Tutorials in Suturing Techniques for Orthopedics

This book introduces the surgical suture techniques in orthopaedics. These techniques have been recognized as a crucial part for wound care and surgery-related prognosis. Training of fellows on suture techniques is of great importance. This book provides a standard tutorial on how to be proficient in surgical suture performance. The history and basic concepts are introduced. Important issues when considering suture methods, including site infections, suturing materials, room setups, cosmetics and drainage are also discussed fully. Different types of suture techniques applying to orthopaedic surgeries are presented with illustrations. The author strives to implement the principle that orthopaedic theory should be connected with clinical practice, highlight the application of theoretical knowledge, strengthen the pertinence and practicality of suture techniques, and reflect domestic and international development trends to the greatest extend. Preface I Preface II Introduction Contents Contributors Editors Deputy Editor 1: The History of Knots and Surgical Suturing 1.1 The History of Ropes 1.1.1 Overview 1.1.2 Materials of Early Ropes 1.1.3 Rope Making Methods 1.1.3.1 Basic Structure of Ropes 1.1.3.2 General Classification 1.1.3.3 How Ropes Were Made 1.2 The History of Knotting 1.2.1 Overview 1.2.2 Development of Knotting 1.3 A Brief History of Surgical Suture References 2: Basis for Soft Tissue Repair and Healing 2.1 Soft Tissue Repair Pathology 2.1.1 Basis for Wound Repair–Regeneration 2.1.1.1 Concept and Classification of Regeneration 2.1.1.2 Regeneration Ability of Histocytes 2.1.2 Formation of Granulation Tissue and Its Significance 2.1.2.1 Formation and Structure of Granulation Tissue 2.1.2.2 Significance of Granulation Tissue 2.1.3 Basic Pathophysiological Process of Wound Healing 2.2 Types of Skin Healing and Healing Disorders 2.2.1 Types of Skin Repair and Healing 2.2.2 Skin Healing Disorders 2.2.2.1 Factors That Cause Wound Healing Disorders Systemic Factors Local Factors 2.2.2.2 Types of Skin Wound Healing Disorders References 3: Measures for Prevention and Control of Surgical Site Infection 3.1 Diagnosis of Surgical Site Infection and Incision Classification 3.1.1 Definition and Diagnostic Criteria of Surgical Site Infection 3.1.2 Classification of Surgical Incisions 3.2 Measures for Prevention and Control of Orthopedic Surgical Site Infection 3.2.1 Evaluation of Risk Factors for Orthopedic Surgical Incision Complications 3.2.2 Incision Suture Techniques in Orthopedic Surgeries 3.2.2.1 Selection of Suture Methods 3.2.2.2 Selection of Suture Materials 3.2.2.3 Suture of Incisions of Special Types 3.2.2.4 New Incision Suture Method 3.2.3 Common Incision Complications as Well as Prevention and Treatment in Orthopedic Surgery 3.2.3.1 Incision Exudate 3.2.3.2 Incision Bleeding 3.2.3.3 Swelling Around Incision 3.2.3.4 Blister Around Incision 3.2.3.5 Ecchymosis Around Incision 3.2.3.6 Incision Infection in orthopedic Surgery (Superficial and Deep) 3.2.3.7 Poor Healing of Incision 3.2.3.8 Incision Scar References 4: Design and Selection of Surgical Suturing Materials 4.1 Surgical Suture Needle 4.1.1 Key Points of