Suture Techniques in Orthopaedics — MCQs
The ideal synthetic material used for femoropopliteal bypass when autologous vein is unavailable is:
All these are techniques to decrease scarring except:
In anterior colporrhaphy, the best method of suture apposing the vaginal flaps is:
If suture marks are to be avoided, skin sutures should be removed by:
In combined tendon and nerve injuries, the preferred sequence of repair is:
Longitudinal incision with Z-plasty closure is used in which of the following?
What is the most effective management strategy for hemarthrosis?
Which type of surgical suture is known to cause the most tissue reaction?
A 6-year-old boy experienced life-threatening shock. His CT scan showed a large amount of ascites, bowel wall thickening, and poor or absent enhancement of the strangulated bowel segment, showing gangrenous bowel on surgical exploration. Which of the following statements about anastomosis is true?
A 6 years old boy experienced life threatening shock, his CT scan showed large amount of ascites, bowel wall thickening and poor or absent enhancement of the strangulated bowel segment, showing gangrenous bowel on surgical exploration. True about anastomosis is:
Suture Techniques in Orthopaedics Indian Medical PG Practice Questions and MCQs
Question 1: The ideal synthetic material used for femoropopliteal bypass when autologous vein is unavailable is:
- A. Dacron
- B. Xenograft
- C. Saphenous vein
- D. PTFE (non-expanded)
- E. Cryopreserved vein graft
- F. ePTFE (Correct Answer)
- . Polyethylene terephthalate (PET)
- . Allograft
Explanation: ***ePTFE (Expanded Polytetrafluoroethylene)*** - **ePTFE** is the preferred synthetic graft for femoropopliteal bypass when autologous vein is unavailable - Offers good **biocompatibility** and relative resistance to **thrombosis** - Provides superior patency rates in above-knee femoropopliteal bypasses compared to other synthetic materials (5-year patency ~50-60%) - The expanded structure allows tissue ingrowth and better integration *Dacron (Polyethylene terephthalate)* - Generally used for **larger diameter vessels** (e.g., aortoiliac grafts) - Has **inferior patency rates** in smaller diameter femoropopliteal position compared to ePTFE - More prone to kinking and associated with higher rates of intimal hyperplasia in peripheral circulation *Saphenous vein* - The autologous saphenous vein is the **gold standard** for femoropopliteal bypass with superior long-term patency (5-year patency ~70-80%) - However, this question specifically asks for synthetic material when vein is unavailable or unsuitable - Not always available or of adequate quality in all patients *PTFE (non-expanded)* - **Non-expanded PTFE** lacks the porous structure of ePTFE - Not used for vascular grafts due to absence of tissue ingrowth capability - The **expanded** form is specifically engineered for vascular applications
Question 2: All these are techniques to decrease scarring except:
- A. Late removal of sutures (Correct Answer)
- B. Tension-free suturing
- C. Finer suture materials
- D. Debridement
Explanation: ***Late removal of sutures*** - **Late removal of sutures** can lead to permanent suture marks and increased scarring, as the epithelial cells grow down the suture track. - This increases the foreign body reaction and the duration of inflammation, ultimately worsening the cosmetic outcome. *Tension-free suturing* - **Tension-free suturing** minimizes mechanical stress on the wound edges, which is crucial for optimal healing and reduced scar formation. - Reduced tension prevents excessive inflammation and tissue ischemia, leading to a flatter, less noticeable scar. *Finer suture materials* - Using **finer suture materials** reduces the amount of foreign body reaction, which is a key factor in scar formation. - Smaller caliber sutures cause less tissue trauma and inflammation, resulting in a more aesthetically pleasing scar. *Debridement* - **Debridement** removes necrotic tissue, foreign bodies, and devitalized tissue from the wound, which are sources of chronic inflammation and impaired healing. - By creating a clean wound bed, debridement promotes healthy granulation tissue and reduces the risk of excessive scarring.
