Table Of Content~ound C:tosure
Biomaterials
Devices
and
\^ o u n d (C lo su re
Diom aterials
£)
and
Edited by
Chih-Chang Chu, Ph.D.
Fiber Science Program
Department of Textiles and Apparel
College of Human Ecology
and
Bioengineering Program
Cornell University
Ithaca, New York
J. Anthony von Fraunhofer, Ph.D., F.A.S.M., F.R.S.C.
Department of Restorative Dentistry
School of Dentistry University of Maryland at Baltimore
Baltimore, Maryland
Howard P. Greisler, M.D.
Department of Surgery
Department of Cell Biology, Neurobiology, and Anatomy
Stritch School of Medicine
Loyola University
and
Department of Surgery Hines V.A. Hospital
Maywood, Illinois
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Library of Congress CataJoging-ln-PubUcatlon Data
Wound closure biomaterials and devices I edited by Chih-Chang Chu, J. Anthony
von Fraunhofer, Howard P. Greisler.
p. em.
Includes bibliographical references and index.
ISBN 0-8493-4964-8
I. Ligature (Surgery). 2. Sutures. 3. Adhesives in surgery. I. Chu, Chih-Chang.
II. Von Fraunhofer, J. A. (Joseph Anthony). Ill. Greisler, Howard P.
RD73.L5W68 1996
617'.9178-dc20
96-8975
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CONTRIBUTORS
Chih-Chang Chu, Ph.D. Yoshito lkada, D.Eng., D.Med.Sc.
Professor, Fiber Science Program Professor
Department of Textiles & Apparel Research Center for Biomedical Engineering
College of Human Ecology and Kyoto University
Bioengineering Program Kyoto, Japan
Cornell University yyikada@ medeng.kyoto-u.ac.jp
Ithaca, New York
[email protected] William Irvin, M.D.
1030 S. Jefferson
Suite 110
j. Anthony von Fraunhofer, Ph.D., F.A.S.M., Roanoke, Virginia
F.R.S.C.
Professor, Department of Restorative Dentistry Steven S. Kang, M.D.
School of Dentistry Assistant Professor of Surgery
University of Maryland at Baltimore Department of Surgery
Baltimore, Maryland Loyola University Medical Center
avfOO I @dental3.ab.umd.edu Maywood, lllinois
skang@ wpo.it.luc.edu
Howard P. Greisler, M.D. Peter H. Lin, M.D.
Professor, Department of Surgery Department of Surgery
Department of Cell Biology, Finch University of Health Science
Neurobiology and Anatomy The Chicago Medical School
Stritch School of Medicine Chicago, Illinois
Loyola University [email protected]
and
Department of Surgery J. R. Perez-Sanz, M.D.
Hines V.A. Hospital College of Medicine
Maywood, lllinois University of Illinois-Chicago
hgreisl @wpo.it.luc.edu Chicago, Illinois
and
Christ Hospital and Medical Center
Mark K. Hirko, M.D. Oak Lawn. Illinois
Department of Surgery and
North Side Medical Center Little Company of Mary Hospital
Youngstown, Ohio Evergreen Park, lllinois
PREFACE
Wound closure biomaterials and devices have played a critical role in human survival since the dawn
of history. It is not an overstatement to say that human lives have been saved by tiny threads of silk or
linen almost since the beginning of time. Wound closure biomaterials have the longest history among
all biomaterials. These biomaterials and devices concern every surgeon because every surgery or wound
requires the use of biomaterials to close them for successful healing. The proper closing of wounds can
influence the success of surgery. Many complications, such as infection, wound dehiscence, and sinus
formation can occur in the wound closure line.
There are three types of wound closure biomaterials and devices: sutures, clips/staples, and tissue
adhesives. Sutures are the most frequently used and have the longest history. As early as 4000 years
ago, linen was used as a suture material. Since then, numerous materials like iron wire, gold, silver,
dried gut, horse hair, strips of hide, bark fibers, silk, linen, and tendon have been used as suture materials.
Among them, catgut and silk dominated the suture market until 1930. The introduction of synthetic
polymers during and after World War II revolutionized the chemical origin of suture materials. The use
of ligating clip/stapler systems in wound closure is relatively new and allows accurate apposition with
minimal tension, reduced operating time, and easy removal. Further, these devices achieve good cosmetic
results. Although metallic clips/staples have the longest history in this group, their use is limited to skin
closure, and synthetic absorbable clips/staples have recently become the dominant player, particularly
for tissues and organs beneath skin. Coover discovered tissue adhesives in the mid-1950s. Although they
are not as popular as suture materials and clips/staples, particularly in the United States, they have a
unique role among wound closure biomaterials. The significant advances in materials science and engi
neering over the past decades provide surgeons with a wide range of choices of wound closure bioma
terials with vast differences in chemical, mechanical, biological and often biodegradable properties, and
clinical performance. As a result of this continuous advance in materials, the art of wound closure has
become far more complex and demanding. Although there has been fragmented review literature describ
ing suture materials in the past two decades, to date there has been virtually no single English-language
volume that systematically and comprehensively describes all required properties of available wound
closure biomaterials and devices. We believe such a comprehensive and timely reference source for
surgeons in the modem health care environment is long overdue.
Meeting the needs of surgeons is half of the goal of this book. Biomaterials scientists have played a
crucial role in the research and development of wound closure biomaterials for the past several decades.
