Jack Hutter DPM, C.ped, FACFAS

Transcription

1 Jack Hutter DPM, C.ped, FACFAS

2 1. Be knowledgeable of basic suturing principles 2. Be able to perform commonly used suturing techniques 3. Be able to determine the type of incision warranted for a particular pathology 4. Be able to determine which types of suturing techniques are indicated for closing incisions involved in treating these pathologies First lets look at some suturing basics

3 The earliest reports of surgical suture date to 3000 BC Egypt Oldest known example of suturing is on a mummy from 1100 BC The Indian sage Sushruta described wound suture and materials in 500 BC Hippocrates described suture techniques Galen described gut suture taken from sheep intestine Lister developed techniques for sterilization of gut suture The modern era of suture begins in 1931 with polyvinyl alcohol synthetic absorbable suture Polyester in the 1950 s, polyglycolic in the 1970 s Today most suture is made of a synthetic polymer

4 The type of suture technique and material chosen can either compliment or hinder the surgical result Improper tissue handling can lead to painful noticeable scars, adhesions, dehiscence, tissue strangulation, hematoma With some specific exceptions, non-dissolvable suture is used to close skin, dissolvable suture is used for subcutaneous closure Simply put, suturing is the act of securely and accurately bringing edges of tissue together using specific instrumentation and materials, and techniques involving suture placement and knot tying

5 Needle holder, forceps or Adson, Adson-Brown pickups, suture with needle Sterile suture packs include the suture material attached to the needle The desired length of the needle is procedure dependent, as is the type and diameter of suture material Suture material diameter is classified in numeric terminology, 1-0 very thick, 5-0 very thin Cutting needles allow for easier tissue penetration Needles are either cutting or reverse cutting, the cutting edge sharp on the inner curve, reverse cutting on the outer curve Reverse cutting needles reduce the chances of the needle and suture cutting cross-ways through tissue

6 The needle holder is held with the tip of the thumb and the 2 nd finger Grasp the needle with the holder at the swage (widest point, usually 1/3 distance from the suture ) of the needle The needle is fragile, easily bent or broken Stabilize the tissue edge with the pick-ups Penetrate at a 90 degree angle Grasp the passed through portion of the needle with the holder before releasing the pick-ups Pull the needle and suture through the tissue Repeat the process or tie off

7 Placement points for needle penetration should be directly opposite and symmetric depending upon the technique When closing skin, the suture should not be more than 3mm from the incision Wound edge inversion is to be avoided, strive for slightly everted edges Sutures placed too tightly will create a larger scar, tissue strangulation, and are harder and more painful to remove

8 Should not be too tight to avoid tissue constriction The surgeons knot is a square knot, created by first two clockwise twists of the needle holder around the suture and grasping the loose end of the suture, and drawing back on the redundant suture to tighten down the first layer of the knot, then repeat for the second layer similarly except with one counter clock wise twist A granny knot will slip A third clockwise twist creates an even stronger locked knot Tissue strangulation occurs with the third twist if the second layer is not securely tightened Leave adequate suture length after each knot for easier and less painful removal

9 Commonly used suture techniques include Simple interrupted Simple running ( continuous ) Continuous with lock Running intra-cuticular Vertical mattress Vertical mattress with pulley Horizontal mattress Simple or continuous subcutaneous Other methods of closure Modified Bunnell suture for tendon repair Ligature

10 Location of the incision Skin thickness How much tension is on the incision and potential for swelling Elimination of dead space Cosmetic result ( reduced scarring )

11 Try to follow skin lines, don t incise diagonally, with linear orientation preferred - reduces scarring, avoids vital structures Be aware of vital structures in the area - nerve, tendon, vascular Scalpel blade should be perpendicular with the skin - better edges for closure, reduces dehiscence Lateral tension on the skin at time of incision eliminates redundancy, allowing for a more accurate incision Consider using a skin marker if incisions are for a excisional or rotational procedure If an excisional procedure, start with incisions smaller rather than too large, reducing the extent of scarring Use appropriate forceps when handling skin to reduce excess trauma, scarring

12 SIMPLE INTERRUPTED Advantages - easily placed - good wound edge strength - less tissue strangulation Disadvantages - minimal edge eversion - time consuming to place