Ideal Suture Needle 4.1.1.1 Materials of Surgical Suture Needle 4.1.1.2 Key Points of Suture Needle Design 4.1.1.3 Selection Principles of Surgical Suture Needle 4.1.2 Structure and Type of Suture Needle 4.1.2.1 Basic Components of Suture Needle 4.1.2.2 Measurement of Suture Needle 4.1.2.3 Suture Attachment End of Suture Needle Advantages of Swaged Needle 4.1.2.4 Needle Body Straight Needle Half Curved Needle or “Ski” Needle Curved Needle Compound Curved Needle 4.1.2.5 Needle Point 4.1.2.6 Needle Tail 4.1.2.7 Material Science of Suture Needle Stainless Steel Alloy Coating 4.1.2.8 Types of Needle Cutting Needle MICROPOINT Suture Needle Other Cutting Needles Taper Cutting Needle Stab-Prevention Blunt Needle 4.1.3 Needle Holder: Important Assistant in Suturing 4.1.3.1 Selection of Needle Holder 4.1.3.2 Precautions When the Instrument Nurses Use Needle Holder 4.1.3.3 Precautions When Surgeons Use Needle Holder 4.1.4 Correct Tissue Suturing Technique 4.1.5 Using Suture Needle Safely 4.2 Surgical Suture 4.2.1 Suturing Materials 4.2.1.1 Ideal Suturing Materials Should Meet the Following Standards 4.2.1.2 Size and Tensile Strength of Suture 4.2.1.3 Monofilament and Multifilament Sutures 4.2.1.4 Absorbable and Non-absorbable Sutures 4.2.2 Introduction to Common Suturing Materials 4.2.2.1 Natural Absorbable Sutures 4.2.2.2 Synthetic Absorbable Sutures 4.2.2.3 Non-absorbable Sutures 4.2.2.4 Surgical Silk 4.2.2.5 Alloy Sutures 4.2.2.6 Synthetic Non-absorbable Sutures References 5: Basic Training of Orthopedic Suture Techniques 5.1 Skin Suturing Training 5.1.1 Training Purpose 5.1.2 Preparation of Articles 5.1.3 Training Process 5.1.4 Skin and Subcutaneous Suturing Steps and Common Suturing Methods 5.2 Tendon Suture Training 5.2.1 Training Purpose 5.2.2 Preparation of Articles 5.2.3 Training Process 5.2.4 Tendon Suturing Steps and Common Suturing Methods 5.3 Nerve Suture Training 5.3.1 Training Purpose 5.3.2 Preparation of Articles 5.3.3 Training Process 5.3.4 Key Points of Epineurial ing Technology 5.3.5 Key Points of Perineurial Suturing Technology 5.4 Blood Vessel Suture Training 5.4.1 Training Purpose 5.4.2 Preparation of Articles 5.4.3 Training Process 5.4.4 Two Fixed-Point End-To-End Interrupted Vascular Anastomosis Technique 5.4.5 Vascular End-to-Side Anastomosis Technique 5.5 Muscle and Fascia Suturing Training 5.5.1 Training Purpose 5.5.2 Preparation of Articles 5.5.3 Training Process 5.5.4 Common Suturing Methods and Steps of Muscles 5.5.5 Common Suturing Methods and Steps of Fascia (Fig. 5.28) 5.5.6 Basic Principles of Muscle Fascia Suturing References 6: Orthopedic Operating Room Settings and Aseptic Techniques 6.1 Orthopedic Operating Room Settings 6.1.1 Location of Operating Room 6.1.2 Layout of Operating Room 6.1.3 Basic Facilities of Operating Room 6.2 Aseptic Techniques [2, 3] 6.2.1 Surgical Items 6.2.2 Surgical Personnel 6.2.3 Surgical Patients References 7: Hand Surgery Tendon Suture Techniques 7.1 Historical Review of Tendon Repair 7.2 Biological Process of Hand Tendon Healing 7.2.1 Hand Flexor and Extensor Tendon Division 7.2.2 Tendon Nutrition 7.2.3 Biological Process of Tendon Healing 7.3 Two Major Issues of Tendon Repair 7.3.1 Tendon Adhesion 7.3.2 Tendon