骨科縫合技術(shù)基礎(chǔ)培訓(xùn)BasicTrainingonOrthopedicSutureTechnique中華醫(yī)學(xué)會(huì)骨科學(xué)分會(huì)創(chuàng)傷學(xué)組推薦醫(yī)師培訓(xùn)項(xiàng)目愛惜康ETHICONapU佛*JqiwHcompany皮膚及皮下組織縫合北京積水潭醫(yī)院創(chuàng)傷骨科劉興華2008年11月愛惜康ETHICONapU佛*JqiwHcompany?傷口愈合?縫合方法?開放傷門處理?縫合小技巧?皮瓣?縫線選擇愛惜康ETHICONapU佛*JqiwHcompany傷口愈合4愛惜康ETHICONacompany傷口愈合分期*V國1nfhmmdtion(V炎癥期0-7天愛惜康ETHICONa^ttieN^oAiucMcompany傷口愈合分期增生期7。21天愛惜康ETHICONacompany傷口愈合分期瘢痕成熟期21天-1年愛惜康ETHICONacompany各種組織自然愈合時(shí)間組織層次愈合時(shí)間組織層次愈合時(shí)間皮膚7-10天關(guān)節(jié)囊3-4周皮下組織7—10天腱鞘2周肌肉筋膜2周骨膜2周肌肉2周血管3周肌腱3一4周神經(jīng)20-24周愛惜康ETHICONa卜“佛*JqiwHcompanybffMXmO01SECOMJ4R>iNTrvnfJVrhjjrim./nnkiiw>tvn\nt)\"u"y,jijIdrhrkhmmlimii，li'>ilk^ui'i?hliV^IIhdri穸hkd.?v**?h康NJdll;傷口愈合方式MJMMAIT^OlIHKLLMLniOUSUrHIAlIM.皞,hiA"wj?mp較rMi狩vwrwTiovAulfHbtfluHn典^<1R^i^dIchi-'tllihhHitxlMtc)影響傷口愈合的因素?年齡?體重?營養(yǎng)狀況?脫水狀態(tài)?血液供應(yīng)?免疫反應(yīng)?合并慢性疾病?藥物或放射治療?吸煙愛惜康1ETHICONacompany1007525?0(WEEKSPOSTINJURYNohce:Eventhe’b＜、thealingimneverbetterthan80^ofuninjuredti^uc:jUvnglhtMIMM*■h?**TableH1IncreasingtensileStrengthofthpWbundAfterlujunacompany組織張力強(qiáng)度變化曲線圖傷口愈合?上皮細(xì)胞是傷口愈合時(shí)唯一可再生的細(xì)胞，上皮再生在傷口閉合后隨即啟動(dòng)。?傷U閉合后不久，基底層細(xì)胞遷移到傷口/切口處真皮組織以閉合接近關(guān)閉的傷口。HuntTK,VanWinkleWJr.Nonna1repair.In:HuntTK.FiindamentalsofWoundManagement.NewYork:AppletoilCentiuyCrofts,1979.愛惜康1ETHICONacompany傷口愈合評(píng)分HollanderWoundEvaluationScale?無錯(cuò)位(absenceofstepoff)>傷口對(duì)合不齊(contourirregularities)?傷口對(duì)合邊距超過2mm(woundmarginseparationgreaterthan2mm)?邊緣內(nèi)翻(edgeinversion)?過分扭曲(excessivedistortion)?整體美觀度(overallcosmeticappearance)（0-6分，6分最佳）愛惜康1ETHICONacompany傷口愈合評(píng)分ModifiedHollanderWoundEvaluationScale?Step-offborders?Contourirregularities?Scarwidth?Edgeinversion?Excessiveinflammation?Overallcosmeticappearanceofthewound(0-6score,0istheoptimal)愛惜康ETHICONa^xnpany縫合方法愛惜康ETHICONacompany傷口的解剖層次^UUKlIIVLrtHM鼇、LtLUL?j*M(_4*t￡i>|bmi?aMiINW*niRMIIM71HFsitkxtamxmsntisIF^iCIVIUilHitMUMIIMTlItFlLKjlAfklVUM愛惜康'ETHICONa^ttieN^oAiucMcompany疤痕美觀效果注意技術(shù)原則?