In brief of suture materials , basic orthopaedic instruments and Implants

1. SUTURE MATERIALS
BASIC ORTHOPAEDIC
INSTRUMENTS & IMPLANTS
Moderator – Dr Kanthesh Yallapur
Assistant professor
Dept of Orthopaedics
Presenter – Dr Raghavendra

2. SUTURE MATERIALS

3. THE IDEAL SUTURE MATERIAL
• Causes minimal tissue injury or tissue reaction (
nonelectrolytic, noncapillary, nonallergenic,
noncarcinogenic)
• Easy to handle
• Holds securely when knotted (no fraying or cutting)
• High tensile strength
• Favourable absorption profile
• Resistant to infection
• Can be used in any tissue
• Cost effective

4. CLASSIFICATION

5. NATURAL SYNTHETIC
Biological, from naturally occurring
resources
Synthetic polymers, man made
Cause intense inflammatory reaction Less or minimal inflammatory reaction
Absorption – enzymatic reaction Absorption – hydrolysis
Examples : catgut , silk Examples: nylon ,prolene

6. MONOFILAMENT MULTIFILAMENT
Single strand of suture material Fibers are twisted or braided together
Minimal tissue trauma, passes easily More tissue resistence, more trauma
Smooth tying but more knots needed Better knot security
Harder to handle due to memory Easier to handle
Resist bacterial harbouring Harbour bacteria
Examples : nylon , monocryl , prolene ,
pds
Examples: vicryl , silk ,polyester

9. ABSORBABLE SUTURES
• They are capable of being absorbed or digested by the body
cells and tissue in which they are embedded during and after
the healing process.
• Usually loose 50% TS within 60 days of implanting
• Examples –
• Polyglycolic acid Polydiaxazone
• Polyglactin 910 Gut
• Glycomer polyglyconate
• Glyconate

10. POLYGYCOLIC ACID(DEXON )
• Synthetic absorable suture
• Braided, multifilament
• Homopolymer of glycolic acid
• Loses Tensile strength within 2-3wks
• Complete absorption within 60-90 days
• Minimal tissue reaction and good knot security

11. • Synthetic absorble suture
• Braided multifilament coated with a mixture of equal parts
of a copolymer of glycolide , L- lactide and calcium
stearate.
• Coating provides a nonflaking lubricant for smooth
passage through tissue and precise knot placement.
• Tensile strength - 75% remains at 2wk
• 50% remains at 3 wk
• 25% remains at 4 wk
• complete absorption within 60 -90 days
Minimal acute inflamatory reaction
POLYGLACTIN 910 (vicryl)

12. SURGICAL GUT
1 - Often referred as catgut
2 - It is derived from submucosa of sheep intestine of
serosa of beef intestine
3 - Types : (a) Plain surgical gut
(b) Chromic surgical gut

13. PLAIN SURGICAL GUT
1- It loses its tensile strength in 7-10 days.
2- It is completely digested within 60 days.
3- used to ligate superficial vessels , suture subcutaneous tissues
and other tissues that heal rapidly
3- Seldom used now due to poor strength and high tissue
reaction

14. CHROMIC SURGICAL GUT
• It is treated in a chromium salt solution to improve handling
and to resist absorption in tissues
• It loses its tensile strength in 3-4 wks
• Completely absorbed within 90 days
• Moderate tissue reaction

15. • Synthetic absorbable suture
• Monofilament
• Loses Tensile strength in 1-2 wks
• Minimal acute inflamatory reaction
• Complete absorption withon 90-120 days
• Frequently used for subcuticular in skin , ligation,GIT and
muscle surgery
POLIGLECAPRONE 25 (MONOCRYL)

16. POLYDIOXANONE
• Synthetic absorbable suture
• Monofilament
• Absorbs nearly in 2-3 months
• Minimal tissue reaction .

