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| ARTICLES |
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| Year : 1970 | Volume
: 18
| Issue : 2 | Page : 45-51 |
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Clinical evaluation of rat tail tendon sutures
Sah Dev, VB Chadha, Hari Gopal, IS Jain
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address:
Sah Dev
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
Dev S, Chadha V B, Gopal H, Jain I S. Clinical evaluation of rat tail tendon sutures. Indian J Ophthalmol 1970;18:45-51 |
First introduced by Pischel[11], rat tail tendon sutures have been extensively tried in experimental ocular surgery with good results (Larmi[8], Morkhat[10], Trautmann[15], Vorosmarthy and Scheidt[7], Taylor, McPherson and Peacock[14], Somov[13], and Gopal, Gupta and Gupta[4]), Although Vannas and Larmi[16], Larmi[8] and others have used these tendon sutures in clinical cataract and corneal surgery where they are partly extruded and partly absorbed or integrated into ocular tissues, yet their use in deeper tissues like muscle and subcutaneous tissue in the lids has attracted little attention so far. Arruga [1] reported good results in squint surgery.
In the following study, comparative clinical evaluation has been done between chromic catgut, silk and rat tail tendons as regards clinical reaction and postoperative wound healing in squint, entropion and pterygium surgery.
| Methods and Material | |  |
Tendons can be easily picked from the tails of adult white rats after deskinning and thorough washing with water. In the fresh condition tendon threads are shiny white and pliable but sticky to handle and approximately 4 to 5 inches in length.
After treating with normal saline for 24 hours to remove tissue fragments and blood, the tendons were soaked in iodine tincture U.S.P. containing 2% metallic iodine and 2.4% sodium iodide dissolved in dil alcohol, (approximately 46%) for 48 hours. Then, these were placed in dil. alcohol 50% for 24 hours to remove iodine. Iodine alcohol solution made the tendons shrivel up, slightly brittle and deep yellow in colour. These changes were only temporary and were readily reversed on washing with alcohol and then with saline.
The tendon fibres were then placed aseptically in aluminium foil which had been heat sterilized at 160°C for one hour in hot air oven. The margins of aluminium foil packets were sealed by turning in the margin three times. The packets were then exposed to hot air oven sterilization at 160° C for one hour (Smith and Conant [12]). Four random samples were found to be bacteriologically sterile.
5/0 chromic catgut and 6/0 braided black silk were used for comparison.
GROUP I. Squint Surgery.
Forty five eyes undergoing recession or/and resection of extra-ocular muscles for squint correction were divided into three series depending upon the type of suture material used:
1) Silk series - 15 eyes
2) Chromic catgut series- 15 eyes.
3) Rat Tail tendon series - 15 eyes.
GROUP II. Entropion Surgery.
Thirty eyes having cicatricial entropion (trachomatous) were operated for wedge resection of tarsal plate. Edges of the tarsal plate were approximated by four sutures of silk, catgut or tail tendons in the three respective series of 10 eyes each. Skin was closed with interrupted silk sutures in all cases.
GROUP III. Pterygium Surgery.
Thirty eyes having pterygium were operated by Terson's technique and divided into three series of ten eyes each depending upon the suture material used.
Skin tests: The suture material used for that particular patient was burried intradermally on the volar surface of fore-arm at the time of operation to determine whether the excessive ocular reaction produced in some cases could be attributed to the suture material.
Thorough clinical examination was done daily for six post-operative days and then at weekly intervals for at least eight weeks with the help of biomicroscope.
Observations regarding congestion, oedema, pain and itching were recorded as under:
1) Congestion: Mild - Mild and limited to operated area.
Moderate - Severe and limited to operated area.
Severe - Severe and diffuse.
2) Oedema: 3 grades as in congestion.
3) Pain: Mild - Aware without distress.
Moderate - Enough to divert attention from routine work.
Severe - Severe, filling the field of consciousness and exclusion of all else.
