PROCEDURE PERFORMED: Left total knee arthroplasty.
DETAILS OF PROCEDURE: The patient was given 2 grams of IV Ancef, IV piggyback, prior to coming back to the operating room. Once he was back, he was transferred from the OR stretcher onto the operating table without complication. After induction of general anesthesia, LMA was placed by the anesthesia department. A well-padded tourniquet was placed on the proximal aspect of the left thigh. The entire left lower extremity was prepped and draped in the sterile fashion with a double DuraPrep scrub. Routine sterile draping technique was used. An Esmarch was used to exsanguinate the left lower extremity prior to inflation of the tourniquet to 300 mmHg. A double DuraPrep scrub was performed. Routine sterile draping technique was used. The patient was brought into the laminar flow room and laminar flow garb was worn by all operating room personnel. A midline incision was made over the left knee. Medial and lateral flaps were developed. The medial parapatellar approach was used to enter the knee joint. The anteromedial takedown was performed about the anteromedial tibia. The patella was everted. The knee was fully flexed and the retropatellar fat pad was excised. The anterior cruciate ligament was transected. A 9.5 drillbit was used to open up the distal femoral canal. A long intermedullary rod was placed. A 5-degree valgus alignment position was used. The distal cutting block was pinned in appropriated alignment. The distal cut was made taking 10-12 mm of bone off the distal femur. The raw surface of the distal femur was sized to be a size #7. A size #7, 4-in-1 cutting block was pinned in neutral rotation. Anterior and posterior cuts were made and then anterior and posterior chamfer cuts were made in a routine fashion with an oscillating saw.
The patella was then evaluated and 2 Lewin clamps were used to stabilize the patella. Freehand oscillating saw cut was made in the patella, taking 10 mm of bone from the raw surface of the patella sized to be at #35. A #35 template was placed in the superomedial position. Drill holes were made and a #35 patella trial was placed. Two Homans were used to expose the tibia, one posterior and one lateral. The mediolateral meniscus was excised. All bleeding points were controlled with cautery. A 9.5 drill bit was used to open the tibial canal. A long intermedullary rod was placed down the canal. Proximal tibial cutting block was pinned. A cut was made perpendicular to the long axis of the tibia and 10 mm of bone was taken off the high side laterally and about 2 mm medially. The cut was made, the raw surface of the tibia sized to be at size #7. All osteophytes were removed from the posterior femur with an osteotome and mallet. A size #7 tibial trial was placed with a trial #11 deep-dish liner and a trial #7 femoral component. The knee was reduced and taken through a full range of motion. There was mild tightness to the medial structures and a medial release was performed of the pes anserine tendon. The instability was equal with valgus and varus stress in both full extension and full flexion. All trial components were removed. Copious amount of normal saline was used to irrigate all the raw bony surfaces. A cement restrictor was placed down the tibial canal about 4 cm. Two packets of the DePuy 1 cement were mixed on the back table.
Once the cement was in its doughy state, it was infiltrated in the tibial canal and on the tibial plateau surface. A final size #7 tibial component was impacted into place. Excess cement was removed with a Freer elevator. The final size #11 deep-dish polyethylene liner was impacted into the tibial tray until it was fully seated. Cement was then coated on the raw surface of the femur, and the final size #7 Oxinium femoral component was impacted into place and excess cement was removed with a Freer elevator. The knee was taken out to a fully extended position. The cement was coated on the raw surface of the patella, and the final size #35 patella button was placed and held with a patella clamp. Excess cement was removed with a Freer elevator. Once the cement was fully hardened, the tourniquet was deflated after 44 minutes. All bleeding points were controlled with cautery. There was 150 cc of blood loss. The deep fascia was closed over a ConstaVac Stryker drain. There was normal patellofemoral tracking and full range of motion of the knee with excellent stability. The deep fascia was closed with interrupted #0 Vicryl figure-of-eight sutures, subcutaneous tissues were closed with interrupted inverted #2-0 Vicryl sutures, and the skin was reapproximated with staples. Dressings were placed with Xeroform, 4 x 4, ABD, and soft bulky dressing with double 6-inch Ace bandage and a cold pack. After reversal of general anesthesia, the patient was extubated in the operating room and transferred to the recovery room in a stable condition.
PREOPERATIVE DIAGNOSIS: Left knee osteoarthritis.
POSTOPERATIVE DIAGNOSIS: Left knee osteoarthritis.
OPERATION: Left total knee arthroplasty.
ESTIMATED BLOOD LOSS: 150 mL.
DRAINS: One OrthoPAT drain.
TOURNIQUET TIME: 43 minutes.
DESCRIPTION OF PROCEDURE: The patient was given 2 grams of Ancef IV piggyback prior to coming back to the operative room. Once he was back, he was transferred from the OR stretcher onto the operating table without complication. After induction of general anesthesia, LMA was placed by the anesthesia department. A Foley catheter was placed in routine fashion. A well-padded tourniquet was placed on the proximal aspect of the left thigh. The entire left lower extremity was prepped and draped in a sterile fashion. A double DuraPrep scrub was performed and routine sterile draping technique was used. An Esmarch was used to exsanguinate the left lower extremity prior to inflation of the tourniquet at 300 mmHg of pressure.