17. NON ABSORBABLE SUTURES
• Strands of natural or synthetic material that effectively
resist enzymatic digestion or absorption in living tissue .
• Retain their breaking strength > 60days
• Examples –
Polyamide Polyester
Polypropylene Silk
Nylon Steel

18. SURGICAL SILK
• Braided or twisted , multifilament suture
• Not a true nonabsorbable material as it loses its much of its
tensile strength after 1yr and disappear within 2 years
• High knot security
• High tissue reactivity

19. SURGICAL NYLON
• Nylon is a polyamide polymer.
• It produces minimal tissue reaction.
• It has high tensile strength
• It degrades by hydrolysis in tissue @15-20% per yr
• It is available in 3 forms – (a) monofilament
(b) uncoated
multifilament
(c) coated multifilament
Used for skin closure , abd. wall closure, plastic surgery
microsurgery , neurosurgery, ophthalmic surgery

20. ETHILON AND DERMALON
(MONOFILAMENT NYLON SUTURE)
• Good tensile strength
• Minimal tissue reactivity
• Disadvantages are its handling and knot security
• High memory , strand is stiffy and coiled hence
difficult in handling

21. SURGICAL STEEL
• Mono or multifilament
• An alloy of iron , nickel and chromium
• Tensile strength - infinite (>1yr)
• Minimal tissue reaction
• Frequently used for sternotomy wound closure

22. POLYESTER SUTURE
• Monofilament or Braided multifilament
• Available in two forms – uncoated and coated
• Infinite tensile strength (>1yr)
• No significant change known to occur in vivo
• Minimal tissue reactivity

23. MERSILENE SUTURE
• Uncoated polyester fiber suture
• Specially used where repairs needing high strength ike A-C
joint reconstruction, ACL reconstruction
• Knot strength & tissue reactivity is average

24. ETHIBOND SUTURE
• Coated polyester fiber suture
• Braided , monofilament
• Has coating of POLYBUTILATE which acts as surgical
lubricant
• Very high strength , avg reactivity
• Knot strength is average &
decreases with thicker sutures

25. POLYPROPYLENE (PROLENE) SUTURE
• Monofilament
• Most inert similar to stainless steel
• Infinite tensile strength (>1yr)
• Frequently used for cardiovascular surgery, plastic,
ophthalmic surgery
• Minimal tissue reactivity
• Average strength , knot is
also insecure hence multiple
knots needs to be applied.

26. • Staples are formed from highquality stainless steel and are
available in regular and wide sizes.
• Staples are relatively easy to place and may shorten the
closure time by 70-80%.
• Infection and tissue reaction may be higher
STAPLES

27. NEEDLE
ANATOMY OF NEEDLE
• Needle point
• Chord length
• Swage
• Needle body

28. TYPES
• Eyed needle - more traumatic , only thread through once
• Eyeless swaged needle – less traumatic , more expensive

29. • Point runs from tip to the max. cross sectional area
of the body.
• Can be -triangular tip/cutting
• -round tip
• -blunt tip
• Cutting needles are Ideal for suturing keratinized tissues
like skin, palatal mucosa, subcuticular layers and for
securing drains.
• Round/tapered needles used for closing mesenchymal
layers such as muscle or fascia that are soft and easily
penetrable

32. SUTURE SIZE
UNITED STATES PHARMACOPEIA
• Sized according to diameter with “0” as reference size Numbers
alone indicate progressively larger sutures (“1”,“2”, etc)
• Numbers followed by a “0” indicate progressively smaller
sutures (“2-0”, “4-0”, etc)
• Smaller<………………………… >Larger
…...”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

33. PACKAGING………
METRIC GUAGE IMPERIAL GUAGE PRODUCT CODE
NEEDLE SIZE &
CURVATURE
NEEDLE TYPE
NEEDLE TIP
NEEDLE PROFILE
STERILIZED
ETHELENE OXIDE
DO NOT REUSE
SEE INSTRUCTIONS FOR USE
EXPIRY DATE BATCH NO

34. BASIC ORTHOPEDIC INSTRUMENTS
Basic instrument categories used for all orthopedic surgeries are:
•Retractors
•Periosteal elevators
•Curettes
•Nibblers / cutters
•Dissectors
•Forceps
•Scissors

35. FORCEPS

36. • They are used to hold, stabilize, rotate, reduce and
compress bone and to position bone screws and plates,
and insert K-Wire during trauma surgery.
• They come with some locking mechanism like ratchet or
screw, which can be easily operated with one hand
• A forceps that corresponds to bone size should be chosen
as excessive forces may shatter the held bone
BONE HOLDING CLAMPS

37. Heygrove’s bone holding forceps
Lowman’s bone holding clamp

38. • Reduction forceps

39. Speedlock bone reduction
Forceps
Self-centering bone holding forceps

40. PLATE FORCEPS
• These come in various sizes and designs depending on the type of
plating system that is being used and the size and type of bone
that is being fixated.
• The foot of the forceps fits into the counter of the plate, ensuring
a firm grip of the plate and the back side of the bone.
• The foot often has the ability to swivel for precise positioning of
the forceps onto the plate.