縫合后傷口有稍許外翻?縫線足夠緊張又不能過緊?如需深層縫合以減少皮膚張力，要埋結(jié)17愛惜康1ETHICONacompany間斷縫合法縫合方法連續(xù)縫合法?優(yōu)點(diǎn)-容易調(diào)節(jié)張力-一個(gè)部位失效影響不大?缺點(diǎn)-需各個(gè)打結(jié)，操作時(shí)間長(zhǎng)-需更多縫線-傷口內(nèi)異物更多?優(yōu)點(diǎn)-'i作時(shí)間縮短-傷口內(nèi)異物較少-—個(gè)部位失效可影響全局_調(diào)節(jié)張力不容易-可能破壞血供更嚴(yán)重愛惜康ETHICONa^>mpany較深傷口的關(guān)閉??"皮下縫合IthTcoJ較深傷口的關(guān)閉…皮下縫合愛惜康ETHICONacompany間斷縫合愛惜康ETHICONacompany垂直褥式縫合愛惜康'ETHICONacompanyTi.*水平褥式縫合愛惜康ETHICONacompany1連續(xù)縫合BaseballStitch?ETHICON饑縫合BaseballStitchIth?co5acompany連續(xù)鎖邊縫合Running-LockClosureacompany連續(xù)鎖邊縫合Running-LockClc^ure廉ETHICONacompany連續(xù)鎖邊縫合Running-LockClo6uje?coSacompany連續(xù)皮內(nèi)縫合愛惜康'ETHICONacompany連續(xù)皮內(nèi)縫合30愛惜康ETHICONacompany開放傷口的處理31愛惜康ETHICONacompany開放傷口處理原則?清創(chuàng)最重要?關(guān)閉傷口方式依據(jù)傷口情況及術(shù)者經(jīng)驗(yàn)決定愛惜康ETHICONapU佛*JqiwHcompany傷口處理?盡力使疤痕順應(yīng)皮膚張力松弛線?皮膚張力松弛線常與其下肌肉纖維長(zhǎng)軸垂直acompany?匈傷口處理?分層縫合?保持皮緣外翻?皮緣松松接觸康ETHICON龕comiwiy傷口處理?張力過大有可能組織壞死愛惜康ETHICONapU佛*JqiwHcompany傷口處理?傷口雙側(cè)縫合組織深度應(yīng)一致以防皮緣重疊惜康'HICON傷口處理?簡(jiǎn)單間斷縫合：注意避免內(nèi)翻?垂直褥式縫合：可能疤痕較大?皮內(nèi)縫合38acompany傷口處理?水平褥式縫合-外翻皮緣-可能影響皮緣血運(yùn)acompany“狗耳朵”的處理惜康國CONacompany復(fù)雜傷口處理11愛惜康'ETHICON復(fù)雜傷口處理?縫合方式一愛惜康'ETHICON復(fù)雜傷口處理?縫合方式二13愛惜康'ETHICON不規(guī)則傷口處理愛惜康ETHICONa戶*潮^comiwiy縫合小技巧45愛惜康ETHICONapU佛*JqiwHcompany不扯斷縫合線情況下破壞縫線材料的記憶性?Prolene等具有相當(dāng)強(qiáng)的記憶性，可影響縫合打結(jié)的牢固度。?正確方法:愛惜康ETHICONacompany不扯斷縫合線情況下破壞縫線材料的記憶性?不正確方法acompany用_F指持捏縫針三角縫合法?尖端不恰當(dāng)縫合會(huì)導(dǎo)致尖端壞死縫合入針點(diǎn)距離尖端過近縫合不恰當(dāng)，使得尖端對(duì)位出現(xiàn)間隙進(jìn)而造成尖端缺血性壞雌惜康ETHICONacompany三角縫合法?正確縫合方法康ETHICONacompany三角縫合法?正確縫合方法-縫合入位-對(duì)合整齊acompany小切口的延遲閉合縫合?所有內(nèi)縫線固定位置后，從兩端向中間打結(jié)愛惜康ETHICONacompany穿皮垂直褥式縫合?適于小而深的切口惜康'■rnicon止血的輔助手段一連續(xù)鎖邊縫合?由于壓力效果很好，要注意避免縫合過緊，防止出現(xiàn)組織絞窄壞死。?不可用于血供少的部位。aeompan/?保證最大限度的皮緣外翻3g愛惜康ETHICONacompany連續(xù)混合褥式縫合連續(xù)混合褥式縫合?保證最大限度的皮緣外翻斜位縫合?改變張力方向閉介鼻唇溝缺損會(huì)使嘴角翹起水平調(diào)整張力方向則無此問題愛惜康ETHICONacompany斜位縫合?改變張力方向acompanyMercedes皮瓣大面積缺損的多皮瓣閉合?