4) Itchiig: 3 grades as in pain.
| Observations | | |
A. Average Ocular Reaction:
The average duration of ocular reaction with three types of sutures in squint, entropion and pterygium surgery, is depicted in [Table - 1]. It is noteworthy that catgut produced more severe and prolonged reaction while silk and tendon sutures produced almost equal reaction (Photo Nos. 3, 4
Mild to moderate degree of irritation and pain in eye was complained of in all series but most marked and prolonged in catgut series.
B. Excessive Ocular Reaction and Skin
Excessive ocular reaction in the form of increased congestion, chemosis and irritation was observed only in catgut series in 3 cases of squint (Photo No. 1 and 3) and entropion each and one case of pterygium [Table - 2]. Skin tests were negative in all cases except these seven cases showing excessive reaction where skin test was positive by 2nd postoperative week (Photo No. 2). In all these cases there was no excessive operative trauma and no definite history of any other allergic disorder. The culture report from conjunctival sac for microbial contamination was negative.
One patient in entropion surgery A presented interesting features. Excessive ocular reaction and positive skin test was seen two weeks after entropion correction of right upper lid using chromic catgut. Now the left eye was operated for entropion using catgut once again. Two weeks later there was much more ocular reaction alongwith positive skin test and the right eye again showed some increase in reaction.
Study of Suture Fragmentation.
In squint surgery the deep scleromuscle catgut sutures could be detected in 13% cases after two months follow up while in no case tendon sutures could be visualized after four weeks of follow up. The silk sutures were visible in all cases throughout this study and in one case silk eroded through the conjunctiva in 3rd week and had to be removed as it caused irritation in the eye.
In pterygium cases, silk sutures were removed on 6th day and by this time about half the knots had already fallen, the rate of disappearance of catgut and tendon suture knots was almost equal, about 1/3rd had disappeared by 4th day, about 2/3rd by 5th day so that by 8th day all knots were absent. All the tendon sutures had disappeared by 4th week and 90% of catgut sutures disappeared by 5th week while rest were still visible upto 8th week.
| Discussion | | |
In ophthalmic practice, silk and catgut sutures have been used most commonly. The main disadvantage of silk is non-absorbability because of which it may be a constant source of irritation, at times responsible for infection and may erode through the thin ocular coats if left in situ. Catgut on the other hand produces severe tissue reaction which is deterrent to wound healing and is absorbed at variable times. It is also a possible source of infection, can produce allergic reaction and an uncomfortable stitch granuloma. Tendon sutures are said to be a compromise between silk and catgut as regards their usefulness.
In the early postoperative period congestion and oedema at the operated site was prolonged and more severe with chromic catgut by 2-3 days as compared to silk and rat tail tendon sutures both of which produced almost similar reaction. In squint cases conjunctival congestion in later days was most prolonged with silk, possibly because the burried suture kept irritating, whereas with tendon sutures it was the least, and subsided 7-10 days earlier than chromic catgut. These findings are more or less in conformity with the earlier reports by Gardilcic[3], Dunnington and Regan[2], Larmi[8], Trautmann and Gopal, Gupta and Gupta.[4] But Ingram[5] found no difference in reaction produced by catgut and silk for first ten days but the reaction around catgut increased on the 14th day, in experimental muscle surgery. By two months catgut sutures were absorbed but some reaction was still present around silk sutures in squint cases.
The delayed local reaction with positive skin test at the end of 2nd postoperative week was seen only in the catgut series, three cases each in squint and entropion groups and one case in pterygium group. This excessive reaction was. we believe due to sensitisation to catgut and is-suppcrted by the fact that one patient in entropion group where catgut had been used for both eyes, showed increased local as well as skin reaction after second exposure of catgut suture. Langston[7] reported that sensitivity to catgut used in rather large doses and repeatedly can be demonstrated by skin test. In sensitized individuals lysis of suture material occurs more rapidly than in non-sensitized persons. The wound complications can occur and affect operative results by interfering with healing processes when sensitivity is highest as demonstrated by skin tests.