Rupture 7.4 Principles of Tendon Repair 7.4.1 Bunnell Proposed the Principle of Tendon Suture in 1918 [14] 7.4.2 Tang Jinbo also Proposed the Principle of Tendon End-to-End Suturing in 2002 [15, 16] 7.5 Methods of Tendon Repair 7.6 Basic Tendon Suture Techniques for Hand Surgery 7.6.1 Bunnell Stitching 7.6.2 Modified Kessler Stitching 7.6.3 Tsuge Loop Stitching 7.6.4 Figure-of-8 Stitching and Double Cross Stitching 7.6.5 Extensor Tendon Repair Technique 7.6.6 Fish Mouth Stitching 7.6.7 Weaving Stitching (Fig. 7.36) 7.7 Common Repair Techniques for Tendon Rupture 7.7.1 Repair of Extensor Tendon Insertion Rupture (Fig. 7.37) 7.7.2 Repair of Middle Phalanx Level Extensor Tendon Rupture (Fig. 7.38) 7.7.3 Repair of Proximal Interphalangeal Joint Level Extensor Tendon Rupture (Fig. 7.39) 7.7.4 Repair of Metacarpophalangeal Level Extensor Tendon Rupture (Fig. 7.40) 7.7.5 Repair of Flexor Tendon Insertion (Zone I Dp1) Rupture (Fig. 7.41) 7.7.6 Repair of Middle Phalanx Level Flexor Tendon Insertion (Zone II Dp2) Rupture (Fig. 7.42) 7.7.7 Repair of Proximal Phalanx Level Flexor Tendon Insertion (Zone II Dp2) Rupture (Fig. 7.43) 7.7.8 Repair of Palm Level Flexor Tendon Insertion (Zone III Dp3) Rupture (Fig. 7.44) 7.7.9 Repair of Wrist Level Flexor Tendon Insertion (Zone IV Dp4) Rupture (Fig. 7.45) 7.8 Early Rehabilitation after Tendon Repair 7.9 Summary of Hand Surgery Tendon Repair References 8: Achilles Tendon Rupture Suture Techniques 8.1 Overview 8.2 Anatomy of Achilles Tendon Injury 8.3 Classification of Achilles Tendon Injury 8.4 Evaluation of Achilles Tendon Injury 8.4.1 Clinical Evaluation 8.4.2 Imaging Evaluation 8.5 Treatment of Achilles Tendon Injury 8.5.1 Treatment Principles 8.5.2 Krackow Lockstitch Suture for Open Repair of Acute Achilles Tendon Rupture 8.5.3 Percutaneous Minimally Invasive Suture and Repair of Acute Achilles Tendon Rupture 8.5.4 Repair of Subacute Achilles Tendon Rupture with Abraham V-Y Plasty 8.5.5 Lindholm Technique to Repair Old Achilles Tendon Rupture 8.6 Complications and Prognosis of Achilles Tendon Injury 8.6.1 Misdiagnosis or Missed Diagnosis of Achilles Tendon Rupture 8.6.2 Incision Issues 8.6.3 Postoperative Adhesion 8.7 Rehabilitation of Achilles Tendon Injury 8.8 Author’s Comments References 9: Suturing Techniques in the Repair and Reconstruction of Peri-Articular Injuries of Upper Limbs 9.1 Clinical Anatomy of Shoulder Joint and Principles for Repair of Injuries 9.1.1 Clinical Anatomy of Shoulder Joint 9.1.2 Clinical Structure of Shoulder Joint and Principles for Repair of Injuries 9.2 Learn to Use Anatomical Landmarks in Reduction and Repair 9.2.1 Anatomical Landmarks of the Shoulder Joint 9.2.2 Surgical Approaches for Shoulder Joint 9.3 Suture-Assisted Technique for Plate Nails and Intramedullary Nails in Internal Fixation of Proximal Humeral Fractures 9.3.1 Suture-Assisted Repair of Proximal Humeral Fractures with Steel Plates 9.4 Shoulder Prosthesis and Suturing Techniques 9.4.1 Overview 9.4.2 Surgical Methods 9.4.2.1 Position and Approach 9.4.2.2 Installation of Glenoid Prosthesis 9.4.2.3 Installation of the Humeral End Prosthesis 9.4.2.4 Tubercular Reconstruction During the Operation 9.4.2.5 Postoperative Management and