Question 3: In anterior colporrhaphy, the best method of suture apposing the vaginal flaps is:
- A. Interrupted (Correct Answer)
- B. Continuous
- C. Interrupted mattress
- D. Interlocking
Explanation: ***Interrupted*** - **Interrupted sutures** are preferred in anterior colporrhaphy to allow for drainage and prevent hematoma formation, which can impair healing. - They also distribute tension more evenly across the surgical wound, reducing the risk of wound dehiscence. *Continuous* - **Continuous sutures** are generally avoided in colporrhaphy as they can create a closed space that traps fluid, increasing the risk of infection and hematoma. - If a single point of the suture breaks, the entire closure can unravel, compromising wound integrity. *Interrupted mattress* - While **interrupted mattress sutures** offer strong apposition, they are often more complex and time-consuming to place compared to simple interrupted sutures. - The added bulk and multiple passes through tissue may also increase the risk of tissue ischemia if tied too tightly. *Interlocking* - **Interlocking sutures** are primarily used for hemostasis and are less suitable for mucosal apposition in colporrhaphy. - They tend to create a tighter, more constricting closure that can impede wound drainage and increase tissue tension.
Question 4: If suture marks are to be avoided, skin sutures should be removed by:
- A. 72 hours
- B. 3 weeks
- C. 1 week (Correct Answer)
- D. 2 weeks
Explanation: ***Correct: 1 week*** - Skin sutures are typically removed around **7 days (1 week)** to prevent the formation of **track marks** or permanent scarring along the suture lines. - By this time, sufficient wound healing has occurred for the incision to withstand normal tension, reducing the risk of **dehiscence**. - This timing balances adequate healing with minimal scarring, especially important for cosmetically sensitive areas like the face and neck. *Incorrect: 72 hours* - Removing sutures after only **72 hours (3 days)** is generally too early, as the wound may not have acquired enough tensile strength, increasing the risk of **wound dehiscence**. - While this might minimize suture marks, the primary concern is proper wound healing and closure before suture removal. *Incorrect: 3 weeks* - Leaving sutures in for **3 weeks** is significantly longer than necessary and will almost certainly result in prominent **suture marks** due to epithelialization around the suture material. - Prolonged presence of sutures can also increase the risk of **infection** and foreign body reactions. *Incorrect: 2 weeks* - While sometimes appropriate for areas of high tension or slower healing (e.g., joints, back), **2 weeks** often leads to more noticeable **suture marks** compared to removal at 1 week, particularly in cosmetically sensitive areas. - The goal is to remove sutures as soon as the wound is stable enough to minimize scar formation.
Question 5: In combined tendon and nerve injuries, the preferred sequence of repair is:
- A. Tendons should be repaired before nerves
- B. Nerves should be repaired before tendons (Correct Answer)
- C. None of the above
- D. Tendons should not be repaired simultaneously with nerves
Explanation: ***Nerves should be repaired before tendons*** - Nerve repairs are **more delicate** and require precise microsurgical technique with minimal tension - Repairing nerves first allows optimal **anatomical positioning** and coaptation without interference from tendon manipulation - Tendon repair involves **greater tissue handling and tension**, which could disrupt a freshly repaired nerve if done first - This sequence is the **standard teaching** in hand surgery (Green's Operative Hand Surgery, Campbell's Operative Orthopaedics) - Once nerves are secured, tendons can be repaired with the necessary tensioning without risk to neural structures *Tendons should be repaired before nerves* - This would subject the **fragile nerve repair to mechanical stress** during subsequent tendon manipulation - Tendon repair requires **forceful suturing and tensioning** that could displace or damage a previously repaired nerve - This sequence makes nerve repair technically more difficult as tendons may obstruct access *Tendons should not be repaired simultaneously with nerves* - While the exact sequence matters, both structures are typically repaired **in the same surgical setting** - The statement is confusing as "simultaneously" could mean same surgery (which is done) versus same moment (which is avoided) - Modern practice favors complete repair in one operation when possible *None of the above* - There is a well-established preferred sequence in combined tendon and nerve injuries - The principle of nerve-before-tendon repair is supported by surgical literature and clinical practice
Question 6: Longitudinal incision with Z-plasty closure is used in which of the following?
