Ethibond suture with underlying infection – A knotty complication

Ganesh Singh Dharmshaktu; Naveen Agarwal; Ishwar Singh Dharmshaktu

doi:10.4103/jssrp.jssrp_7_22

CASE REPORT

Year : 2022 | Volume : 3 | Issue : 3 | Page : 67-69

Ethibond suture with underlying infection – A knotty complication

Ganesh Singh Dharmshaktu, Naveen Agarwal, Ishwar Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission	30-Apr-2022
Date of Decision	18-Jun-2022
Date of Acceptance	20-Jun-2022
Date of Web Publication	19-Dec-2022

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jssrp.jssrp_7_22

Abstract

The surgical site infection is a therapeutic challenge and requires additional interventions, prolonged treatment, and increased health-care expenditure. Superficial infections are easier to treat with debridement, regular dressing, and an appropriate antibiotic regimen. Retained and buried sutures are an occasional source of infection and are reported in the literature. Braided nonabsorbable sutures like Ethibond may be the uncommon reason for adjacent area infection that may present later as nonhealing draining sinuses. We report one such encounter in which an adult patient with chronic nonhealing sinuses over the proximal tibia region underwent debridement to unearth embedded sutures used in previous surgery, the removal of which led to gradual recovery and healing of wounds.

Keywords: Braided suture, Ethibond, nonabsorbable suture, sinuses, surgical site infection, sutures

How to cite this article:
Dharmshaktu GS, Agarwal N, Dharmshaktu IS. Ethibond suture with underlying infection – A knotty complication. J Surg Spec Rural Pract 2022;3:67-9

How to cite this URL:
Dharmshaktu GS, Agarwal N, Dharmshaktu IS. Ethibond suture with underlying infection – A knotty complication. J Surg Spec Rural Pract [serial online] 2022 [cited 2023 Mar 31];3:67-9. Available from: http://www.jssrp.org/text.asp?2022/3/3/67/364432

Introduction

Ethibond (Ethicon INC, Somerville, New Jersey) is a braided, nonabsorbable synthetic suture having high tensile strength and relatively low tissue reactivity. It is used widely in surgeries requiring tendon, muscle, and capsular repair.^[1] Suture-related infection is not an uncommon complication in orthopedic surgery and many sporadic case reports are added annually in the medical literature. Absorbable sutures are reported to cause suture-related pseudoinfection and complicate critical procedures such as arthroplasty surgeries in rare instances.^[2] These events may mimic prosthetic joint infection and contribute to the increased treatment cost and agony of the patient. Recurrent negative microbiological samples and histological evidence of a foreign body reaction are important points for their diagnosis. The infection related to nonabsorbable sutures like Ethibond has been occasionally reported in the literature with varying grades of superficial infection to grave osteomyelitis.^[3] Deep bone infection or osteomyelitis is a dreaded condition with a huge impact on health-care costs and morbidity of the patient and its prevention is critical in developing countries. The knowledge of sutures as a potential source of surgical site infections can be instrumental in adapting to good practices that not only help prevent but also manage these complications at the earliest. Our case was a learning point for us and shall be for others also, especially in a resource-limited environment where acknowledgment of these complications may help anticipate and treat the condition promptly in a standard manner to avoid negligence and further complications.

Case Report

A 52-year-old male patient presented to us with elsewhere operated left upper leg injury 1 year back with multiple discharging sinuses over the previous surgical site. He had a history of open proximal tibia fracture with severe soft tissue and patellar tendon laceration which was managed 1 year back by suturing of the patella tendon following debridement and screw fixation. The wounds and fracture healed but for the last 5 months, few sinuses with occasional discharge were noted over the proximal leg area [Figure 1]. He used to dress the wound at a local dispensary and they seemed to get better for few days only to recur again. His fracture was healed and the cleaning, debridement, and deep-tissue sample collection for culture and sensitivity were planned following a period of 2-week drug holiday. The crust over the sinuses was removed only to reveal green treads resembling suture material [Figure 2]a. All four sinuses contained similar materials in deep tissues which were removed and underlying tissues underwent debridement. The materials were Ethibond suture on the appearance of braided strong suture and also corroborating with the previous history of tendon repair at the same site [Figure 2]b. Following the removal of embedded sutures, the wounds healed completely without recurrence, and the culture of materials was found sterile on microbiological studies. The diagnosis of superficial suture-related localized infection was made. The case was surgically managed in March 2022 and has had well-healed wounds since then with no recurrence. The patient gave informed consent regarding the publication of this report.

Figure 1: The image showing multiple discharging sinuses over proximal tibia region with old healed scars of previous surgery

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Figure 2: The peeping green threads after cleaning and debridement of wound (a) and removal of the embedded suture (b) buried in the wound beds. The cleaning of the wound bed was followed by the removal of sutures

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Discussion

Absorbable sutures such as polydioxanone (PDS) sutures are demonstrated to have fewer wound complications than polyester (Ethibond) sutures in surgeries like Achilles tendon repair.^[4] It is understandable that in areas with less soft tissue or muscular coverage, the wound complications rate may be higher. Our case also had proximal tibia region involvement which also had less soft-tissue coverage. Apart from various complications noted with Ethibond sutures, granuloma formation is another complication that was reported in a case presented with tibialis anterior Ethibond suture granuloma in a child following clubfoot surgery.^[5] Granuloma formation may be a delayed complication in the settings of localized necrosis in tissues surrounding the embedded suture material. In a case with patellar tendon repair, 4 years after the index surgery, patellar tendon necrosis and fibrosis were observed with histological evidence of foreign body reaction around synthetic Ethibond suture.^[6] Swelling, pain, and discharge over the previous surgery site should raise suspicion of infection and granuloma formation and removal of granulomatous tissue may have embedded suture.^[7] Owing to the increased wound complication rate in nonabsorbable sutures should be kept in mind and their usage in appropriate indications and cautious use in places notorious for wound breakdown should be ensured.^[8] Many such cases highlight the cautious follow-up in cases where these sutures have been used and exclude infection related to them in suspected cases. Suture-related infections can be prevented by good hygiene and a healthy lifestyle and nonabsorbable sutures may require vigilant follow-up for any untoward complications.

Conclusion

A superficial skin infection is an untoward event and appropriate management results in early recovery and complications are avoided. The diagnosis of the underlying causes of infection can be sought by surgical exploration at the earliest. The nonabsorbable sutures are uncommon sources of infection and may be kept in the differential diagnosis in relevant circumstances.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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