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Absorbable Sutures, Revisited

In a previous post, I gave my take on the evidence in support of using absorbable sutures for superficial wound closure. A study published in 2014 adds to this body of literature. It’s generated some buzz that’s worth a brief discussion.

In this new study by Tejani et al, the use of absorbable sutures was compared with non-absorbable sutures for closure of wounds on the trunks and extremities of pediatric and adult patients.  Specifically, the authors examined the use of vicryl rapide as the absorbable suture of choice for extremity wound closure.  This is the first study I have seen addressing this question, which was great–it’s something I advocated for in my 2013 post, albeit based on reasoning through suture properties rather than scientific data.

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Is use of this suture (without planned removal) ready for everyday ED use?

 

Study Highlights, in a nutshell:

  • Randomized controlled study design; patients not blinded (not possible) but the plastic surgeons evaluating the wounds were.
  • No standardization of wound preparation; a range of practitioners (excluding medical students) performed the repairs; all wounds were repaired in a single layer with simple interrupted sutures.
  • Many enrolled were lost to follow up at 3 months; but the authors did manage to enroll and follow through on the number of patients needed to determine a significant difference in cosmesis between groups.  This was not the case for the secondary outcomes of complications such as infection, dehiscence, and “train-tracking.”

Outcomes:

  • Non-inferiority of vicryl rapide compared with prolene in terms of cosmesis, but overall both techniques had lower scores on the visual analog scale for cosmesis than seen in other studies using absorbable sutures–attributed to the lack of inclusion of facial wounds (which heal better) and a shorter follow up period.
  • A greater percentage of infections and train tracking occurred in the vicryl rapide group compared with the prolene group, which was not statistically significant.

This study was reviewed by EMRAP’s “Paper Chase” in October 2014.  Sanjay and Mike are some smart guys–they definitely know how to dissect a study and relate it back to clinical practice. They opined that the high rates of infection (even if not statistically significant) noted in the vicryl rapide group begged some caution with use of this technique.  Fair point.  No one is looking to worsen outcomes for our patients.

Still, I am going to go bat for the authors here.  The devil is in the details, or rather, in the Discussion section of their article. Among the wound infections in the vicryl rapide group, each was reported by parents during follow up calls, rather than in office visits with a physician.  Not to say that these were not true infections, but there are undoubtedly some inter-rater reliability issues even between clinicians, and adding parents as reporters adds another dimension to this.  Still, I applaud the authors for giving the parents the benefit of the doubt and classifying these wounds as infected.

If infection rates with absorbable sutures truly are higher, I would postulate that this is due to the foreign body effect of a retained suture fragment sitting in the wound. Indeed, in this study, although the patients in the absorbable suture group had follow up visits when possible, no one in this group had their suture fragments removed.  As I discussed in my previous post on the topic, Luck’s study from 2013 already taught us that absorbable sutures tend to linger even after they are no longer providing effective wound support.  Thus, it’s our responsibility as providers to make sure the patients (or their parents) understand exactly what “absorbable suture” means.

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What is vicryl rapide?

Vicryl Rapide (Ethicon) is a braided, undyed suture.  In contrast to regular vicryl, this suture has been treated to speed its absorption. At 5 days, 50% of the suture’s retention strength is intact, and at 14 days, 0% of its retention strength remains. Thus, somewhere at about the 10-14 day mark, the suture knot breaks and its effective wound support is nil.  But, the thread of suture sitting in the wound takes much longer than this (up to 41 days reported) to completely dissolve. It’s a nidus for infection in this time window!

What’s the bottom line?

Is this a technique we can be/should be using?  I contacted Dr. Tejani for comments on the study and the technique.  Here is what she had to say:

” At our shop we all use [vicryl rapide] for trunk and extremity lacerations and we tell patients that if sutures are in place for longer than 10 -14 days take them out (or since many are pediatric patients come back and we will take them out). As the study was not powered to assess for complications one cannot call into question the technique on that basis. Forthcoming on the topic is a retrospective study looking at all the lacerations we have done with vicryl rapide to see if patients are returning with infection. But anecdotally no one has come back with wound complications.”

Look ma, no scar! Three month outcome in a hand laceration repaired with vicryl rapide. Courtesy Dr. Cena Tejani.

Look ma, no scar! Three month outcome in a hand laceration repaired with vicryl rapide. Courtesy Dr. Cena Tejani.

A range of outcomes were noted with vicryl rapide repair.  Generally, a less well-perfused and higher tension area led to more noticeable scarring, which is also true of the non-absorbable counterparts. Photo courtesy Dr. Cena Tejani.

A range of outcomes were noted with vicryl rapide repair. Generally, a less well-perfused and higher tension area led to more noticeable scarring, which is also true of the non-absorbable counterparts. Photo courtesy Dr. Cena Tejani.

To me, the best testament to the utility of this technique is that the authors actually believe in it, and moreover, are using it in clinical practice.  I appreciate any feedback from practitioners who have employed this technique in their own practices.  As the optimal usage of absorbable sutures is refined, expect more on this topic in years to come.

 

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