適用于頭皮、軀干、四肢等設(shè)計(jì)丫三個(gè)三角縫介三角形每條底邊與缺損*tsM的切點(diǎn)，部分閉介切口Mercedes皮瓣大面積缺損的多皮瓣閉合?適用于頭皮、軀干、四肢等缺損的進(jìn)一步閉介采用內(nèi)縫合閉合愛惜康ETHICONacompany皮60愛惜康1ETHICONacompanyFusiform(Eliptical)ExcisionfTH?co*acompanyDogEar愛惜康ETHICONacompanyAdvancementFlapThelengthis2.5to3timesthewidth愛惜康ETHICONacomiwiyLengthRotationFlapRotationlimb(arc)DefectLimb(arc)2-4timeslongerthanthedefectlimb(arc)TriangluardefectRotationlimb(arc)is2-4timeslongerthantriangulardefectlimb(arc).愛惜康ETHICONaJei*潮^comiwiyZ-PlastyETHICONacompanyNoteFlap愛惜康ETHICONacompanyBilobeFlap愛惜康ETHICONa^ttieN^oAiucMcompanyRhombicFlap愛惜康ETHICONacompany縫線選擇69愛惜康ETHICONacompanySutureClassification?NaturalorSynthetic(manmade)?MonofilamentorMultifilament(braided)?AbsorbableorNon-Absorbable愛惜康ETHICONapU佛*JqiwHcompanyTheIdealSuture?Minimaltissuereaction?Smoothness-minimumtissuedrag?LowCapillarity?Maxtensilestrength?Easeofhandling-Minimummemory?Knotsecurity?Consistencyofperformance?Predictableperformance?Costeffectiveness愛惜康ETHICONapU佛*JqiwHcompanySutureClassificationMonofilamentMultifilament(braided)愛惜康'ETHICONacompanyBraidedv?Hascapillaryaction?Increasedinfectionrisk?Lesssmoothpassage?Lesstensilestrength?Betterhandling?BetterknotsecurityMonofilament?Nocapillaryaction?Lessinfectionrisk?Smoothtissuepassage?Highertensilestrength?Hasmemory?Morethrowsrequired愛惜康ETHICONapU佛*JqiwHcompanyAbsorbableSutures?Theseareabsorbedwithinthelivingtissue?Twomaincharacteristicsare:?Tensilestrengthretention?AbsorptionrateMaxon:Day14:75%Absorption:180daysCaprosyn:Day10:30%Absorption:56days74愛惜康ETHICONapU佛*JqiwHcompanyCharacteristicsofNon-AbsorbableSutures?Permanent?Onlyusedwhenlongtermsupportisrequired?Removedwhenusedforskin(e.g.inA+E)?Tissuereactiongenerallylow(exceptsilk)?Howeversilk,linenandevennylonwilllosetensilestrengthoveraperiodoftime?Truenon-absorbablesuturesincludepolyester,polyethylene,polybutester,polypropyleneandsteel75