Because of the multidisciplinary nature of wound closure biomaterials and devices, a book that will also
satisfy biomaterials scientists and engineers must have ample information about structures and basic
material properties, such as molecular weight, synthesis, and tensile properties, so that they can use the
book as a major reference for future research and development of improved wound closure biomaterials
and devices.
With these goals in mind, we are introducing this book to both the medical and biomaterials
science/engineering communities. The book has five basic parts: wound healing, suture materials,
clips/staples, tissue adhesives, and emerging new wound closure biomaterials. It has 12 chapters with a
distinct emphasis on suture materials because of their preeminence in wound closure use. Coherence
within this book has been maintained by linking and cross-referencing the contents of the 12 chapters.
In doing this, we feel we have avoided the common failing of many monographs that resemble a series
of unrelated reviews by different authors.
After the first chapter, Introduction, a review of the basics of wound healing, particularly relating to
wound closure biomaterials, is given in Chapter 2. This chapter should provide readers with a reasonable
background in the basic phenomena and some recent findings of wound healing that wound closure
biomaterials experience all the time. Chapter 3, Surgical Needles, describes an integral part of sutures,
particularly their biomechanical properties, that are frequently ignored in the published literature.
Chapter 4, Classification and General Characteristics of Suture Materials, provides comprehensive
classifications of suture materials in terms of size, biodegradability, physical form, and coating materials
and an overview of four general characteristics that every suture material should have, namely physi
caVmechanical, handling, biocompatibility, and biodegradation, if applicable. Following an overview of
suture materials in Chapter 4, Chapter 5, Chemical Structure and Manufacturing Processes, provides
far more detailed information about the basic chemical properties of suture materials and how they are
made. This chapter is written mainly for chemists, material scientists, and engineers rather than surgeons.
However, surgeons may use this chapter to acquire additional in-depth material information about the
suture materials that they use every day.
Chapters 6 through 8 cover the three most important properties of suture materials in great detail,
i.e., mechanical, biodegradable, and biological properties. These three chapters provide the core infor
mation for both the medical profession and materials scientists/engineers for their comprehensive under
standing of the vast differences in the three most essential properties of suture materials. Several
properties of suture materials that are often unfamiliar to the medical profession, such as viscoelasticity,
carcinogenicity, and many new findings in biodegradation properties like computational chemical mod
eling of the biodegradation property of absorbable suture materials and plasma surface modification of
absorbable sutures to alter their biodegradation properties, are also explained in these three chapters.
Chapter 9, Suture Techniques and Selection, is written primarily for surgeons and has practical
information about the actual use of sutures in a variety of fields of surgery.
Chapters 10, Ligating Clips and Staples, and 11, 1issue Adhesives, provide detailed technical infor
mation about the other two types of wound closure biomaterials and devices. Because they are less
frequently used than sutures, there are relatively few reported studies of these two alternative wound
closure biomaterials and devices. However, the landscape of wound closure biomaterials and devices
may change in the next century when new materials and technology emerge.
Chapter 12, New Emerging Materials for Wound Closure, provides a preview of some new inventions
and developments that could have major impact on wound closure biomaterials and devices in the next
century. Those wound closure biomaterials that are currently used outside the United States but have
not been approved by the FDA are also mentioned in this chapter. This chapter also suggests the direction
of new research and development efforts in wound closure biomaterials by addressing some of the
challenging problems, such as efficient control of wound infection, the promotion of wound healing via
the incorporation of growth factors into wound closure biomaterials/devices, control of their biodegra
dation behavior for better and more predictable wound healing in demanding clinical cases, and improved
handling properties of sutures.
We have done our best to provide readers with the most up-to-date and core information that we
could find in the published literature. We primarily limited our database to English journals to ensure
timely publication and wider appeal. A lot of the information used in this book is from the authors' own
research activities over the past several decades. Some of the information provided in this book is not
yet in the public domain, such as pending patents. We have also tried our best to balance the content of
this book between the needs of clinicians and basic biomaterials scientists/engineers. We wrote this book
with two basic goals in mind: clinicians would be provided with a book that has much practical
information for their daily practice while researchers of either biomaterials science/engineering or with
a medical background would find that this book has a wealth of research information for their research
and development work on wound closure biomaterials and devices.
Finally, we would particularly like to thank Dennis D. Jamiolkowski of Ethicon, Drs. Griffin Lewis
and Walter Sabisiak of Davis & Geck, and Drs. C.K. Liu andY. Jiang of US Surgical for their continuous
support with samples, some illustrations, and information. We would also like to acknowledge the
graduate students, postdoctoral fellows, and interns of the editors for their research work, upon which
this book is largely based.
Chih-Chang Chu
Cornell University
Howard P. Greisler
Loyola University
J, Anthony von Fraunhofer
University of Maryland at Baltimore
DEDICATION
We would like to dedicate this book to
Martha A. Mutschler-Chu, Chen-Wei and Hope Ho-Hui Chu, and Shirley C. Chu, for their encour
agement, patience, sacrifice, and understanding during those many evenings, weekends, and holidays
that were consumed for the past two decades of RID of wound closure biomaterials that led to the
publication of this book.
C. C. Chu
Elizabeth, whose unswerving support, understanding, and social conscience have enabled me to not
become my own enemy.
Howard P. Greisler
Nancy, for her patience and support, and to my friends for not letting me lose my sense of humor
during the writing of this book.
}. Anthony von Fraunhofer