The patient was brought into the laminar flow room and the laminar flow garb was worn by all operating room personnel. A midline incision was made over the left knee. Medial and lateral flaps were developed. A medial parapatellar approach was used to enter the knee joint. An anteromedial takedown was performed about the anteromedial tibia. The patella was everted, the knee was fully flexed, and the retropatellar fat pad was excised. The anterior cruciate ligament was transected.
A 9.5 drill bit was used to open the distal femoral canal. Long intramedullary rod was placed up the canal using a 5-degree valgus alignment position. A distal cut was made taking 10-12 mm of the bone off the distal femur, the raw surface of the distal femur sized to be a size 6. A size 6, 4-in-1 cutting block was pinned in neutral rotation. Anterior and posterior cuts were made. Anterior and posterior chamfer cuts were made in routine fashion. The cutting block was removed. Two Lewin clamps were used to stabilize the patella. A freehand oscillating saw cut was made in the patella, taking 10 mm of bone. The raw surface of the patella sized to be at 35. A #35 template was placed in the superomedial position. Drill holes were made and a #35 patella trial was placed.
Two Homans were used to expose the tibia, one posterior and one lateral. The mediolateral meniscus was excised with pickups and scalpel. All bleeding points were controlled with cautery. A 9.5 drill bit was used to open the tibial canal. A long intramedullary rod was placed down the tibial canal. An oscillating saw was used to make the cut. The proximal tibial cutting block was pinned taking 8 mm of bone laterally and about 2 mm of bone medially. The cut was made with an oscillating saw. The raw surfaces of the tibia were sized to be at size #6. All osteophytes were removed from the posterior femur. A size #6 tibial trial was placed with a trial #11 deep-dish liner and a trial of #6 femoral component. The knee was reduced and taken through a full range of motion, had normal patella-femoral tracking, and excellent stability with varus-valgus stress in full extension and full flexion.
All trial components were removed. Two packs of DePuy 1 cement were mixed on the back table. Copious amounts of normal saline were used to irrigate out the raw bony surfaces. A cement restrictor was placed down the tibial canal about 4-5 cm. Once the cement was in its doughy state, it was infiltrated into the proximal tibial canal and tibial plateau surface. The final size #6 tibial component was impacted into the tibia. Excess cement was removed with a Freer elevator. A final size #11 deep-dish polyethylene liner was impacted into the tibial tray until it was fully seated. Cement was then coated on the raw surfaces of the distal femur and the final size #6 Oxinium femoral component was impacted into place and excess cement was removed with the Freer elevator. The knee was taken down to fully extended position. Cement was coated on the raw surface of the patella and a final size #35 patella button was placed and held with a patella clamp. Excess cement was removed with the Freer elevator. Once the cement was fully hardened, the tourniquet was deflated after 43 minutes.
There was 150 mL of blood loss. The OrthoPAT drain was placed exiting superolaterally with normal patellofemoral tracking and full range of motion of the knee with excellent stability. The deep fascia was closed after copious amounts of normal saline irrigation with interrupted #0-Vicryl figure-of-eight sutures.
Subcutaneous tissues were closed with interrupted inverted 2-0 Vicryl sutures and the skin was reapproximated with staples. Dressings were placed with Xeroform, 4 x 4, ABD, soft bulky dressing with double 6-inch Ace bandage and a cold pack. After reversal of general anesthesia, the patient was extubated in the operating room and transferred to the recovery room in stable condition. He tolerated the procedure well.
PREOPERATIVE DIAGNOSIS: Right anterior cruciate ligament tear.
1. Right anterior cruciate ligament tear.
2. Right medial meniscal tear.
3. Chondromalacia of the patella.
1. Right anterior cruciate ligament reconstruction using quadruple hamstrings.
2. Repair of medial meniscus.
3. Chondroplasty of patella.
TOURNIQUET TIME: 100 minutes
DESCRIPTION OF OPERATION: The patient was brought to the OR. He was seen in the preoperative room and the correct operative extremity was identified. Informed consent had been obtained in the office. He was taken back to the operating room and placed supine on the table and a general anesthetic administered, which he tolerated well. Examination of the right knee under anesthesia demonstrated range of motion 0-130, positive grade 3 laxity and Lachman was noted. Positive pivot shift was noted.
The right knee was then prepped and draped in the usual fashion for knee arthroscopy. Incision overlying the mid aspect of the pes anserine bursa was made. Careful dissection down to the soft tissue was performed. The sartorial fascia was found and an incision was made just superior to the gracilis tendon. The sartorial fascia was then retracted and the gracilis and semitendinosus tendons were located. The gracilis tendon was initially tagged first with suture in the running fashion. Sutures were placed through the tendon for harvesting purposes. The tendon was then elevated off the anterior crest of the tibia, and using the tendon harvester, the tendon was then harvested off of the muscle belly.
