A Chronic, Nonhealing Wound of the Finger Caused by Polypropylene Suture Material

Chronic wounds usually result from poor peripheral circulation, neuropathy, pressure, radiation, or infection. Such common types of chronic wounds are easily diagnosed and managed with traditional wound care techniques. In contrast, chronic nonhealing wounds caused by cancerous skin lesions, mycobacterial infections, and foreign-body reactions that are refractoryto traditional wound therapy present a particular diagnostic challenge, resulting in erroneous or delayed diagnosis. Therefore, an unusual presentation of a chronic wound should be taken into account when establishing differential diagnosis. In an effort to enhance recognition of chronic wounds caused by foreign-body reactions and facilitate their proper management, the authors report a case of a chronic nonhealing wound on the dorsum of a finger that was associated with the use of polypropylene suture and lasted for 3 years.

Wounds that do not heal within 3 months are considered chronic.¹ Chronic wounds do not heal in an orderly set of stages and in a predictable amount of time. Instead, they seem to get held up in 1 or more of the phases of wound healing, often remaining in the inflammatory stage for too long.^2,3 Chronic wounds are frequently attributable to poor peripheral circulation, neuropathy, pressure, radiation, and infection. Thus, diabetic ulcers, venous ulcers, pressure ulcers, and radiation ulcers are common types of chronic wounds. However, chronic wounds can also be manifestations of cancerous lesions, mycobacterial skin infections, and foreign-body reactions. Because such wounds do not heal with traditional wound treatments, they require specified management dependent upon the eitology of the wound; therefore, correct diagnosis is of paramount importance for proper management. Accordingly, unusual presentations of chronic wounds should be considered in a differential diagnosis.

The authors report a case of a chronic nonhealing wound on the dorsum of a finger associated with the use of polypropylene suture material. These findings will facilitate recognition of chronic wounds caused by foreign-body reactions and assist with their proper management.

A 65-year-old woman presented to the department of plastic and reconstructive surgery at the Kangwon National University Hospital, Chuncheon-Si, Gangwon-Do, Republic of Korea, with a 3-year history of a chronic recurrent skin ulcer on her finger (Figure 1). Her wound was managed conservatively at a local clinic, and she was taking oral antibiotics. The lesion would appear to begin healing, then get worse again with frequent recurrences. On her visit to Kangwon National University Hospital, the patient complained of pain in the right middle finger and moderate limitation of flexion of the distal interphalangeal joint. On physical examination, she had a 7-mm granulomatous skin lesion on the dorsum of the middle phalanx of the right middle finger. No other abnormalities were observed. The results of the general laboratory examination were within normal limits. According to her medical history, the patient had undergone an operation on her finger at another hospital 5 years previously, but she could not recall the specific operation type. The postoperative course had been uneventful, but intermittent redness, swelling, and pain intractable to antibiotic treatment developed on the dorsum of her right middle finger 2 years after the operation, followed by a skin ulcer with purulent discharge. On her current visit to the hospital, a wound culture was ordered and wound care with an antiseptic dressing was started along with oral antibiotics, but the wound did not improve. The wound culture showed no significant microorganism growth. A commercial polymerase chain reaction (PCR) assay (AdvanSure TB/NTM real-time PCR assay, LG Life Sciences Ltd., Seoul, Korea) and tissue biopsy were performed to exclude mycobacterial skin infection and malignant skin lesion. Repeated PCR assays were negative. Histological examination did not identify malignant cells, but histiocytes, giant cells, and lymphocytes were found, consistent with a foreign-body reaction. The authors explored the wound while the patient was under digital block anesthesia and found several strands of bluish-colored suture material on the wound base (Figure 2A). All these strands were extracted (Figure 2B), and the granulation tissue was thoroughly removed via curettage. The wound was repaired primarily. The suture material was identified as polypropylene using infrared spectroscopy. The patient remained well and without any limitation of finger motion during 6 months of follow-up (Figure 1). 

Common types of chronic wounds caused by various medical conditions are easily recognized and managed with traditional methods of wound care. On the contrary, chronic wounds originating from skin cancers and tuberculous or nontuberculous mycobacterial infections present a particular diagnostic challenge because of their unusual presentations. Proper management depends on the etiology of a particular wound: wide excision for skin cancers, long-term use of antimycobacterial drugs for mycobacterial infections, or removal of the foreign body for foreign-body reactions. Therefore, correct diagnosis of chronic wounds is essential.

Foreign-body reactions most commonly result from buried suture materials, and serious complications can occasionally occur despite the fact that such materials do not usually induce clinical symptoms as they react minimally with tissues. While foreign body reactions caused by suture materials are manifested with suture granulomas in deeper tissues, stitch abscesses occur in superficial tissues. Foreign-body granulomas associated with the use of various suture materials during surgery have been reported,^4-6 whereas stitch abscesses are often seen after facial surgeries when unabsorbable suture materials are buried under very thin skin.⁷ Such abscesses are easily detected by surgeons, and removal of the suture material usually solves the problem. 

Polypropylene has been widely used in medicine as a suture material or in a mesh form. In addition to superficial skin sutures, this nonabsorbable monofilament is often used and buried in tendon repair and facial surgery^8,9 because it elicits little or minimal tissue reaction.

In the described case, a polypropylene suture material had originally been used for the extensor tendon repair. Foreign-body reactions of granuloma related to polypropylene sutures have been reported in the face when used as suspension material for ptosis or ectropion correction.⁹ However, to the best of the authors’ knowledge, foreign-body reactions associated with these sutures after tendon surgery have never been reported. On the contrary, late foreign-body reactions caused by different suture materials such as coated, braided polyester sutures (Ti-Cron Sutures, Covidien, New Haven, CT)^5,10 and coated, braided polyethylene sutures (Fiberwire, Arthrex, Naples, Florida)⁶ have been reported after tendon surgery. Pabari and coauthors⁵ suggested the use of excessive suture material increases the amount of foreign body. This results in greater tissue reaction, eventually leading to suture granuloma. Considering the total length of suture material found in the presented case was approximately 5 cm, it is possible the large amount of suture material contributed to the foreign-body reaction.

Interestingly, the postoperative course of the patient had been uneventful for 2 years following the operation on her finger, and the possibility that the lesion was related to this previous surgery had therefore been overlooked by both the patient and the physicians she had seen with regard to the finger problem. The resulting lack of proper management and delayed diagnosis led to the progression of the lesion to a chronic nonhealing wound. Hence, although a variety of diagnostic tools can be used for differentiation, it is important to take medical history into consideration when diagnosing foreign-body reactions

A chronic nonhealing wound refractory to traditional wound therapy should be considered a possible manifestation of a foreign-body reaction. In addition, care should be taken to consider the patient’s entire medical history to appropriately diagnose the wound, such as in the described case.

Affiliation: Kangwon National University, Chuncheon-Si, GangwonDo, Republic of Korea

Correspondence: Dr. Sang-Yeul Lee
Department of Plastic and Reconstructive Surgery,
Kangwon National University Hospital,
Baekryeong-ro 156,
Gangwon Do, 200-722, Republic of Korea
serafin5@unitel.co.kr

Disclosure: This study was supported by 2014 Research Grant (No. 120141486) from Kangwon National University.