愛惜康ETHICONacompany可吸收縫線縫線名稱手術(shù)操作手感剩余張力打結(jié)牢靠程度組織反應(yīng)吸收時(shí)間人工合成可吸收縫線Vicry唯喬縫線（聚糖乳?!H?）多股編織好5周時(shí)張力消失好很小56-70天PDS普迪思縫線（聚二氧六環(huán)酮）多股編織尚好4周時(shí)剩余50%-70%張力好很小180.210天Monocnl單喬縫線（聚糖S內(nèi)先胺）單股好4周時(shí)張力消失好很小91-119天7f愛惜康ETHICONapU佛*JqiwHcompany不可吸收縫線ETHICONacompany縫線名稱類型手術(shù)操作手感剩余張力打結(jié)牢靠程度組織反應(yīng)天然材質(zhì)絲線編織/紐織很好1年后張力為0好中度人工合成不可吸收縫線尼龍NytonZ愛惜良Ethilon單股尚好1年時(shí)剩余20%張力尚好很小普理靈Prolene（聚丙烯＞單股尚好永久支撐差很小愛惜邦Ethibond（聚酯＞多股編織很好永久支撐好很小不銹鋼紋申股差永久支樣好很小I!'vlouverthesulurcsia-number,thtlw「Ohi<kt-r)th*-diameterandthehigherrenter,*-trongcr)thetensilestnn^th.1hehigherthesuturi-sizenumber，thesmaller(thinner)thediameterandthelower(lessweakerjthetensilestrengthSutureSiloSutureDiameterT*n*iiaStran^th14)Largerithicker)Iligh(greater,strongerJ*2-003-000440TX)5-00000WKXXXXJMJOOOOOOfHWOOOOQO9-ormKXWi&mmxxwiMXJOOOOOnorw5ni*?]lvr^thinner!Lerner)縫合線一規(guī)格與張力強(qiáng)度ETH?CONae&mpan^縫線歷史悠久砧確細(xì)致的閉合抗張力強(qiáng)度最大傷口裂開率最低打皮釘服Wifr刖乎永帶應(yīng)用快捷組織反應(yīng)性低廉價(jià)針剌風(fēng)險(xiǎn)低愧作快捷感覺舒適可抵抗細(xì)闡笮生無需拆除廉價(jià)無針刺危險(xiǎn)組織反成性鉍低感染風(fēng)險(xiǎn)最小揀作快捷感覺舒適廉價(jià)無針刺危險(xiǎn)缺點(diǎn)崙賢拆除需耍麻醉組織反問忡砧人最昂貴操作緩慢傷口對(duì)合精細(xì)度較縫線低可能會(huì)被CT或MRIf■憂抗張力強(qiáng)度較縫線低髙張力部位（關(guān)卞〉的傷口容易裂開抗張力強(qiáng)度較縫線低最易發(fā)生傷口裂開必須使用有毒性的添加劑不能用在有毛發(fā)的部位必須保持干燥康11ONcompanyAComparisonofThreeMethodsofWoundClosureFollowingArthroplastyAProspective,Randomised,ControlledtrialTaNtl?IPalitnlchancten^hciTetellilpiepl4c*iMiiiTomIkiieeiepU[vii*n*Skindips⑷■36)OCA*(ii-S刪ic(??-33JSkindi"(h

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惜康1ETHICONacompany80iKlian,RJK,FickD.YaoRJBoneJointSuigBi,2006,88-B:238-4AComparisonofThreeMethodsofWoundClosureFollowingArthroplastyAProspective,Randomised,ControlledtrialillEarlyandlatewauntlcomplcahonsTnldllilp斤HintHiTcstrtlkn?eIn?2了IOCASumrein-3”Skindip*In?34OCA*…-33}Sivtuie(n-33)Evrly2AX212029Prolongeddischarge211472Infedion020101000000AltergcreKtion0601c0U4eNome302&29222126Prolongeddischarge332233Infection320331Abscess001001Allergc『eactionH010ha■OCASKhanJUK,FickD,YaoFJBoneJointSurgBr.2006,88-B:2384置T

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