13 SIMPLE RUNNING ( CONTINUOUS ) Advantages - less knots, making placement quicker with less scarring - good for long incisions - locking stitch helps to maintain suture tension Disadvantages - tissue strangulation if too tight, causing dehiscence - avoid if tissue is hypovascular

14 CONTINUOUS INTRA - CUTICULAR Advantages - removal not needed - improved cosmetic result Disadvantages - time consuming - lots of dissolvable material, potential scar hypertrophy - steri-strip reinforcement often needed if excessive swelling is anticipated

15 HORIZONTAL MATTRESS Advantages - used when there is increased wound tension, swelling - good edge eversion, reduces dehiscence - easily removed if not too tight Disadvantages - strangulation with dehiscence if too tight - time consuming to place

16 VERTICAL MATTRESS Advantages - good edge eversion - dead space closure - strong approximation, especially if spaced with simple interrupted sutures Disadvantages - strangulation of tissue if too tight, especially if excessive swelling

17 SIMPLE SUBCUTANEOUS Advantages - layer closure of smaller spaces reducing dead space - dissolvable material - reduces tension on skin incision Disadvantages - tissue strangulation if too tight - inclusion cyst if material doesn t dissolve

18 CONTINUOUS SUBCUTANEOUS Same advantages and disadvantages as simple subcutaneous closure - often combined with simple subcutaneous closure for larger spaces

19 Linear -Straight, uncomplicated, no angular correction Curvi-linear ( semi-elliptical ) -Used to accommodate tissue irregularity, angular correction Converging semi-ellipitical -Excision of lesion, tissue redundancy Lazy S -Used where a large amount of exposure is desired, reduced tension on skin edge V- Y Advancement -Lengthens skin contracture Teardrop -Derotational incision

20 Cutaneous Subcutaneous Digital Metatarsal Midfoot Rearfoot

21 EPIDERMIS/EPIDERMIS Mass, pigmented lesion, scar, foreign body - linear or converging semi-elliptical incision - closure simple interrupted or horizontal mattress, 4-0 or 5-0 nylon - complications scarring NAIL Various common nail pathologies involving matrixectomy, nail bed excision, biopsy, nail fold excision - curvilinear incision with ends joined by a linear incision - closure 4-0 or 5-0 nylon, possibly gel foam or similar material to fill in void at nail bed - complications scarring, incomplete nail bed closure

22 EPIDERMIS, DERMIS TOE NAIL

23 CYST, FOREIGN BODY NEUROMA Ganglionic cyst, sebaceous cyst, foreign body - linear incision - closure simple or continuous subcutaneous 4-0 vicryl, skin simple interrupted or horizontal mattress 4-0 nylon - complications dehiscence, infection, reoccurrence Second or third metatarsal interspace - linear incision if dorsal approach, transverse curvilinear incision proximal to sulcus if plantar approach - subcutaneous closure simple interrupted 4-0 vicryl, skin closure horizontal mattress 4-0 nylon - complications dehiscence, infection, stump neuroma

24 CYST, FOREIGN BODY INTERMETATARSAL NEUROMA

25 FIBROMA TENDON LENGTHENING Plantar fibromatosis - lazy S incision allows for better exposure, less skin traction - subcutaneous closure 3-0 vicryl bringing edges of plantar fascia together, and 4-0 vicryl for subcutaneous layer closure, 4-0 nylon for skin closure simple interrupted alternating with horizontal mattress - complications dehiscence, hematoma, hypertrophic scar, reoccurrence Extensor tendon contracture - tendon incision Z plasty technique - closure Bunnell technique, 4-0 vicryl, increases closure strength considering longitudinal orientation of tendon fibers - complication rupture of tendon closure

26 FIBROMA TENDON LENGTHENING

27 DIGITAL TENDON CONTRACTURE CAPSULE CONTRACTURE Lesser digital flexor tendon contracture - transverse linear plantar skin stab incision PIPJ or DIPJ level - skin closure simple interrupted, 4-0 nylon - complications vascular damage, nerve damage, digital hyperextension Digital IP joint capsule - linear stab incision plantar capsule lesser digit, often in conjunction with tenotomy - skin closure as with percutaneous tenotomy - complications as with digital tenotomy, and IP joint malalignment