- A. Hand surgery (Correct Answer)
- B. Thyroid surgery
- C. Breast reconstruction surgery
- D. Hernia repair surgery
Explanation: ***Hand surgery*** - **Z-plasty** is frequently employed in hand surgery to **lengthen constricted scars** or to **reorient tension lines**, especially across joints or creases. - This technique helps to improve **range of motion** and prevent contractures that can severely impair hand function following injury or surgery. *Breast reconstruction surgery* - While various flap techniques are used in breast reconstruction, the primary incision or closure does not typically involve a **longitudinal incision with Z-plasty**. - Procedures often focus on re-shaping and volume replacement using **tissue flaps** or implants, or linear scar realignment for aesthetic purposes. *Thyroid surgery* - Thyroidectomy typically involves a **transverse incision** in the neck (a **Kocher collar incision**) to minimize visible scarring and follow natural skin folds. - **Z-plasty** is not a standard technique for closing the primary incision in thyroid surgery. *Hernia repair surgery* - Hernia repair usually involves a **linear or curvilinear incision** in the groin or abdominal wall, followed by direct closure or mesh placement. - The goal is strong tissue repair, and **Z-plasty** is not used as a closure method for the primary incision in hernia repair.
Question 7: What is the most effective management strategy for hemarthrosis?
- A. Immobilization with a P.O.P. cast
- B. Application of a compression bandage
- C. Needle aspiration to remove excess blood (Correct Answer)
- D. All of the options
Explanation: ***Needle aspiration to remove excess blood*** - **Aspirating the blood** from the joint effectively reduces intra-articular pressure, pain, and inflammation. - This procedure also helps prevent **synovial hypertrophy** and **cartilage damage** caused by the presence of blood in the joint. *Application of a compression bandage* - While helpful for reducing swelling and providing support, a **compression bandage alone** does not remove the accumulated blood. - It may alleviate some discomfort but does not address the underlying issue of **intra-articular blood accumulation**. *Immobilization with a P.O.P. cast* - **Immobilization** can help rest the joint and reduce pain, but it does not remove the blood from the joint space. - Prolonged immobilization can lead to **joint stiffness** and **muscle atrophy**, which are undesirable outcomes. *All of the options* - While compression and immobilization can be supportive measures, they are not the **most effective primary strategy** for managing hemarthrosis. - The direct removal of blood via **aspiration** is crucial for alleviating pressure and preventing long-term joint damage.
Question 8: Which type of surgical suture is known to cause the most tissue reaction?
- A. Plain Catgut
- B. Polydiaxonone
- C. Silk (Correct Answer)
- D. Chromic catgut
Explanation: ***Silk*** - Silk is a **natural, braided, non-absorbable suture** that is known to elicit a significant **inflammatory reaction** due to its natural protein composition and braided structure. - While it was historically used for its good handling properties, its high tissue reactivity makes it less ideal for situations where minimal scarring or inflammation is desired. - **Silk causes the most tissue reaction** among commonly used sutures. *Plain Catgut* - Plain catgut is a **natural, absorbable suture** derived from purified collagen of animal intestines, causing a moderate to high tissue reaction. - However, its absorption by enzymatic hydrolysis is relatively rapid, limiting the duration of the inflammatory response compared to non-absorbable natural materials like silk. *Polydiaxonone* - Polydiaxonone (PDS) is a **synthetic, monofilament, absorbable suture** known for causing a relatively **low tissue reaction**. - Its slow absorption profile and monofilament structure contribute to its minimal inflammatory response, making it suitable for tissues requiring prolonged support. *Chromic Catgut* - Chromic catgut is a treated form of plain catgut that has been coated with chromium salts, which prolong its absorption time and reduce its tissue reactivity compared to plain catgut. - Although it is still a natural, absorbable suture, its tissue reaction is **less than both plain catgut and silk**, but greater than synthetic monofilament sutures like PDS.
Question 9: A 6-year-old boy experienced life-threatening shock. His CT scan showed a large amount of ascites, bowel wall thickening, and poor or absent enhancement of the strangulated bowel segment, showing gangrenous bowel on surgical exploration. Which of the following statements about anastomosis is true?
