Académique Documents
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Skin Anatomy
Wound Healing
University of Texas Health Science Center at San Antonio, San Antonio, TX.
Address reprint requests to Mark Bagg, MD, Hand Center of San Antonio, 21
Spurs Lane, Ste 310, San Antonio, TX 78240. E-mail: mbagg@
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sels in combination with growth factors produced by macrophages allows fibroblasts in the wound to begin production
of the new extracellular matrix, which will restore structure
and function to the injured tissue.5 This fibroblast-rich granulation tissue is composed mostly of type I collagen and other
supporting structural proteins.3 Finally, around the second
week of wound healing, remodeling begins, as the myofibroblast becomes predominant in the granulation tissue, providing compaction and contraction of the wound through
attachments and crosslinks with collagen.1,3,4 This reinforcement of the wound provides sufficient strength to allow suture removal around the second week in most cases. The
developing scar continues to remodel and strengthen over
the coming weeks and months, but it only regains about 80%
of its original breaking strength.6
Classification of Wounds
Polyglactin 910 (Vicryl, Ethicon Inc.) is a synthetic absorbable braided suture made of glycolide and lactide. It is also
available with an antimicrobial coating called triclosan (Vicryl Plus).8,13 Polyglactin 910 retains 75% of its tensile
strength at 2 weeks and only 25% at 4 weeks, with complete
resorption by hydrolysis within 90 days.14,15 It has the advantages of strong knot security, good initial 2-week strength,
and relatively fast absorption.13 Disadvantages of polyglactin
910 include increased potential for wound infection because
of microbial ability to hide within its multifilament braid.
Avoidance of use in the cutaneous region is recommended
because slower absorption time in this area sometimes leads
to the knot being extruded from the healed wound, compromising the appearance of the scar and causing patient anxiety.8
Surgical gut (plain, chromic, fast absorbing) is a purified,
collagen-based absorbable suture derived from the small intestine of sheep or cattle.8,13,15 It retains only 40% of its tensile
strength at 7 days and is completely absorbed by 2 weeks.8
Treating it with chromium salts increases its holding time to
14 days and delays absorption to 3 weeks.13,15 In contrast,
heat treating the plain gut causes loss of tensile strength and
faster absorption. Surgical gut has the advantage of fast absorption without need for removal; however, this also leads
to high tissue reactivity and rapid loss of tensile strength,
which are considered to be disadvantages of using this suture.13
Poliglecaprone 25 (Monocryl) is a synthetic absorbable
monofilament suture made of glycolide and -caprolactone.
It maintains about 50% of its original tensile strength at 1
week and 0% at 3 weeks, with complete absorption by hydrolysis within 120 days. Poliglecaprone 25 has the advantages of minimal tissue reactivity and strong initial tensile
strength.15 Disadvantages include a fast loss of tensile
strength and a significantly higher cost compared with other
absorbable sutures.
Polydioxanone (PDS) is a synthetic absorbable monofilament suture made from polyester p-dioxanone. It maintains
about 70% of its tensile strength at 2 weeks and 50% at 4
weeks, with complete absorption by hydrolysis within 6
months. It has the advantages of long-lasting tensile strength,
integrity maintenance in presence of infection, and minimal
Suture Material
Important in the understanding of wound closure is also
knowing what closure material is available. Most operating
rooms have a suture cart with many different types of suture
material. The following is a brief summary of the most common types of suture used for orthopedic wound closure today, including an explanation on their advantages/disadvantages and biomechanical characteristics (Table 1).