In the similar fashion, the semitendinosus was also harvested. The incision was then packed with a sponge, which was removed at the end of the case. On the back table, the two hamstrings were prepared. They were found to be 7.5 mm in diameter and 138 mm in length. They were placed on the Arthrex tensioning device and a moist lap sponge was placed over them during the remainder of the procedure.
The arthroscopic procedure was then initiated. Standard inferior and lateral portals were used to achieve entry into the knee. Upon entering the knee, a grade 3 chondromalacia of the patella was noted. The arthroscope was then passed into the medial joint space where a bucket-handle tear of the medial meniscus was noted as well as a parrot-beak component. Using a spinal needle, a medial portal was established superior to the anterior rim of medial meniscus. The interchondral area was evaluated and ACL, that was found to be deficient. Next, the lateral meniscus was visualized and probed and was found to be intact. No articular or cartilage changes were noted.
Next, attention was turned to the patellofemoral joints using a shaver and an ArthroCare I. Chondroplasty was performed until there was smooth stable margins of the patella. Next, the arthroscope was passed in the medial joint space. The peripheral rim of the meniscus was debrided. A spinal needle was used to perforate the meniscus and the joint capsule to allow for vascular channel access. Using a Meniscal Mender set, the meniscus was repaired using Prolene suture. The parrot-beak component to the meniscal tear was then debrided back to stable margins. The suture for the meniscus was then hemostated for knot tying at the completion of the procedure. Next, notchplasty was performed. The patient did need to have a rather tight notch, which required an extensive notchplasty. Following sufficient notchplasty and debridement of the ACL stump, the targeting device was placed in through the medial portal. The guide was set at 55 degrees. A targeting pin was drilled through the guide into the footprint of the ACL and an 8 mm reamer was requested and the tibial tunnel was then reamed. Any bony debris were then removed at the completion of reaming.
Next, a 5 mm over-the-top guidewire was placed in the distal femur. The knee was flexed and a guidewire was advanced into the distal femur to 36 mm in length, once again 8 mm was requested and a femoral tunnel was created. Once again, any bony debris were washed out of the knee. Next, the lateral J-guidewire was placed into the tibia, into the femoral tunnel. A small lateral incision was made on the lateral aspect of the knee. The iliotibial band was pulled along its fibers. The targeting device was advanced to the lateral cortex of the femur. The guidewire was drilled across the femur, out medially. The 9 mm wire was then passed through the J-guide and was advanced through the femur into the knee, all through the tibia.
Next, the hamstring autograft was then placed over the 9 mm wire and advanced through the tibia and the knee up into the femur. The transfixed pin was then advanced across the 9 mm wire. The 9 mm wire was then removed. Careful attention to make sure that the transfixed pin appeared within the lateral aspect of femur, and it was. A smooth contour to the lateral cortex of femur was found. Following this, the knee was ranged through motion multiple times. The hamstring graft was then loaded. Following this, the knee was then brought into 30 degrees of flexion and with a small posterior drawer, a 10 mm delta screw was inserted into tibial tunnel. Adequate fixation was found of the autograft within the tibial tunnel and it was determined the patient would not need secondary fixation. The remaining graft was then cut from the tibial tunnel. Following this the tibial incision was then irrigated out and closed in layered fashion. The arthroscope was passed into the knee once again and the sutures, which had been passed out posteromedial, were tied down to the capsule under good visualization. The meniscus was then probed and found to be intact.
Following this, the incisions were irrigated out and closed in layered fashion. The Stryker pain pump catheter was inserted within the knee, 30 mL of Marcaine was infiltrated into the knee for postoperative pain. The knee was then cleaned and sterilely dressed. Tourniquet was released at approximately 100 minutes of operative time. The patient was taken to the postoperative unit in stable condition.
PREOPERATIVE DIAGNOSIS: Right 7-week-old radial shaft fracture.
POSTOPERATIVE DIAGNOSIS: Right 7-week-old radial shaft fracture.
1. Debridement, radial shaft.
2. Open reduction and internal fixation, right radial shaft with Synthes 7-hole dynamic compression plate.
3. Bone grafting.
IV FLUIDS: 1300 mL.
ESTIMATED BLOOD LOSS: 50 mL.
TOTAL TOURNIQUET TIME: 120 minutes.
DESCRIPTION OF OPERATION: The patient was seen in the preoperative holding area. The correct operative site was identified. He was transported to the operative suite by Department of Anesthesia. He was then transferred supine to the operating table. Department of Anesthesia administered a general anesthetic without difficulty. He was also given 1 gram of intravenous Ancef for prophylactic antibiotic coverage.
After proper patient positioning, a well-padded tourniquet was placed in his right upper extremity. The right upper extremity was then prepped with DuraPrep solution, and he was draped in the usual sterile manner for this case. Initially, a C-arm was brought in to evaluate the fracture site as well as the distal radial ulnar joint. The radioulnar joint did appear to be slightly wide but not particularly unstable at this point. The fracture site was identified, marked on the skin with a skin scribe. Right upper extremity was elevated and exsanguinated with an Esmarch bandage. Tourniquet was inflated to 250 mmHg.