28 FLEXOR TENDON RELEASE, IPJ CAPSULOTOMY

29 HAMMERTOE DEFORMITY Joint contracture, arthroplasty, arthrodiesis - linear skin incision converging, or semielliptical incisions, teardrop incision for contracted and varus rotated 5 th toe to derotate 5 th toe - capsule linear incision - closure capsule 4-0 vicryl, continuous; skin closure simple interrupted or horizontal mattress, 4-0 nylon - complications dehiscence if excessive skin tension, hypertrophic scar, vascular compromise

30 LINEAR, EXCISION OF SKIN REDUNDANCY TEARDROP, EXCISION OF SKIN REDUNDANCY AND RE-ROTATION OF VARUS DEFORMITY

31 HALLUX Subungual exostosis (osteochondroma) - incision semi-elliptical, distal tip of hallux - closure simple interrupted subcutaneous 4-0 vicryl, skin closure simple interrupted alternating with horizontal mattress, 4-0 nylon - complications dehiscence, infection, toenail bed trauma causing loss of toenail

32 SUBUNGUAL EXOSTOSIS, OSTEOCHONDROMA

33 HALLUX Inter-phalangeal joint hypertrophy - incision linear medial plantar aspect IP joint level - closure same as for subungual exostosis - complications infection, dehiscence, nerve damage medial plantar digital nerve, IP joint damage Hallux interphalangeus - Linear skin and subcutaneous incision - closure of periosteum and subcutaneous tissue continuous 4-0 vicryl, skin closure horizontal mattress 4-0 nylon - complications EHL tendon damage, medial and lateral digital nerve trauma, infection

34 INTER-PHALANGEAL JOINT HYPERTROPHY HALLUX INTERPHALANGEUS

35 1 ST METATARSAL PHALANGEAL JOINT Hallux valgus - linear skin and subcutaneous incisions, inverted L capsule incision - capsule closure continuous and simple interrupted 3-0 vicryl, skin closure horizontal mattress 4-0 nylon - dorsal medial neurovascular bundle damage, EHL tendon trauma Hallux rigidus - skin, subcutaneous, and capsule incisions linear - closure same as for hallux valgus ` - complications same as for hallux valgus

36 HALLUX VALGUS, HALLUX RIGIDUS

37 METATARSAL Metatarsus primus varus, elevatus - linear skin, subcutaneous, periosteum incisions - periosteum closure simple interrupted 4-0 vicryl, subcutaneous layer closure 4-0 vicryl, skin closure 4-0 horizontal mattress - complications neurovascular and EHL tendon trauma Lesser metatarsal malalignment, Tailor bunion - incisions, closure, complications same as for 1 st metatarsal pathologies Dorsal exostosis - 1st, 2nd and/or 3rd metatarsal cunieform joints - linear skin, subcutaneous, capsule incisions - capsule closure continuous 4-0 vicryl, subcutaneous layer closure 4-0 vicryl, skin closure horizontal mattress 4-0 nylon - complications deep peroneal nerve branches and dorsalis pedis artery are in this vicinity

38 1 ST METATARSAL SHAFT, BASE, AND METATARSAL CUNEIFORM JOINT LESSER METATARSALS, INCISION BETWEEN ALLOWS ACCESS TO BOTH

39 MID FOOT, REAR FOOT Haglunds Deformity - linear skin incision to expose posterior lateral aspect of the calcaneus, linear subcutaneous and periosteum incisions - closure periosteum continuous 4-0 vicryl, subcutaneous closure continuous 4-0 vicryl, skin closure horizontal mattress 4-0 nylon - complications Achilles tendon rupture, sural nerve trauma if incision is too high if Plantar calcaneal spur - Medial approach, open curvilinear skin incision for skin, linear incision for periosteum, linear skin incision percutaneous approach - open procedure, closure periosteum continuous 3-0 vicryl, subcutaneous closure 4-0 vicryl continuous, skin closure horizontal or vertical mattress, 3-0 nylon; percutaneous procedure skin closure horizontal mattress 4-0 nylon - complications hematoma, dehiscence, medial calcaneal nerve trauma

40 HAGLUNDS DEFORMITY PLANTAR CALCANEAL SPUR, PLANTAR FASCIOTOMY

41 1. Linear incision 2. Semi- elliptical incision 3. Converging semielliptical incision 4. Lazy S incision 5. Linear subcutaneous incision 1. Simple continuous closure 2. Continuous subcuticular closure Simple interrupted closure 4. Horizontal mattress closure 5. Continuous SubQ closure

42 Thank You!