Absorbable
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Table 1 Suture Material
Suture
Absorbable
Vicryl (polyglactin 910)
Surgical gut
Plain
Chromic
Fast-absorbing
Monocryl
(poliglecaprone 25)
PDS II (polydioxanone)
Nonabsorbable
Ethilon (nylon)
Prolene
(polypropylene)
Composition
Tensile Strength
Retention
Absorption Rate
Tissue
Knot
Reaction Security*
75% at 2 weeks
25% at 4 weeks
Complete absorption
within 90 d
Minimal
Collagen-based submucosa
of sheep or cattle
Treated with chromium
salts
Heat treated
Glycolide and caprolactone
Polyester p-diozanone
40% at 1 week
Complete absorption
by 2 wks
Complete absorption
by 3 wks
Faster than plain
Complete absorption
within 120 d
Complete absorption
within 6 mo
Moderate
Moderate
Moderate
Minimal
Slight
N/A
Minimal
N/A
Minimal
Polyamide polymer
Polymer of propylene
Nonabsorbable
Nylon (Ethilon) is a synthetic nonabsorbable monofilament
composed of a polyamide polymer.13,15 It displays high elasticity, memory, and tensile strength and loses only about
15% of its tensile strength per year by hydrolysis.8 Another
important characteristic of nylon is that it can be made more
pliable and easier to handle by wetting the suture. Advantages of nylon include the following: it is an inexpensive
suture material, causes minimal tissue reactivity, and has
long-lasting tensile strength.13,15 Its disadvantages include
need for eventual removal, as well as poor knot security secondary to its high memory.8,13
Polypropylene (Prolene) is a synthetic nonabsorbable
monofilament suture made of an isostatic crystalline hydrocarbon polymer, making it relatively inert and resistant to
enzyme degradation.8,15 It easily passes through tissue because of its nonadherence properties.8,13 Similar to nylon,
advantages of polypropylene include high tensile strength
and minimal tissue reactivity. Because polypropylene has
high plasticity and is able to accommodate wound edema, it
is less susceptible to cut out of tissue.13 Disadvantages of
polypropylene include poor knot security, need for eventual
removal, and increased cost, which is almost double the cost
of nylon.8,15
Surgical staples have become increasingly popular over
recent years, likely because of quickness and ease of use.
Most staples are made of 316L-grade stainless steel and cause
minimal tissue reactivity. They have the advantage of being
easy to use, allowing rapid closure, and promoting good skin
apposition. Surgical staples have a lower incidence of infection compared with sutures when closing contaminated
wounds.15 Disadvantages of surgical staples include need for
Needle Selection
In addition to suture selection, the surgeon is frequently
questioned regarding the particular type of needle he or she
would like to use. Often, we rely on our surgical technicians
to know what type of needle we need, as we are unknowledgeable about the different types of needles that are available. As with all aspects of surgery, proper needle selection
can promote efficiency and decrease confusion in the operating room.
A general understanding of needle anatomy, shape, and
type is crucial in all aspects of wound closure. Suture needles
are composed of 3 basic components: eye, body, and point.14
The eye of modern needles is almost always of the swaged
type, in which the suture is manufactured into the eye.15 The
needle is matched to the suture caliber, which makes it less
traumatic upon exit. The shape of the needle is also important, with a 3/8 circle needle being the most commonly
used for wound closure. A 1/2 circle needle can also be used
to facilitate closure of deeper wounds, although this requires
more pronation/supination of the wrist. Another important
feature used in many modern needles today is longitudinal
ribbing along the body, which provides added needle control
by way of a crosslocking action with the needleholder.14
Although there are many different types of needle points
currently in use, the most commonly used are of the cutting
and tapered type. Cutting needles have 3 cutting edges,
allowing for excellent penetration into tough tissues such as
skin. They can also be subcategorized into either standard or
reverse cutting, with the difference depending on which way
the third edge points. Standard cutting needles have the third
edge pointing toward the wound edge. Reverse cutting nee-
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MEANING
BN
CE
CFS
CP
CPX
CT
CTB
CTX
EN
FS
FSL
LH
MH
MO
OS
PS
RH
SH
Bunnell
Cutting edge
Conventional for skin
Cutting point
Cutting point extra large
Circle taper
Circle taper blunt
Circle taper extra large
Endoscopic needle
For skin
For skin large
Large half
Medium half (circle)
Mayo
Orthopedic surgery
Plastic surgery
Round half (circle)
Small half (circle)
dles have the third edge pointing away from the wound edge,
which helps avoid the possibility of cut-out through the
wound. Tapered needles, however, have a body that is round
and tapers smoothly to a point. Unlike cutting needles, they
spread through the tissue without cutting it. They are most
commonly used in less resistant tissue such as fascia and
subcutaneous fat.15
In an attempt to simplify and abbreviate needle selection,
needles are often categorized by acronym and number, corresponding to design and size, respectively (eg, PS-1, FS-2,
CT-3). A list of the most commonly used acronyms in needle
selection are listed in Table 2.14
Wound Management
Timing
Classically, the golden period for managing acute wounds
has been defined as 6 hours. This has been supported by
clinical and research studies, which show an increased risk of
infection if debridement is not carried out within this window. However, practical realities, such as lack of operating
room time and delayed presentation, often impede early
wound management, which has resulted in newer techniques
to optimize this period and thus challenge the 6-hour rule.