Rehabilitation 9.4.3 Efficacy of Reverse Shoulder Joint Replacement with Prosthesis and Prevention of Complications 9.5 Suturing Technique for Repair and Reconstruction of Peripheral Injury of the Shoulder Joint 9.5.1 Repair of Rotator Cuff Injury 9.5.1.1 Causes of Rotator Cuff Injury 9.5.1.2 Pathology and Classification 9.5.1.3 Clinical Manifestation and Diagnosis 9.5.1.4 Repair of Rotator Cuff Injury 9.5.2 Repair and Reconstruction of Shoulder Joint Capsule Injury 9.5.2.1 Capsular Ligament Avulsion on the Attachment Surface of Humeral Head (HAGHL) 9.5.2.2 Capsular Ligament Laxity of the Shoulder Joint 9.5.2.3 Absence of Capsular Ligament 9.5.2.4 About Superior Capsular Reconstruction (SCR) Technique 9.5.3 Repair of Acromioclavicular Joint Injury 9.5.3.1 Anatomical Structure of the Acromioclavicular Joint 9.5.3.2 Mechanism of Joint Injury 9.5.3.3 Assessment of Acromioclavicular Joint Injury 9.5.3.4 Therapeutic Regimens 9.5.4 Repair and Reconstruction of Coracoclavicular Ligament Injury 9.5.4.1 Reconstruction Technique of Ligament Between Coracoid Process and Clavicle 9.5.4.2 Non-Anatomical Reconstruction of Coracoclavicular Ligament 9.5.4.3 Anatomical Reconstruction of Coracoclavicular Ligament 9.5.5 Reconstruction of Rotator Cuff Functions in Artificial Shoulder Arthroplasty 9.5.5.1 Role of Rotator Cuff in Shoulder Joint Movement 9.5.5.2 Reduction of the Greater and Lesser Tubercles of the Humerus and Rotator Cuff Functions 9.5.5.3 Free Soft Tissue Protection as well as Prosthesis Position and Rotator Cuff Functions 9.5.5.4 Reverse Shoulder Arthroplasty and Functional Substitution of Rotator Cuff 9.5.5.5 Recovery of Rotator Cuff Functions After Artificial Shoulder Arthroplasty 9.6 Suture Techniques for Repair and Reconstruction of Injuries Around the Elbow Joint 9.6.1 Repair and Reconstruction of Ulnar Collateral Ligament Injuries of the Elbow Joint 9.6.1.1 Direct Repair of Ulnar Collateral Ligament Ruptures of the Elbow Joint 9.6.1.2 Reconstruction of Ulnar Collateral Ligament Old Injuries of the Elbow Joint 9.6.2 Repair and Reconstruction of Lateral Collateral Ligament Complex Injuries of the Elbow Joint 9.6.2.1 Diagnosis of Lateral Collateral Ligament Injuries of the Elbow Joint 9.6.2.2 Surgical Technique 9.6.2.3 Postoperative Management 9.6.2.4 Complications 9.6.3 Repair and Reconstruction of the Triceps Brachii Tendon Insertion Rupture 9.6.3.1 Direct Repair of Triceps Tendon Injuries 9.6.3.2 Repair Techniques for Chronic Injuries with Partial Loss and Retraction of the Tendon 9.6.3.3 Repair Technique of Old Triceps Brachii Rupture 9.6.3.4 Postoperative Rehabilitation and Prognosis 9.6.3.5 Complications and Key Points 9.6.4 Repair and Reconstruction of Distal Rupture of the Biceps Tendon 9.6.4.1 Direct Repair Method of Distal Biceps Tendon Rupture 9.6.4.2 Delayed Reconstruction 9.6.4.3 Postoperative Management 9.6.5 Suture Techniques for Repair of Articular Cartilage Fractures Around the Elbow Joint 9.6.5.1 Overview 9.6.5.2 Suture Techniques for Various Cartilage Fractures Around the Elbow Joint References 10: Incision Suture Technique After Total Hip and Knee Arthroplasty 10.1 Hip and Knee Joint Replacement Surgical Approach 10.1.1 Hip Joint Replacement