A standard anterolateral incision was made, centered, over the fracture site. This incision was approximately 4-5 cm in length, was taken down through the skin and subcutaneous tissue. At that point, a careful blunt dissection was carried down to the level of the deep fascia, which was split just lateral to the flexor carpi radialis tendon. The radial artery and its vena comitantes were also identified and freed up. These were retracted medially with the flexor carpi radialis tendon and underlying muscles. The brachioradialis was retracted laterally. Care was taken to avoid damage to superficial radial nerve underneath the brachioradialis. In addition, careful dissection of the radial artery and its veins was carried out.
Hemostasis was achieved with Bovie cautery during the approach. At that point, wrist was pronated and the lateral aspect of the radial shaft was identified. A 15-blade scalpel was then used to incise the periosteum at the lateral aspect of the radius, and the fracture site was easily visualized, and there was a large, hard callus present. The actual fracture was difficult to identify using visualization; however, it was easily seen with C-arm fluoroscopy. A periosteal elevator was then used to circumferentially dissect around the hard callus. In addition, the periosteum from the volar aspect of the radius was dissected free.
Curved osteotomes were then used to debride much of hypertrophic callus so that the actual radial shaft and fracture site could be identified. This was performed circumferentially around the radial shaft. Fracture site was eventually visualized with the help of C-arm and with debridement of the radius. After a thorough debridement was performed, the fracture site was gapped and a curette was used to remove soft tissue from the fracture ends. When debridement was completed and the hard callus was essentially removed, there was a large area of bone loss at the lateral aspect of the fracture. It was determined at that point that bone grafting would be necessary.
A serrated bone-reduction forceps was then used to reduce the fracture and hold it in place. This was confirmed with AP and lateral views of the C-arm. Two interfragmentary screws were then placed using lag fashion. These were placed lateral to medial, beginning proximally in the lateral aspect and proceeding distally to the medial aspect of the fracture. These were 2, 3, and 5 fully threaded cortical screws, which were inserted using lag technique. Satisfactory maintenance of the fracture was held with these screws.
At that point, a 7-hole dynamic compression plate was slightly bent and placed on the volar aspect of the radial shaft. This was then held in position with proximal and distal serrated bone-reduction forceps. AP and lateral C-arm images were used to confirm satisfactory placement of the plate. At that point, a 3.5 fully threaded cortical screw was placed using neutral mode of the drill guide. It was placed in the second hole distal to the fracture. Excellent compression of the plates on bone was noted.
At that point, using second hole proximal to the fracture site, the compression mode drill guide was then used. Using standard technique, a 3.5 fully threaded cortical screw was placed into the plate in compression mode. Excellent fixation of the plates to the bone was noted proximally as well. At that point, distally, the first screw was loosened at which time the screw closest to the fracture was then inserted using compression technique. All the following screws were 3.5 fully threaded cortical screws. After the screw was placed, the initial screw was again tightened.
Instruments were removed from the wound, and AP and lateral C-arm images were used to confirm satisfactory reduction of the fracture as well as plate placement. At that point, the remaining screws in the plate were filled using standard technique with 3.5 fully threaded cortical screws. The hole overlying the fracture site was left open. While putting on the plate, 120 minutes of tourniquet time did pass, until the tourniquet was let down.
Initially, saline-soaked Ray-Tec was placed into the wound with some compression with a Webril. After a few minutes,however, this was removed, and it was noted that excellent hemostasis had been achieved during the approach. The radial pulse was noted to be completely intact. After the screws were placed into the plate, AP and lateral C-arm images were used to confirm satisfactory maintenance of fracture reduction as well as plate placement. At that point, the wound was copiously irrigated with sterile saline solution and several mL of BonePlast 2 putty was placed into the fracture site for bone graft.
When that was completed, the periosteum and deep soft tissue were closed with 0-Vicryl sutures. The deep antebrachial fascia was also closed with 0-Vicryl sutures using figure-of-eight interrupted stitches. At that point, 2-0 Vicryl sutures were used to perform subcutaneous closure and the skin was approximated with skin staples.
Prior to closure, the distal radial ulnar joint was visualized with the C-arm and it was noted that the joint had reapproximated and was stable. Therefore, no fixation was to be used. The skin was anesthetized around the incision site with 10 mL of 0.25% Marcaine plain. When that was completed, the skin was cleansed and dried. Xeroform gauze was placed over the incision followed by sterile 4 x 4s and an ABD dressing. Sterile Webril was used to wrap this, at which time the remainder of the drapes were removed from the patient. The rest of the skin was cleansed and dried. A well-padded sugar-tong splint was then placed on the patient’s right upper extremity with the forearm in supination. The Department of Anesthesia reversed the general anesthetic without difficulty. The patient was transferred supine in the operative gurney and was transported to the postanesthesia care unit in stable condition.
OPERATION PERFORMED: Total hip replacement, arthroplasty, left hip. Zimmer VerSys system utilized, a 50-mm outside diameter cup, 28-mm head, 12-mm femoral stem with a standard length neck.