Some of these newer techniques, such as silver-coated dressings and negative-pressure wound therapy, have leveraged
newer technologies to optimize wound care.
Assessment
Before closure, all wounds require a systematic assessment. Skin and subcutaneous tissue need to be carefully
evaluated, paying particularly close attention to the vascularity. Nonviable skin is dusky and without capillary refill.
It does not bleed when excised. Subcutaneous fat, when
necrotic, is dull and grayish brown to black. Probably, the
most consistent adjunct in determining skin viability is
Wound Debridement
Wound debridement remains the most fundamental principle in the successful management of open wounds. After a
thorough assessment of the wound, abscess cavities require
drainage, elevated compartment pressures should be decompressed, and devitalized, infected, or necrotic tissue requires
excision from the wound. Probably, the best determinant to
guide the surgeon on the extent of debridement is whether
the tissue in question bleeds. This generally will provide a
useful end point regarding the extent of debridement. However, there are specialized tissues, such as cartilage, tendon,
and bone, which require the judgment of the surgeon on
whether to debride the tissue. In many cases, it may require a
second or third debridement to achieve a stable wound that is
ready for closure. Sequential debridement is necessary when
tissue viability and the extent of debridement are not predictable. The viable margins of the wound can then be identified
and borderline tissue may be preserved without the risk of
infection by early wound closure.
Wound Irrigation
Wounds should be cleansed with a sufficient volume of irrigant to reduce or eliminate particulate matter and bacterial
loads from the wound. There is some debate as to the proper
pressure that is ideally required in the delivery of the irrigant.
High-pressure delivery has been shown to initially decrease
bacterial burden on the surface of tissues; however, it may
drive bacteria deeper into the tissues, which results in a rebound of bacterial colonization after several days. Therefore,
delivery through a bulb syringe may be the ideal method of
irrigating contaminated wounds. Generally, normal saline is
the most appropriate irrigant when available; however, when
tap water has been used, rates of infection have remained the
same. Povidoneiodine, hydrogen peroxide, and detergents
should be avoided because of their tissue-toxic properties.
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Negative-Pressure
Wound Therapy
The goal of any surgical dressing covering an open wound is
to provide a barrier to contamination and infection, to decrease edema within the wound by actively or passively eliminating fluid exudates, and, finally, to reduce pain and discomfort by preventing desiccation of tissues. Negativepressure wound therapy exposes the wound bed to
mechanically induced negative pressure, resulting in active
removal of fluid from the extravascular space, improving circulation, enhancing the proliferation of granulation tissue,
and decreasing the burden of bacteria. The following are
indications in which negative-pressure wound therapy may
be appropriate: infected open wounds after debridement;
open fracture wounds; acute soft-tissue wounds with exposed white tissue, such as bone, nerve, tendon, and joints;
wounds with exposed shiny tissue, such as hardware; fasciotomy wounds after compartment release; surgical wounds
that are difficult to close because of tension; and surgical
wounds weeping serous fluid. Generally, pressure settings of
125 mm Hg are used for most wound types, with the exception of weeping surgical incisions that have already been
closed, in which the pressure setting is lowered to 50 mm
Hg. Generally, the wound vac is an intermediate step before
obtaining definitive wound coverage. Because of its use in
accelerating wound healing by promotion of granulation tissue, flap coverage of a wound is enhanced and sometimes
altogether circumvented. The wound vac has become a very
popular method of wound coverage; however, it is absolutely
not a substitute for a thorough surgical debridement. When
negative-pressure wound therapy is chosen as a method to
cover an open wound, negative pressure should be continuously applied to the wound bed. If negative pressure is not
being delivered to the wound bed, wound infections may
occur or worsen. Essentially, a sealed wound without negative pressure equates to closing a contaminated wound.
Therefore, it is important that the wound vac dressing be
carefully monitored to ensure that negative pressure is continuously delivered to the wound. For chronic nonhealing
wounds, the wound vac was shown to be superior to moist
saline dressings.
Summary
Today, almost any wound of any complexity can now be
successfully closed. Some of this success can be attributed to
the newer methods that have evolved over the past decade,
such as the advancements in wound dressings and advanced
surgical techniques, including free-tissue transfer. However,
for these new methods of wound closure to be successful, the
principles of meticulous surgical debridement and wound
management must be continually emphasized, as they remain unchanged.
References
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