Surgical Approach 10.1.1.1 Posterolateral Approach 10.1.1.2 Direct Lateral Approach (Modified Hardinge Approach) 10.1.1.3 Direct Anterior Approach 10.1.2 Knee Joint Replacement Surgical Approach 10.1.2.1 Medial Parapatellar Approach 10.1.2.2 Auxiliary Exposure Technique 10.2 Incision Suturing Technique for Joint Replacement Surgeries 10.2.1 Incision Suturing of Hip Joint Replacement 10.2.1.1 Posterolateral Approach 10.2.1.2 Direct Lateral Approach 10.2.1.3 Direct Anterior Approach 10.2.2 Incision Suturing of Knee Joint Replacement 10.3 Prevention and Treatment of Incision Complications References 11: Cosmetic Skin Suture and Irregular Skin Wound Suture 11.1 Skin Structure 11.1.1 Skin Anatomy 11.1.2 Relaxed Skin Tension Line 11.2 Skin Cosmetic Suture Methods and Techniques 11.2.1 The Principle of Cosmetic Skin Suture 11.2.2 Standard Suture Technique 11.2.3 Suture Techniques for Irregular Wounds 11.2.4 Special Suture Technique 11.2.4.1 Continuous Intradermal Suturing 11.2.4.2 Vertical Mattress Suture (Donati Suture) 11.2.4.3 Interrupted “Heart-Shaped” Subcutaneous Suturing 11.2.4.4 Zhang’s Super Relaxation Suture 11.3 Selection of Instruments and Sutures 11.3.1 Device Selection 11.3.2 Suture Selection 11.3.2.1 Incision with Less Tension (Subcutaneous Suturing + Skin Suturing) 11.3.2.2 Incision with Greater Tension 11.3.2.3 Needle Selection 11.4 Wound Healing and New Wound Closure Products 11.4.1 Wound Healing 11.4.2 New Wound Closure Products References 12: Microsurgical Reconstruction Suture Techniques 12.1 Training Requirements for Microsurgery Repair Techniques 12.2 Suture of Blood Vessels 12.2.1 Vascular Repair 12.2.2 Angiorrhaphy 12.2.2.1 End-to-End Anastomosis 12.2.2.2 End-to-Side Anastomosis 12.2.2.3 Disc-to-Side Anastomosis 12.2.2.4 Disc-to-End Anastomosis 12.2.2.5 Mosaic Anastomosis 12.3 Nerve Reconstruction Suture Techniques 12.3.1 Basic Principles to be Emphasized Before Nerve Suture 12.3.2 Nerve Suture Methods [3] 12.3.2.1 Epineurial Suture 12.3.2.2 Perineurial Suture 12.3.2.3 Combined Epiperineurial Suture Method 12.3.2.4 End-to-Side Neurorrhaphy 12.3.2.5 “Fish-Mouth Like” Suture 12.3.3 Comparison of Epineurial Suture and Perineurial Suture References 13: Suture Techniques for Spinal Soft Tissue Reconstruction 13.1 Suture Techniques for Posterior Spinal (Cervical, Thoracic, and Lumbar) Surgery 13.1.1 Anatomical Features of Spinal Soft Tissue 13.1.2 Characteristics of Dorsal Spinal Soft Tissue and Suture Requirements 13.1.3 Suture Techniques of Cervical Posterior Soft Tissues Reconstruction 13.1.4 Incision Closure Technique for Thoracolumbar Posterior Median Approach 13.2 Incision Closure Technique for Anterior Cervical Spine Surgery 13.2.1 Incision Selection 13.2.2 Incision Closure 13.2.3 Cerebrospinal Fluid Leakage 13.2.4 Esophagus Fistula 13.3 Incision Closure Technique for Scoliosis Orthopedics 13.3.1 Anatomy by Posterior Approach 13.3.2 Exposure by Posterior Approach 13.3.3 Closure Method of Posterior Incision 13.3.4 Risk Factors and Prevention of Incision-Related Complications 13.4 Repair and Suturing of Spinal Dura Mater and the Prevention and Treatment of Postoperative Cerebrospinal Fluid Leakage 13.4.1 Understand Dural Suturing Repair and