DETAILS OF OPERATION: With the patient appropriately anesthetized, all bony prominences were carefully padded and a roll of padding was placed underneath the axilla as the patient was rolled into the left decubitus position, left side up. The operative site was cleansed, prepped, and draped in the usual fashion. Betadine preparation was used upon the skin. The patient received 1 gram of prophylactic Ancef prior to the start of the procedure. An incision was made from the posterior third of the greater trochanter distally back approximately towards the posterior inferior iliac spine. The length of the incision was approximately 6 inches. It was taken down through the subcutaneous tissue. Fascia was entered and split, and the gluteus muscle was split in line with its fibers. Self-retaining retractors were placed, care being taken to locate and protect the sciatic nerve. The posterior aspect of the left hip joint was then entered, incising and retracting the short external rotators and then incising in a T-like fashion the capsule. The hip was then dislocated without complication, and appropriate resection was performed utilizing the template provided for the purpose as well as an oscillating saw. With careful retractors in place, the acetabulum was carefully exposed, and appropriate acetabular reaming was done in a serial graduated fashion, starting from small to large. It was eventually decided to use a 50 mm outside diameter acetabulum, which appeared to be well fitted without complication. All peripheral rim osteophytes were carefully removed. The femur was then prepared utilizing a box osteotome and a graduated series of reamers from small to large, ultimately stopping at a 12-mm outside diameter reamer, which appeared to have the correct sizing. Femoral stem broaches were then utilized, working from small to large in a serial fashion, ultimately leaving the 12-mm diameter stem in place, found to be quite stable. Trial reduction was then undertaken with a trial acetabular liner as well as a trial standard neck and head. This was found to be quite stable in all ranges of motion, even with the patient adducted and rotating to 45 degrees with the hip flexed at 90 degrees. All trial components were removed. Careful preparation throughout the procedure was done with antibiotic irrigant to remove all loose debris. The permanent prostheses were then inserted without complication, including the appropriate liners for the acetabular component. The femoral stem was placed and ball and head were placed and reduced and taken through range of motion and found to be quite stable. Closure was then undertaken in layers, closing the capsule, reattaching the short external rotators, closing the fascia and subcutaneous tissue, and eventually closing the skin with subcuticular stitch augmented with Steri-Strip application. A lightly compressive dressing was applied. No drain was inserted. The patient was placed in an abduction pillow prior to moving her to a postoperative stretcher, and she was brought to the postanesthesia care unit in stable condition, alert and moving all extremities. The abduction pillow was in place prior to moving the patient.
OPERATION PERFORMED: Open reduction and internal fixation of right distal femur periprosthetic fracture.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. In the holding area, her right knee was scrubbed with Betadine. She was given 2 grams of Ancef IV piggyback. She was then brought into the operating room, placed in the supine position on the operating room table on a fluoro table, and general endotracheal anesthesia was administered by Dr. John Doe and staff. A tourniquet was then carefully placed high on the right thigh. Fluoroscopic pictures in the AP and lateral projection with the reduction revealed an adequate reduction of the distal femur fracture. However, she did have a fairly large fracture of the medial femoral condyle.
The right lower extremity was then carefully prepped in a sterile fashion as per protocol. An Esmarch tourniquet was used to exsanguinate the right lower extremity, and the tourniquet was elevated to 300 mmHg. The right lower extremity was then flexed over a knee roll, which reduced the fracture fairly adequately, except that she did still need some axial traction, and a straight midline incision was made utilizing approximately 3 cm of the original total knee incision. Sharp dissection was made down to the patellar tendon. The patellar tendon was split in the direction of its fibers longitudinally; however, I could not gain adequate visualization of the intercondylar notch and the box of the posterior stabilized component because of the poly, so a limited capsular arthrotomy was completed using the medial incision from previously. The patella was not everted. It was just retracted laterally, which allowed for much better visualization of the posterior stabilizing box.
After the reduction was completed, an awl was placed into the box for a starter. This was assured in good position on AP and lateral projection. This was a cannulated awl, so a guide pin was placed through the awl into the shaft of the femur. The awl was then removed. Because she had a very tight diaphyseal area of the femur, I chose to ream this to a 12 so I could get a 10 mm expandable nail in and be able to expand to a 12. So, sequential reamers from a 9 to a 12 were used. Then, a 10 x 260 mm expandable disc Orthopedics fixed in its disc Orthopedics Fixon femoral nail, the guidewire was removed and the nail was placed without difficulty. Then, using the appropriate hydrostatic pump, the pump was elevated to 70 mmHg, which expanded the nail very well. This allowed for fairly good reduction and stability of the fracture.
Because it was such a distal fracture, I felt that at least she needed one interlocking screw distally. The second screw was too proximal, and I felt it would be right at the fracture site, so using the standard technique with the appropriate outrigger from lateral to medial, one screw was placed through the distal interlocking hole using a drill depth gauge placement of a self-tapping screw. Again, this was a fairly comminuted distal fracture, and under fluoroscopy in real time, the fracture was quite stable in varus and valgus and flexion and extension, and there was no motion at the fracture site. However, using a large fracture reduction clamp, one more stainless steel 7.3 mm Synthes screw was placed from lateral to medial using standard Synthes technique of drill depth gauge and placement of a self-tapping partially threaded stainless steel screw. This allowed for better fixation of the medial femoral condylar piece. Again, final fluoroscopic pictures in the AP and lateral projection revealed a near anatomic reduction of the fracture fragments and good position of the hardware.