41. RETRACTORS/LEVERS
• Hand held or self retaining
• First one requires constant holding that includes
bone levers
• Self retaining type can be inserted and left
unattended
• Bone levers can also be used to maniplulate bone
fragments to achieve reduction.

42. SELF RETAINING RETRACTORS
.
Mayo adson / Beckman retractor Mastoid retractor
• Self-retaining, finger-ringed instrument with a ratcheted
release device on the shanks. Two hinged arms extend from the
shank to three outward-curved prongs on one side and four on
the other. These prongs can be sharp or dull.

43. • Used for retraction in procedures involving deep tissue,
such as the spine, and in proximal femur fractures
Mollison Self-retaining

44. Charnley retractor
• A square-shaped frame with attachable blades.
• Is a self-retaining retractor, most commonly used during
arthroplasty of the hip.
• It is used when initial incisions are made and maintains
exposure of the hip area so the surgeon has an unobstructed
view.

45. HAND HELD RETRACTORS
• Meyerding
• Langenbeck
• Volkmann Catspaw.

46. Meyerding retractor
• Meyerding Handheld Retractor is frequently
used to hold back tissue and muscle in
spinal and neurosurgical procedures such
as laminectomy.
• Langenbeck Retractor
used to retract skin, superficial fascia

47. VOLKMANN CATSPAW RETRACTOR
These may have two to six claws that may be blunt
or sharp. The handle has a teardrop opening.
Used for superficial retraction of wound edges.

48. Mini hohmann retractor
• A flattened, smooth handle with thin, slightly curved
blades and with a small,upward-curved, pointed tip.
• Used for retracting tissue or bone in tight, small areas.
The mini Hohmann retractor is often used during open
reduction internal fixation (ORIF) of the ankle.

49. SHARP HOHMANN RETRACTOR
• Flat handle with two holes placed distally to aid in
grasping the handle.
• The blade is shaped in a square with an upward, slightly
curved prong at the end.
• Used for retracting a large area of tissue, usually close
to bone.

50. BONE CURETTE
• It is used to scrape away and
remove fibrous tissue and other
debris from bone.
To clear out cavities and abscess
Volkmann Double Ended Curette

51. OSTEOTOME / CHISELS / GOUGES
•Used to cut, scrape, clean, scoop or sculpt the
bone.
•They differ in the type of tip.
•Osteotome are beveled on both surfaces.
•A chisel has one beveled edge.
•Gouges have a cupped tip to scoop out bone
material.
•They are used with a mallet.

52. STILLE OSTEOTOME
LEXER OSTEOTOME

53. Capener Lamina Gouge
CHISEL

54. PERIOSTEAL ELEVATOR
• Used to elevate and dissect the bone , tissues, nerves and to
clean and scrape the bone.
• Help to expose the bone
in fracture fixation
• They strip the portion of
periosteum covering the
exterior of the bone.

55. FARABEUF PERIOSTEAL
ELEVATOR
Bristows periosteal elevator

56. BONE CUTTER AND BONE NIBBLER
• Bone cutters are used to cut bone or remove the bone
splinters
• Bone nibblers are used to cut or remove small pieces of
tissue or bone.
• Nibblers have hollowed ,cup like working end where as
cutting forceps have bevelled, scissor like edges.
• Used to reshape the bone during osteotomies, amputations.
• Straight or curved
• Single action or double action

57. Ruskin bone cutting forceps double
action
Liston-Stille bone cutting forceps single
action

58. Leksell’s rongeur
Bone nibbler single action curved

59. BONE HOOK
• Thick handle with an extremely sharp curved hook
at the working end.
• Used for retracting bone or heavy tissue.

60. PLATE BENDERS
• The plate is slid into the jaws and compressed to bend the
plate. These come in various sizes and designs depending on
the type of plating system that is being used and the size and
type of bone that is being fixated.
• Used during open reduction internal fixation (ORIF) to bend
the plate to conform to the contour of the bone in which it is
being implanted.

