Logan Steele
Muscle injuries are challenging problems for surgeons to navigate. While most muscle injuries can be treated non-surgically, more severe muscle injuries may require surgical repair. There are many different suturing techniques, and the best method is still debated. Suturing can help muscles heal, but it does not prevent the formation of scar tissue, which can lead to incomplete muscle recovery. The main factors used to classify suture types are absorbable vs non-absorbable, synthetic vs natural, and monofilament vs multifilament.
| Characteristics | Values |
|---|---|
| Muscle injuries treated non-surgically | Most |
| Muscle injuries treated surgically | Severe cases |
| Muscle injuries involving tendons | Can be repaired with sutures that offer high pullout resistance |
| Muscle injuries involving the muscle belly or musculotendinous junction | Challenging for surgeons due to a lack of reliable suture methods |
| Suturing techniques | Conventional (Kessler stitches, horizontal mattress, figure eight stitches) and complex (Modified Kessler suture, modified Mason-Allen suture, combination stitch, muscle suture with augmentation) |
| Suture types | Absorbable vs. non-absorbable, synthetic vs. natural, monofilament vs. multifilament |
| Suture selection factors | Ease of use for the surgeon, appropriate strength and secure knots, tolerance to wound changes, minimal inflammation or infection risk, visibility |
| Muscle suture outcome | Can aid muscle healing but does not prevent scar tissue formation, leading to incomplete functional recovery |
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What You'll Learn
The best suturing technique is yet to be defined
Muscle injuries can be challenging for surgeons to treat, and while most can be treated non-surgically, larger tears or lacerations may require surgery. The primary goal of suturing is to approximate and bring together the wound margins, eliminating dead space between wound walls and edges to aid underlying tissue healing.
Various suture techniques have been described, including conventional methods like Kessler stitches, horizontal mattress, and figure-eight stitches, and more complex techniques like the modified Kessler suture, modified Mason-Allen suture, and combination stitches. The figure-eight technique, for example, is known for its simplicity and efficiency, while the Mason-Allen technique is valued for its innate "grasping" of tissue during tightening.
The optimal suturing technique for muscle injuries remains a subject of ongoing research, with the regenerative capacity of skeletal muscle and the formation of scar tissue being key considerations. While suturing can aid muscle healing, it does not prevent scarring, which can lead to incomplete functional recovery.
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Conventional suture techniques
Suturing is a means of primary repair of the skin and deeper layers to promote wound healing. It is a challenging procedure, especially in the case of muscle belly lacerations, as sutures pull out and the likelihood of clinical failure is high.
There are two main suture categories: absorbable and non-absorbable. Absorbable sutures lose most of their tensile strength over a few weeks to several months and are digested by enzymes in the body's tissues. Non-absorbable sutures, on the other hand, need to be removed by a doctor at a later date or may be left in permanently. Absorbable sutures are often used for deep temporary closures until the tissues heal. Synthetic or natural materials are used for sutures, although this distinction is not particularly useful since all suture materials are sterilized. Monofilament sutures, made of a single thread, are used for repairing internal soft tissue wounds or lacerations. Braided sutures, on the other hand, consist of several small threads braided together, offering better security but a higher risk of infection.
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Complex suture techniques
The Mason-Allen technique is considered the most complex suture technique, requiring more knots than other techniques. It also only realigns two points of the muscle. The Perimeter technique, which is also a complex technique, is more time-consuming and requires visualization of the entire muscle, including the backside. The Figure-eight technique, on the other hand, is considered simple and requires little complexity to perform. It also achieves faster repair than the other two techniques.
The choice of suture technique depends on the specific case and the muscle group being treated. For example, the Perimeter technique may not be possible in cases with limited surgical fields.
The septocolumellar suture technique is another complex technique used in facial plastic surgery. It is a single-loop suture usually done with 5-0 non-absorbable material. It is introduced from a point low at the feet of the medial crura on one side and taken out at the opposite side at the foot of the medial crura. The knot is tied in the midline, bringing the medial crura and columellar complex close to the caudal septum.