Postoperative Cerebrospinal Fluid Leakage 13.4.2 Dural Repair by Suturing and Treatment of Postoperative Cerebrospinal Fluid Leakage in Anterior Cervical Surgery 13.4.3 Dural Repair and Treatment of Postoperative Cerebrospinal Fluid Leakage in Posterior Thoracic Surgery 13.4.4 Dural Repair and Treatment of Postoperative Cerebrospinal Fluid Leakage of Posterior Lumbar Surgery 13.5 Prevention of Spinal SSI and Treatment of Infected Incisions 13.5.1 Background 13.5.1.1 Early Superficial Infection 13.5.1.2 Early Deep Infection 13.5.1.3 Delayed Deep Infection 13.5.2 Spinal Surgery Infection Prevention and Infected Wound Suturing Technique References 14: Orthopedic Knotting Techniques 14.1 Surgical Instruments Concerning Suture Technology 14.1.1 Surgical suture 14.1.2 Surgical Suture Needle 14.1.3 Needle Holder 14.1.4 Selection of Surgical Gloves 14.2 Common Orthopedic Suture Knots 14.2.1 Structure of a Suture Knot 14.2.2 Types of Suture Knot 14.3 Application of Suture Technique in Fracture Reduction and Fixation 14.3.1 Proximal Humeral Fracture 14.3.2 Avulsion Fracture of ACL (Anterior Cruciate Ligament) 14.3.3 Treatment of Butterfly Fragments 14.3.4 Olecranon Fracture 14.3.5 Calcaneus Fracture References 15: Orthopedic Drainage 15.1 Overview 15.1.1 Historical Review 15.1.2 Purpose of Drainage 15.1.3 Classification of Drainage 15.1.4 Common Drainage Materials and Time Limit for Application 15.1.5 Indications and Common Methods of Orthopedic Drainage 15.1.6 Precautions for Orthopedic Drainage 15.1.7 Time for Removal of Various Drainage Methods 15.2 Vacuum Sealing Drainage Technology 15.2.1 Vacuum Sealing Drainage 15.2.1.1 Technical Principle of VSD 15.2.1.2 Application of VSD Technology 15.2.1.3 Advantages of VSD Technology 15.2.2 Closure of Drainage Port 15.2.3 Precautions for Orthopedic Drainage 15.2.4 Time for Removal of Various Drainage Methods References 16: Debridement and Closure of Soft Tissue Injuries 16.1 Soft Tissue Injury Classification and Injury Mechanism 16.1.1 Classification 16.1.1.1 Closed Trauma 16.1.1.2 Open Trauma 16.1.2 Morel-Lavallée Injury 16.1.2.1 Injury Mechanism and Pathological Process 16.1.2.2 Clinical Symptoms 16.1.2.3 Imaging Examination 16.1.2.4 Treatment Methods 16.2 Treatment of Open Fracture with Soft Tissue Injury 16.2.1 General Treatment of Traumatic Patients 16.2.2 Debridement and Routine Treatments in Trauma Rooms 16.2.3 Bacterial Culture, Anti-Infection, and Tetanus 16.2.4 Wound Dressing 16.3 Principles of Debridement of Soft Tissue Injury 16.3.1 Debridement and Suturing 16.3.2 Debridement Procedures 16.3.2.1 Washing 16.3.2.2 Cleaning 16.3.2.3 Repairing 16.4 Wound Closure 16.4.1 Wound Treatment Concept 16.4.2 Patient Assessment and Wound Assessment 16.4.3 Preoperative Plan and Selection of Operation Timing 16.4.3.1 Preoperative Plan 16.4.3.2 Selection of Operation Timing 16.4.4 Primary and Secondary Closure of Wounds 16.4.4.1 Primary Wound Closure 16.4.4.2 Secondary Wound Closure 16.4.5 The Method for Closure of Some Special Wounds 16.5 Wound Coverage 16.5.1 Wound Assessment 16.5.2 Skin Grafting and Skin Substitutes 16.5.2.1 Skin Grafting 16.5.2.2 Skin Substitutes 16.5.2.3 Skin Flap Grafting 16.5.2.4 Decision on Wound Coverage References