarded as the least stiff suture of the samples. When comparing greatest stiffness, No. 2 Fiberwire™ was on the top of the list in 3 out of the 5 studies in which it was evaluated.12,15,18 No other suture type had multiple studies corroborating its high stiffness.
When evaluating all properties simultaneously, No. 2 Fiberwire™ demonstrated high stiffness and resistance to elongation across multiple studies, making it appealing to the surgeon requiring a suture type that will not alter in shape or size after insertion. This would be beneficial during soft tissue repairs, where laxity and separation between stitches should be minimized. On the contrary, No. 2 Ultrabraid™ showed its ability to take on high amounts of load at the expense of altering its length to do so.
There is no perfect suture for soft tissue repair. Choosing the optimum suture should be dependent upon the desired outcome or parameters of repair that are most critical to the surgeon and tissue being repaired. The ideal suture should have a high load to failure to prevent detachment during the healing process, low displacement to prevent suture elongation resulting in non-anatomic healing, and high stiffness to avoid deformation under loading conditions. Furthermore, as certain repairs are intra-articular with permanent suture material, the suture and associated knots may be in contact with articular cartilage. A suture that is susceptible to induce cartilage abrasions may lead to iatrogenic chondromalacia and cartilage damage.22
There are several limitations to this study. Firstly, we were unable to quantify the findings due to the variability in testing methods used in the studies. Instead, we decided to qualitatively analyze the sutures in their respective studies. Secondly, most of the studies were completed on a mechanical model in dry conditions which do not adequately represent the working environment of the knots in-vivo. Other models used in the studies include use of bovine, porcine, cattle, and cadaveric specimens, which may not accurately represent true physiologic conditions. Evaluating suture mechanics in an in-vivo environment just isn't feasible. Finally, sutures may have properties that induce biologic healing that were not and cannot be assessed with biomechanical testing. Therefore, clinical outcomes studies on differing repair techniques of respective tissue with varying sutures should be utilized before making final treatment decisions for patients.
5. Conclusion
Biomechanical testing demonstrates significant variability amongst suture materials with regard to elongation, load to failure, stiffness, and abrasion. The ideal suture should have a high load to failure to prevent acute failure, low elongation to prevent non-anatomic healing, and high stiffness to avoid deformation under loading conditions. Overall, Fiberwire™, FiberTape™, and Ultrabraid™ demonstrated the highest load to failure while Ethibond™ consistently was the weakest. Fiberwire™ was found to have the lowest elongation while Ultrabraid™ had the highest. Fiberwire™ was also noted to be the stiffest while PDS, Ethibond™, and Orthocord™ were found to be the least stiff. Final treatment decisions on which suture to utilize to optimize repair integrity and healing are complex, and rarely solely dependent upon the biomechanical properties of the materials used.
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical statement
This systematic review was IRB exempt.
CRediT authorship contribution statement
Andres R. Perez: participated in methodology, data collection, Data curation, Writing – original draft, Writing – review & editing. Carlo Coladonato: participated in data collection, Writing – original draft, Writing – review & editing. Rahul Muchintala: participated in data, Formal analysis, Writing – review & editing. Nicholas Christopher: participated in data collection, Writing – review & editing. John Matthews: participated in data collection, Writing – review & editing. Fotios P. Tjoumakaris: participated in conceptualization, Supervision, Writing – review & editing. Kevin B. Freedman: participated in conceptualization, Supervision, Writing – review & editing.
Acknowledgements
None.
References
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