Both, chromic catgut as well as tendon sutures, started disappearing (absorption) at the end of the second postoperative week and by the 3rd week 67% of chromic catgut and 87% of tendon sutures had disappeared. While tendon sutures were absorbed by the end of fourth week, chromic catgut could be detected in 13% cases at the end of 2 months follow up. Excessive reaction was seen around chromic catgut sutures which were absorbed early as compared to those which persisted longer. Further, the rate of absorption of catgut material was variable as also emphazised by McPherson[9]. Kettesys stated that rat tail tendon sutures can be detected even after 10 years of follow up in keratoplasty cases, so should not be called absorbable sutures. Larmi[8] mentioned irregular time of absorption of tendon sutures and agreed that they should not be called absorbable sutures as they can be detected for 3-12 months in cornea. However, it may be interesting to study the amalgamation of these essentially collagenous sutures into the collagenous ocular tissues like sclera and cornea.
Our experience, while operating, was that tendon sutures are pliable, could be threaded in needles and passed through tissue with equal ease. There were a few disadvantages also like the limited length and poor tensile strength, and at times these colourless sutures became mixed with tissues resulting in significant waste of time.
| Summary | | |
Tendon sutures were found to be a pliable and easy to handle suture material but having poor tensile strength.
Rat tail tendon sutures when used in clinical squint, entropion and pterygium surgery were tolerated well, produced tissue reaction comparable to silk and definitely much less than that excited by chromic catgut. Stitch granuloma and skin sensitization were observed with chromic catgut but not with tendon or silk sutures. Tendon sutures disappeared earlier than catgut without evoking untoward reaction[17].
| References | | |
| 1. | Arruga, A., vide Ophthalmic Litt., XIX. Abstract 4703, (1965).  |
| 2. | Dunnington, J. H. and Regan, E. F., Absorbable Sutures in Catract Surgery, A.M.A. Arch. Ophthal., 50, 545, (1953). |
| 3. | Gardilcic, A., Quoted by Larmi, 1961. |
| 4. | Gopal, H., Gupta, J. S. and Gupta, S. D., Rat tail tendons as suture material, Orient. Arch. Ophthal., 6, 72 and 115 (1968). |
| 5. | Ingram, R. M., Rate at which muscle becomes joined to sclera after operations of recession and resection, Brit. J. Ophthal., 49, 18 and 235, (1965). |
| 6. | Kettesy, A., Quoted by Larmi, 1961. |
| 7. | Langston, H. T., Ann. Surg. 115, 141, (1942). |
| 8. | Larmi, T., Collagenous suture material in surgery of cornea and sclera, Acta Ophthal. Supp. 63. |
| 9. | McPherson, S. D. Jr., Quoted by Larmi, 1961. |
| 10. | Morkhat, I. V., vide Excepta Medica Ophthal., 18, Abstract, 1940, (1963). |
| 11. | Pischel, K., Quoted by Larmi, 1961. |
| 12. | Smith, D., and Conant, N. F. Ed., Zinsser's Microbiology, Appleton, Century Crafts Inc. Ed. XII, 82 and 102, (1960). |
| 13. | Somov, E. E., Vide Excerpta Medica Ophthal. 18, Abstract 2427, (1964). |
| 14. | Taylor, S. R. Jr. McPherson, S. D. Jr. and Peacock, E. Jr. The experimental use of rat tail tendons as a corneal suture material, Amer. J. Ophthal. 56, 549 (1963). |
| 15. | Trautmann, I., vide Surv. Ophthal., 10, 476 (1965). |
| 16. | Vannas, S. and Larmi, T., Th- use of collagenous suture material in surgery of cornea and sclera, Acta Ophthal., 37, 371, (1959). |
| 17. | Vorosmarthy, D. and Scheid, P., Vide Surv. Ophthal., 10, 581, (1965). |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2]
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