61. BONE FILE
• Bone file/rasp - To smooth, sculpt and clean bone
particularly to smoothen end of amputated bone
stump.
• They may have coarse or fine teeth and teeth may
be forward or backward cutting.

62. PLIERS WITH CUTTER
Pliers with cutter:
• Used in the implantation and removal of pins and
wires. To store, pull, twist, cut and tighten wires,
pins and rods

63. Basic instruments
• Forceps:
• Used to grasp, hold or exert traction upon tissue or
material.
• To clamp and restrict arteries or tissue, to control the flow of
blood. Dissection and probing of soft tissue.

64. 1x2 toothed tissue forceps
• Available as 1x2 or 2x3 or 3x4
• Used to hold tough structures
like skin while suturing.
• Used to hold scalp while scalp
suturing.
Plain Thumb Forceps
• Used to gently move tissues out of
the way during exploratory surgery
• Used to insert packing into or
remove objects from deep cavities

65. ARTERY FORCEPS/HAEMOSTAT
• Smalmosquito / Halsted
• Medium spencerwell
• Large baileyforceps
Suturing
Catch hold of bleedingponts
Straight/curved

66. NEEDLE HOLDER
• Used to hold and pass a suturing needle
through tissue
• Has groove to hold needle within jaws
• Criss cross striations
• Length of blade = length of box joint

67. BARD PARKER HANDLE
Blades 10,11,12 and 15 fit in B.P handle 3.
Blades18,19,20,21,22, 23
and 24 fit in B.P handle 4.

68. SCISSORS
• STRAIGHT MAYO SCISSORS
• Heavy scissors with straight blades.
• Used for cutting sutures
CURVED MAYO SCISSORS
Heavy scissors with curved blades and
blunt or sharp tips.
Dissect or undermine heavy fibrous
tissues

69. CURVED METZENBAUM SCISSORS
• Longer thinner scissors with curved or
straight blades that can have blunt or sharp tips.
• Dissect and undermine delicate tissues.

70. LISTER BANDAGE SCISSORS
• Used to remove bandages and dressings
• Probe tip is blunt; inserted under
bandages with relative safety

71. IMPLANTS
•Screws
•Plates
•Nails

72. PARTS OF SCREW
• Head
• Shaft
• Thread
• Tip

73. Head
• Functions
• Attachment of ascrewdriver –to apply torque
Arrest forward motion
A) Slotted
B) Cruciate
C) Philips
D) Hexagonal / Allen
E) Torx Stardrive

74. SHAFT
• Smooth Link
• Not present in standard cortex screw
• Present in cortical shaft screws Or Cancellous screws

75. RUN OUT
Transition between shaft and thread
Site of most stress riser
Screw Break:
Incorrectly centered hole
Hole not perpendicular to the plate

76. THREAD
A thread can be visualized as a long wedge
encircling the core
PROFILES:
V-Thread Profile: more stress at sharp corner
Butress thread Profile: Less Stress at the rounded
corner
The two main thread types of
surgical screws are for
cortical finer thread
cancellous coarse thread

77. DIAMETER
The shaft has two diameters
Inner core diameter - without the
thread
The breaking and torsional strength of a
screw depends on
its core diameter and strength of a screw
varies with the
cube of its diameter.
.
Outside diameter or thread
diameter - determines the pull-out
strength of the screw. The larger the outer
diameter, the greater is pull-out strength.

78. PITCH & LEAD
The distance between two adjacent threads
CORTICAL Screws – Small pitch
CANCELLOUS Screws – Larger Pitch
The Lead of the screw is the length travelled by
the screw with each 360° turn of the spiral

79. TIP
Five types of tips
Self-tapping tipNon self-tapping tip

80. Self drilling Self Tapping
Trocar tip
Corkscrew tip

81. CORTICAL SCREWS CANCELLOUS SCREWS
Machine type
Smaller thread
Lower pitch
Larger core diameter
Smaller pitch higher holding power
Higher surface area
Better hold in cortical bone
Wood type
Core diameter is less –Larger threads
Higher Pitch
Greater surface area for Purchase
No need for tap
Pilot hole equals core diameter
Better fixation in Soft cancellous Bone

82. HERBERT SCREW
Introduced by Timothy Herbert in scaphoid fractures
Specialized implant to achieve
interfragmentary compression.
No head and threads on both ends with
a pitch differential
In small bones, such as the scaphoid,
self compressing, double pitch
screws can be Used
These are usually cannulated.
Used in scaphoid capitellum fractures
navicular fractures malleolar fractures
talus fractures arthrodesis of small
joints radial head fractures