The wound was then copiously irrigated with antibiotic pulsatile lavage. The incision was closed anatomically with the capsular incision closed with 1 Vicryl figure-of-eight sutures, subcutaneous tissue with 2 Vicryl interrupted sutures, and skin was closed with staples. Sterile dressings were applied. A compressive Ace-type bandage was applied from the toe to the groin prior to closure to maintain hemostasis. Tourniquet was released at 62 minutes, and hemostasis was obtained with electrocautery. The patient was awakened and taken to the recovery room in stable condition.
OPERATION PERFORMED: Transmetatarsal amputation of the right foot with Achilles tendon tenotomy.
DETAILS OF OPERATION: The patient was taken to the operating room and placed on the operating table in a supine position for the administration of local anesthesia and IV sedation. After IV sedation was administered, a 50:50 mixture of 0.5% Marcaine and 2% lidocaine were administered as a regional block to the right foot, approximately 30 cc. After this was done, the foot was prepped and draped in the usual aseptic manner and the following procedure was performed.
Attention was directed to the right foot where there was lateral gangrenous fourth and fifth metatarsal heads, exposed bone with cellulitis in the medial aspect of the forefoot. Two semielliptical incisions were made from dorsal to plantar. At this time, the first metatarsal, second metatarsal, and third metatarsal phalangeal joints were disarticulated and removed from the surgical site in toto. At this time, it was noted that there was very minimal bleeding. The amputation was taken back to the base of the metatarsals and resected using a sagittal saw. At this time, the skin was noted to have a moderate-to-good amount of bleeding. The aerobic and anaerobic cultures were taken. The wound was copiously flushed with 2 liters of antibiotic solution. The medial aspect of the dorsal and plantar skin was reanastomosed with 3-0 Vicryl with simple interrupted sutures. The lateral aspect of the wound remained open. The wound was packed with 1 inch iodoform packing. There was a good plantar flap noted after the procedure.
At this time, Achilles tenotomy was performed using an 11 blade. The skin was reanastomosed with 4-0 nylon with simple interrupted sutures. The wound was dressed with bacitracin, Adaptic, 4 x 4, Kling, and Ace bandage. The patient left the operating room for the recovery room with vital signs stable and the condition of the foot will be guarded.
OPERATION PERFORMED: Left third trigger finger release.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the table in the supine position. An adequate level of Bier block anesthesia was obtained. Tourniquet was applied to the left upper extremity and prepped and draped in normal sterile fashion. The correct site was verified prior to making the incision.
An incision was then made overlying the A1 pulley of the third digit and dissection carried down bluntly to the pulley. Retractors were then placed on the radial and ulnar side of the pulley as it was sharply incised under direct visualization from proximal to distal. There was complete release of the pulley and the tendon had full excursion.
Thorough irrigation was performed. Interrupted skin sutures were placed with nylon, and sterile dressings were applied. The patient was transferred to the recovery room in good, stable condition. There were no complications.
1. Open reduction and internal fixation of right distal radius fracture utilizing a Hand Innovations medium volar distal wrist plate and a Synthes spanning external fixator.
2. Carpal tunnel release.
DESCRIPTION OF OPERATION: The patient was identified in the holding area. Thoracic surgery clearance was confirmed. The patient was brought to the operative room in a stable condition. Chest tube was hooked up for wall suction, and general endotracheal anesthesia was induced by the anesthesia chief without complications. The patient received an additional gram of Ancef for perioperative prophylaxis. The tourniquet cuff was applied to the patient's right upper extremity. The right upper extremity was then prepped and draped in the usual sterile fashion.
Once the patient was adequately prepped and draped, the right upper extremity was evacuated with a venous port and Esmarch bandage. Once this was completed, attention was brought toward placing a spanning Synthes external fixator across the wrist to regain the length of the distal radius. A 2.5 cm longitudinal incision was made on the dorsal radial surface of the left second metacarpal. The skin and subcutaneous tissues were incised. The lumbrical muscle was gently elevated off of the volar and radial surfaces of the metacarpal in the area of the incision. Two self-tapping, self-drilling 2.5 mm threaded Synthes external fixator pins were placed in the first and the second metacarpal. Similarly, another couple of pins were placed in the radius proximal to the fracture.
A couple of pins were again placed in the 2.5 mm incision. Superficial radial nerve was identified underneath the brachioradialis. A couple of pins were placed just volar to the brachioradialis, thereby protecting the nerve. Meticulous dissection was carried down, thereby placing these two pins. Once the pins were placed, their position was confirmed with the image intensifier. A spanning external fixator was then applied to the two couple of pins and had a temporary reduction. This demonstrated the height that these rays could be reestablished, but because of the degree of comminution, the articular surface remained dorsally translated and comminuted. Because of the spanning, it was felt that internal fixation would also be required.