- A. should be done with catgut
- B. should be done by single layer taking submucosa (Correct Answer)
- C. should be done by continuous layers as it takes less time
- D. should be done by single layer seromuscular Lembert sutures
Explanation: ***should be done by single layer taking submucosa*** - **Single-layer anastomosis including the submucosa** is the preferred technique in modern bowel surgery, including in compromised bowel after resection of gangrenous segments. - The **submucosa is the strongest layer** of the bowel wall, providing the greatest tensile strength and holding power for sutures. Including it is **essential** for a secure, leak-resistant anastomosis. - Single-layer technique reduces operative time, minimizes tissue handling, and has comparable or better outcomes than two-layer techniques in terms of **anastomotic leak rates** and stricture formation. - Either interrupted or continuous sutures can be used, with non-absorbable or slowly absorbable synthetic sutures (e.g., polyglactin, polydioxanone). *should be done by single layer seromuscular Lembert sutures* - **Lembert sutures** are **seromuscular inverting sutures** that deliberately **exclude the submucosa** and mucosa. They were traditionally used as the outer layer in two-layer anastomoses. - Without incorporating the **submucosa** (the strongest layer), Lembert sutures alone do not provide adequate tensile strength for a secure anastomosis, especially in compromised bowel. - Modern evidence favors single-layer techniques that **include the submucosa**, not purely seromuscular sutures. *should be done with catgut* - **Catgut** is an obsolete suture material that has been largely replaced by synthetic absorbable sutures (polyglactin, polydioxanone). - Catgut has unpredictable absorption rates, higher tissue reactivity, and inferior tensile strength retention compared to modern synthetic sutures. - In compromised bowel, reliable suture strength during the critical healing period (7-10 days) is essential to prevent **anastomotic dehiscence**. *should be done by continuous layers as it takes less time* - **Two-layer anastomosis** techniques are outdated and have been shown to have no advantage over single-layer techniques. - Multiple layers increase operative time, cause more tissue trauma, may compromise blood supply, and can lead to luminal narrowing. - While continuous suturing can be faster than interrupted sutures, the key issue here is "continuous **layers**" (plural), which implies a multi-layer technique that is no longer recommended.
Question 10: A 6 years old boy experienced life threatening shock, his CT scan showed large amount of ascites, bowel wall thickening and poor or absent enhancement of the strangulated bowel segment, showing gangrenous bowel on surgical exploration. True about anastomosis is:
- A. Should be performed using catgut sutures, which are absorbable.
- B. Should be performed using single-layer sutures incorporating the submucosa. (Correct Answer)
- C. Should be performed using continuous sutures to save time.
- D. Should be performed using single-layer seromuscular Lembert sutures, the standard technique.
Explanation: ***Should be performed using single-layer sutures incorporating the submucosa.*** - **The submucosa is the strongest layer** of the bowel wall, providing 80-90% of the tensile strength necessary for anastomotic integrity. - **Single-layer extramucosal technique** including the submucosa is the current gold standard for intestinal anastomosis, providing adequate strength while minimizing tissue trauma. - This approach ensures proper healing with **lower leak rates** compared to techniques that exclude the submucosa, as it provides the critical structural support during the healing phase. - Modern evidence supports single-layer over two-layer anastomoses, with equivalent or better outcomes and reduced operative time. *Should be performed using single-layer seromuscular Lembert sutures, the standard technique.* - **Lembert sutures are seromuscular only** and intentionally exclude the mucosa and submucosa, which is the strongest layer. - This technique was historically used as a **second layer** in two-layer anastomoses but is now considered outdated as the sole anastomotic technique. - Without incorporating the submucosa, the anastomosis lacks the **critical tensile strength** needed during healing, increasing the risk of dehiscence and leakage. - Modern surgical practice has moved away from purely seromuscular techniques in favor of single-layer methods that include the submucosa. *Should be performed using catgut sutures, which are absorbable.* - **Catgut sutures** are associated with higher inflammatory response and unpredictable absorption rates, making them less ideal for intestinal anastomoses. - Modern practice favors **synthetic absorbable sutures** (polyglactin, polydioxanone) which provide more consistent tensile strength retention during the critical healing period. - Catgut's rapid and unpredictable degradation can compromise anastomotic integrity before adequate tissue healing, increasing leak risk. *Should be performed using continuous sutures to save time.* - While **continuous sutures** can be used safely by experienced surgeons, they carry risk of **purse-string effect** leading to luminal narrowing and potential stricture formation. - Continuous sutures can compromise **microcirculation** if placed too tightly, increasing risk of ischemia and anastomotic breakdown. - **Interrupted sutures** allow better control of tension and preserve blood supply to the anastomotic edges, which is particularly important in compromised bowel.
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