83. PLATES

84. PLATE FUNTIONS
Plate function Biomechanics
Compression The plate produces compression at the fracture side to provide absolute
stability
The plate neutralizes bending and rotation forces to protect a lag screw
fixation
Protection
Buttress The plate resists axial load by applying force at 900to the axis of
potential deformity
Tension band The plate is attached to the tension side of a fracture and converts the
tensile force into a compressive force at the cortex opposite the implant
Bridging The plate provides relative stability by fixation to the two main
fragments, achieving correct length, alignment, and rotation. The
fracture side is left undisturbed

85. Tension band
Buttress
Bridging
Protection

86. PLATE DESIGNS
• DCP
• LC-DCP
• Tubular Plates
• Reconstruction plates
• LCP

87. DYNAMIC COMPRESSION PLATE (DCP)
The screw holes in the DCP are
best described as a portion of an
inclined and angled cylinder. Like a
ball, the screw head slides down
the inclined shoulder of the
cylinder

88. Dynamic compression principle
The plate is being
moved horizontally
when the screw is
driven home
 Broad 4.5 for Femur & Narrow 4.5 for Humerus & Tibia
 DCP 3.5 for Forearm, Fibula, Pelvis & Clavicle

89. LIMITED CONTACT DYNAMIC COMPRESSION
PLATE (LC-DCP)
• Has cuts on the undersurface of the bone
• greatly reduced the area of the plate-bone contact
• less compromised the capillary network of the periosteum
underneath

90. TUBULAR PLATES
• 1mm thick
• useful in areas with
minimal soft-tissue
covering
• Limited stability
+ lateral malleolus
+ olecranon
+ distal end of the ulna.

91. RECONSTRUCTION PLATES
• Deep notches between the
holes
• Also dynamic compression
• Useful in bone with
complex 3-D geometry
+ Pelvis
+ Acetabulum
+ Distal humerus
+ Clavicle

92. Locking compression plate
• Specially designed holes that can be used in standard
compressed mode or neutral mode.
• Screw hole have been specially designed to accept either:
cortical screw and locking screw
• Provides more stable construct with locking screws

93. INTRAMEDULLRY NAILS
• These are intramedullary (IM) devices used to
stabilize fractures.
• They act as internal splint and are load sharing
devices
• They can be
Rigid ( eg- k nail, square nail )
Flexible [TENS nail, Enders nail].

94. MECHANICAL PROPERTY OF NAILS
Depends on
Material : Stainless steel (316L) , titanium
• Steel is stiffer than titanium and bone and leads to a more
rigid fixation.
• Titanium is a more elastic material and has modulus of
elasticity closer to that of bone leading to less stress shielding.
• It is also the preferred material for flexible nail systems.

95. Cross section:
• A variety of cross sections are available ranging from square
to V to clover leaf.
• Most commonly used designs are AO, Russell Taylor, Grosse
Kempf.
• Clover leaf design resists bending most effectively but has
less torsional stability.

96. Diameter:
• Torsion and bending resistance in a nail is proportional to the
fourth power of its radius.
• In case of a cannulated nail, it is proportional to the difference
to the fourth power in the inner and outer radius.
• When the radius is increased by a thicker wall or a greater
diameter, rigidity increases. Increasing the diameter of an IM
nail by 1 mm increases its rigidity by 30–45%

97. Working length:
The working length of the nail is that
portion of the nail that is in contact
with the bone proximal and distal to
the fracture. It is this length that
transmits load from one main fragment
to the other.

98. Curves:
• The normal femoral and
tibial canals are not straight
but curved in both planes.
• The design of nail must
closely mimic these curves
to maximize the contact
between the bone and nail.
• Third generation femoral
nails are therefore curved
both in AP & mediolateral
planes.
• Similarly tibial nails have
an angulation of 11 degrees
in the proximal part known
as angle of Herzog.

99. Number and orientation of
locking screws:
• Greater the number of locking
screws, the stiffer is the fixation.
• Generally for transverse midshaft
fractures one lock distal and
one proximal is enough, whereas
comminuted and segmental
fractures require two locks on
either side of fracture.
• If locking screws are inserted in
different planes, the fixation is
more stable.

100. THANK YOU