A 7 cm longitudinal incision was made on the volar surface of the brachioradialis. Skin and subcutaneous tissues were incised along the length of the incision. Brachioradials and flexor carpi radialis tendons were identified. Radial artery was identified. The extensor digitorum communis tendon was also identified. In the interval between the flexor carpi radialis and extensor digitorum communis, dissection was carried down to a robust quadratus muscle. This was gently elevated off of its radial insertion. Meticulous dissection allowed visualization of the distal radial fragment. By loosening and manipulating the external fixator, anatomic reduction of the fracture could nearly be obtained. It was felt that with volar plate fixation, this reduction could be established and maintained.
A Hand Innovations volar wrist plate was then placed on the volar surface of the radius. Its position was confirmed with the image intensifier and held temporarily in place with two 1.6 mm K-wires. The plate was then secured with a 3.5 mm screw utilizing the standard technique through the elongated hole in the mid portion of the plate. Final adjustments to the plate were then created after the K-wires were removed. Once the plate was in an appropriate position, the distal articular surface was reduced to the plate indirectly. This was then held in place with a separate 1.6 mm K-wire directed through the dorsal surface of the fracture and flexed towards the dorsum of the hand. Sauve-Kapandji intrafocal pin was then secured in the volar surface of the distal radius by holding the articular surface anatomically reduced. The articular surface then was secured with seven fully threaded 2.0 mm locked pins into the distal aspect of the Hand Innovations plate. The plate was then further secured to the proximal fragment with three additional 3.5 mm screws. An image intensifier was utilized throughout the procedure to establish reduction. Once this reduction was confirmed, a large bony void was appreciated.
The Sauve-Kapandji intrafocal pin was removed with placement of screws through this prior dorsal incision, which was placed in between the extensor tendons between the third and fourth dorsal compartments. A trocar was placed, and viscous slurry of MIIG-X3 calcium sulfate bone graft was injected into the void. Placement of this graft was facilitated with the image intensifier and 1.5 cc of this calcium sulfate was positioned. The void was filled and the trocar was removed. The patient's wound was then copiously irrigated out with normal saline. The external fixator was then adjusted into a cock-up wrist position to support soft tissues and act as a secondary buttress for the degree of dorsal comminution.
Final image intensifier examination of the wrist was then carried out, which demonstrated anatomic reduction with stable internal and external fixation. Because of the degree of dissection, it was felt that carpal tunnel release would be required. The volar incision was extended, and a modified carpal tunnel incision was created with a Brunner-type incision across the wrist crease. The carpal tunnel was visualized, and the transverse carpal ligament was visualized both above and below the ligament. This was then released along its length along the ulnar border of the fourth digit.
The carpal tunnel was then released. The wounds were irrigated. The dorsal incision was closed with #3-0 nylon suture. The volar incision was closed with layers of #2-0 Vicryl sutures and #3-0 monocryl sutures for the volar plate incision. The carpal tunnel incision was closed with #2-0 Vicryl suture and a #3-0 nylon suture. A bulky sterile dressing was then applied to the patient's wound. The patient was then extubated in the operating room and transferred to the recovery room in a hemodynamic and stable condition having tolerated the procedure well without complications.
PROCEDURE PERFORMED: Transmetatarsal amputation, right foot.
DETAILS OF PROCEDURE: After suitable general anesthesia, the patient's right lower extremity, with a tourniquet cuff in place, was prepped and draped in the usual sterile fashion. First, the outline of the amputation flap was made on the dorsum. The outline was marked out, starting on the medial side, mid lateral forefoot, and curved dorsally to the mid lateral part of the lateral border of the foot. On the plantar surface, there was a ulcer situated about 3 cm proximal to the bases of the toes in the second intermetatarsal space and the plantar flap outline had to come proximal to the ulcer area, but beyond that, it was extended onto the bases of the toes. On both borders of the foot, it joined the dorsal outline. Next, the tourniquet cuff was then elevated to 300 mmHg after exsanguination of the extremity with the help of Esmarch. First, the skin on the dorsal aspect was cut and the flap was fashioned. The extensor tendons were exposed. Any large veins encountered were clipped and ligated. The dorsal nerves were isolated as best as possible. However, they seemed to be very thin and atrophic looking. These were put under stretch and sectioned so that they retracted proximally. The dorsal flap was fashioned out after cutting the extensor tendons. The dissection was carried out to the middle of the metatarsal level. The first metatarsal was small and deformed. Next, the dissection was carried out onto the plantar aspect, and the plantar flap was similarly fashioned and here also the flexor tendon was sectioned and allowed to retract proximally. In the region of the ulcer area, there was marked scar tissue and as much as possible of this scar tissue, which had been infected in the past, was removed. Here also the plantar nerve and vessels were identified, and the plantar vessels clipped and ligated while the nerves were put under stretch and sectioned. Next, the bony cuts were made, and these were made approximately at the mid level of the metatarsals and in a cascade fashion, transecting all of the 5 metatarsal bones. Next, the amputated forefoot was then removed. Next, the cut ends of the bone were rasped smooth. Following this, the wound was thoroughly irrigated and then swabbed for culture. Studies were obtained from the proximal cut end of the second and third metatarsal bones. Next, the tourniquet was released, and bleeding points controlled with electrocautery. After full hemostasis had been obtained, the wound was again thoroughly irrigated and then the dorsal plantar flap was further tailored so that the plantar flap was lying in a dorsal direction. The subcutaneous tissue was closed with interrupted sutures using #2-0 Vicryl and then finally the skin with interrupted sutures using a combination of #3-0 and #4-0 nylon. A Xeroform and a bulky foot dressing were applied, and the patient awakened and transferred to the recovery room in a stable condition. The total tourniquet time was 52 minutes and the needle and sponge counts correct at the end of the procedure.
