Orthopedic surgery is a complex and difficult undertaking. Featuring some of the most innovative medical techniques being used today, these high-demand procedures allow surgeons to deliver beneficial outcomes faster and better than ever before. Even when it’s time to close the incision, surgeons and patients alike benefit from a wide variety of options.
The history of wound closure technology is a long one, but the last half century has seen a tremendous amount of change in available modalities. Here is a brief look at how advances in medical technology have affected the procedure.
A Brief History of Sutures
Since the earliest known usage of sutures in the 16th century BCE, a wide variety of materials have been used for wound closure. For much of that history, sutures were non-absorbable, meaning they would not break down naturally and had to be removed after healing. While many synthetic materials are used today, silk and cotton were long considered the ideal choices. Silk in particular was prized for its high tensile strength and easy handling. As an animal protein, however, it did carry significant risk of infection.
Today, a wide range of materials are used for non-absorbable sutures, including nylon, polypropylene, and polyester. In some cases, sutures are also coated with teflon, polybutilate, or silicone to make them easier to handle. The preferred material varies on a case-by-case basis, depending upon the characteristics of the wound being closed and the preferences of the surgeon. Synthetic sutures present a variety of trade-offs between strength, knot security, and handleability.
Before the development of synthetic materials that could break down over time, catgut was the most commonly used absorbable suture. Obtained from sheep or cattle intestines, catgut had a number of shortcomings. As a foreign protein, it often caused inflammation and was more likely to lead to infection at the wound site. Catgut also degrades rapidly, causing it to lose about 50 to 70 percent of its tensile strength within seven days. For all its problems, catgut was useful for its ability to dissolve rapidly, making it ideal for closures that healed quickly.
Several synthetic absorbable solutions have been developed since the 1970s. Materials like polyglycolic acid and polyglactin 910 proved stronger, longer lasting, and far less inflammatory than catgut. Later polymer-based sutures, like polyglyconate and polydioxanone, deteriorated even more slowly, retaining about 90 percent of their tensile strength after a week. By the early 1990s, materials like poliglecaprone 25 made it possible to emulate the fast-absorbing qualities of catgut with few of the side effects.
Modern Suture Technology
There have been a few noteworthy advancements in suture technology over the last twenty years as well. Barbed sutures, which feature tiny barbs along the length of the suture that hold it in place after insertion, were introduced around 2004 and eliminated the need for tying knots, which had always been a difficult challenge for conventional sutures. Concerns over knot slippage often led surgeons to over-tighten suture knots, which could cause uneven tension distribution over the surface of the wound and lead to suboptimal healing results as well as excessive scar tissue.
Alternative Wound Closure Technologies
A number of innovations have provided orthopedic surgeons with alternative methods for closing wounds over the last few decades. While many of them have proven highly effective in very specific use cases or as a supplement to traditional closure, they have failed to displace sutures as the primary closure modality for most surgeons.
First developed by the Hungarian physician Hümér Hültl in 1908, the first surgical staplers were cumbersome and difficult to use. By the 1970s, however, surgical staples had become a widely used wound closure modality. Typically made of stainless steel or titanium, staples are used to close deep wounds unsuitable for sutures or areas of the body under high tension. Absorbable subcutaneous stapling devices, which utilize polymer based staples that break down by hydrolysis within 12 weeks, debuted in 2006, but most surgeons continue to use staples made from non-absorbable materials.
Although surgical staples can be applied much faster than sutures and are often used when incisions must be closed quickly and securely, there are a few disadvantages to using them. In the first place, their appearance can be unsettling for patients. Moreover, they are more difficult to remove and are three times more likely to result in infection than sutures. Surgical staples tend to result in greater scarring because their application makes precise wound alignment difficult.
Cyanoacrylates, the scientific name for the material in conventional super glue, were first developed in the 1940s. The first adhesives caused severe inflammation, making them unsuitable for medical use (although they were used in some cases by combat medics during the Vietnam War). By the 1990s, extensive chemical research had developed new versions of cyanoacrylates that were less toxic and safe for wound closure.
As a closure modality, however, adhesives are difficult to use. Messy and hard to apply, they are also difficult to remove if there is a problem with the closed wound. In most instances, they are best used as a sealant in conjunction with conventional sutures to protect against infection.
Surgical tapes are excellent for small cuts and minor wounds, but have several limitations as a primary option for surgical closure. Since the adhesive used to hold them in place tends to degrade over time and can be severely weakened by contact with water, tapes are best used to support other wound closure methods. Tape can also be used to reinforce wounds following suture or staple removal. As a surgical wound closure option, however, tape simply lacks the strength or stability to hold wound edges securely in place long enough for the healing process to begin.
A recent innovation that offers an alternative to sutures is the zipper device, which uses two sticky strips joined by a set of adjustable ratchet ties. The strips are placed on either side of an incision and then the ties are pulled tight to close the wound. By distributing tension evenly over the wound surface, zippers result in an even closure that’s less likely to leave behind ugly scarring.
Although faster than conventional sutures, the device is not particularly intuitive, requiring a multi-step process to apply and requiring a fair amount of finagling to position it correctly. The ends of the ties need to be cut after application, and the device itself has a raised plastic profile that could potentially catch on loose clothing or a patient’s surroundings. Furthermore, the device can only be applied to straight incisions since the adhesive strips must fit on either side of the wound site.
BandGrip: Wound Care 2.0
Newly available in 2018, BandGrip Micro-Anchor Skin Closures represent a major advancement in wound closure technology. Simple, intuitive, and non-invasive, its patented micro-anchors grip the skin tightly and securely to hold wound edges together. Easy to apply and remove, BandGrip can be applied much faster than sutures, completely eliminates the risks associated with needlesticks, and doesn’t require a return visit for removal. About the size of a household bandage, it can also be tiled to close larger or irregularly shaped wounds.
With its familiar look, feel, and smooth surface, BandGrip can help set patients at ease, bringing them a sense of normalcy and confidence. With no raised surfaces, they’re significantly less likely to catch on clothing or dressings and therefore allow for a much higher degree of ambulation. Patients can even shower with them on after 24 hours since the water will not affect the micro-anchors. Since BandGrip pulls wound edges together to facilitate the body’s natural healing process, it can achieve better wound alignment and put less strain on the skin, which greatly reduces scarring.
As wound closure techniques continue to improve, orthopedic surgeons have far more options at their disposal than ever before. When deciding the best options for wound closure, they must take into consideration what will be most efficient for them and most satisfactory for the patient. With simple and intuitive innovations like BandGrip Micro-Anchor Skin Closures, they can often satisfy both needs at once.