The hemi-transdomal suture is a new technique that has yielded excellent results. It is a variation of the conventional transdomal suture and is used to narrow the dome and evert the lateral crus slightly to avoid concavities of the nostril rim.
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Absorbable vs non-absorbable sutures
When suturing muscle, it is important to consider the type of suture material to be used. The suture material can be broadly classified as either absorbable or non-absorbable. Absorbable sutures, also known as dissolvable stitches, are those that lose most of their tensile strength over a few weeks to several months and are naturally digested by the body's enzymes. They are often used for deep temporary closure until the tissues heal. This means that absorbable sutures do not require removal by a doctor.
Non-absorbable sutures, on the other hand, are intended to remain in the body and not be degraded through chemical means. They are essential in surgeries where the wound should not be permanently closed, such as in cardiovascular or orthopedic procedures, where mechanical stress is constant or healing takes longer. Non-absorbable sutures provide long-term strength and stability to hold tissues together during the healing process. They can be left in the body permanently or may need to be removed by a doctor at a later date.
Some popular uses of non-absorbable sutures include skin closure procedures, cardiovascular surgeries, and bone surgeries. Monofilament sutures, such as polyester sutures, are ideal for muscle, tendon, or ligament repairs, and cardiovascular surgeries as they require long-term tissue approximation. Stainless steel sutures are the strongest and most permanent type of non-absorbable sutures, offering tremendous tensile strength and anti-corrosive properties. They are useful in surgeries that require high tensile strength and proper alignment of tissues, such as orthopedic procedures and thoracic surgeries.
The choice between absorbable and non-absorbable sutures depends on the specific surgical requirements and the type of wound being treated. While absorbable sutures are convenient as they do not require removal, non-absorbable sutures provide long-term support and stability in wounds that require prolonged healing times and high-tension areas. It is important to select the appropriate suture material to ensure optimal healing and avoid compromising the results of the surgery.
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The likelihood of clinical failure
Muscle injuries are challenging problems for surgeons. While most muscle injuries can be treated non-surgically, larger tears/lacerations require surgical repair. The repair of muscle belly lacerations is technically demanding, and the likelihood of clinical failure is high. The suture methods used for muscle belly or musculotendinous junction injuries are often unreliable, and the sutures may pull out.
Optimal suturing of muscles may permit early rehabilitation with a low risk of stitch pullout or re-rupture. However, the formation of scar tissue is still possible, leading to incomplete muscle functional recovery. The limited ability of skeletal muscle to self-regenerate may require biological or synthetic augmentation to repair large damage.
The ideal suture is easy for the surgeon to handle, provides appropriate strength and secure knots, can accommodate wound changes, minimises inflammation and infection risk, and is easily visible. The main factors used to classify suture types are absorbable vs. non-absorbable, synthetic vs. natural, and monofilament vs. multifilament. Absorbable sutures are often employed for deep temporary closure until the tissues heal.
Several studies have compared different suture techniques, including conventional methods such as Kessler stitches, horizontal mattress, and figure-eight stitches, and complex methods such as the modified Kessler suture, modified Mason-Allen suture, combination stitch, and muscle suture with augmentation. The figure-eight technique was found to be quick and efficient, with a higher peak failure point and stiffness than the Mason-Allen technique. The Perimeter technique also showed a higher peak failure load than the Mason-Allen technique.
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Frequently asked questions
Muscle injuries are challenging for surgeons as sutures can pull out, and the likelihood of clinical failure is high. The suture method must be chosen carefully to ensure it is suitable for the specific incision.
Suture techniques can be divided into conventional and complex techniques. Kessler stitches, horizontal mattress stitches, and figure-eight stitches are examples of conventional techniques, while the modified Kessler suture and the modified Mason-Allen suture are examples of complex techniques.
The main factors used to classify suture types are absorbable vs. non-absorbable, synthetic vs. natural, and monofilament vs. multifilament.
Suturing offers advantages such as low dehiscence rates and greater tensile strength compared to other closure methods like staples or surgical glues.