PROCEDURE PERFORMED: Closed reduction and internal fixation utilizing the Ace-Fischer captured hip screw system.
DETAILS OF PROCEDURE: After a suitable subarachnoid block anesthesia, the patient was carefully transferred from a bed onto the fracture table. The right lower extremity was fixed in the foot stirrup in the neutral position. Gentle longitudinal traction was then applied. The C-arm image intensifier was brought into position and AP lateral imaging of the right hip was done. On the AP view, the fracture was noted to be now out to length with good contact at the medial calcar. On the lateral view also, the neck-shaft angle was restored. Next, the patient's right lower extremity from the knee proximally to include the hip, buttock, and lower abdomen was prepped and draped in the usual sterile fashion. A longitudinal incision was made extending from just distal to the greater trochanter distally for a short distance. Skin incision was deepened. Bleeding points were controlled with electrocautery as the dissection proceeded. Fascia lata was incised in line of the skin incision, and the vastus lateralis muscle was exposed. There was noted to be some hemorrhagic edema and hematoma posteriorly, which was removed. Next, the vastus lateralis was incised from its insertion at the base of the greater trochanter distally along the lateral femoral shaft and then subperiosteally dissected. After hemostasis had been obtained, then 1/8-inch Ace-Fischer guidewire was taken, set at an angle of 135 degrees, and biplanar C-arm fluoroscopy was introduced through the lateral femoral cortex into the neck and head of the femur. On the AP view, the guidewire was noted to be slightly inferior to the center of the femoral neck, and on the lateral view, it was in the center of the femoral neck. This position was accepted, and the guidewire was then advanced to within 1 cm of the subchondral margin of the femoral head, and measurements were taken, and it was seen that a 100 mm length hip screw would be required. Next, the guidewire was then further introduced through the femoral head into the acetabulum to stabilize it during the reaming process. Next, the Ace-Fischer step-down reamer was taken, set to a depth of 100 mm, and advanced over the protruding end of the guidewire, and under biplanar C-arm fluoroscopy, the neck and head were reamed. The cancellous bone was felt to be of good quality, so therefore pretapping for the screw thread was done. Next, a 100 mm length hip screw with a 135 degree barrel was taken. This was assembled over a 4-hole plate, and the whole assembly was then passed over the protruding end of the guidewire. Under biplanar C-arm fluoroscopy, the hip screw was inserted into the neck and head of the femur. The barrel of the screw was gently impacted taking care that the plate was maintained in a midlateral position of the femoral shaft. Next, through the last hole in the plate, a drill hole was made in the loading phase and an Ace-Fischer bone screw of appropriate length was inserted but not tightened. At this point, the circulating nurse was instructed to release the traction, at which point impaction of the fracture site was done through the plate and then the screw was tightened. Then, through the rest of the holes in the plate, drill holes were made in the neutral phase and Ace-Fischer bone screws of the appropriate length were inserted and tightened. The sliding hip screw was then further tightened and then the hip was gently flexed and extended while observing it on the C-arm fluoroscopy, and the fracture site was found to be rigidly fixed. Spot images of the right hip in the AP and cross-table lateral views were taken, and then the wound was thoroughly irrigated. The vastus lateralis was approximated with interrupted sutures using #1 Vicryl. A Hemovac was placed in the depth of the wound and brought out through a separate stab incision situated distally. Fascia lata was approximated with interrupted sutures using #1 Vicryl and then the subcutaneous tissue was closed with interrupted sutures using a combination of 1-0 Vicryl and 2-0 Vicryl, and finally the skin with staples. A Xeroform, 4 x 4, ABD pad dressing was then applied, and then the patient's leg was released from the foot stirrup and the patient was then carefully transferred from the fracture table onto a bed to the recovery room in a stable condition. The estimated blood loss during surgery was less than 50 cc. No blood transfusion was given during surgery. Needle and sponge counts were correct at the end of the procedure. No intraoperative complications were noted.
A. Left third distal interphalangeal joint arthroplasty with K-wire fixation.
B. Flexor digitorum longus tenotomy, left third digit.
C. Right hallux interphalangeal joint condylectomy.
DETAILS OF PROCEDURE: Under mild sedation, the patient was brought to the operating room and placed on the operating room table, where a left and right well-padded pneumatic ankle tourniquet was placed. Next, the above-mentioned cocktail was injected on the left third digit, in a digital block and a hallux block about the right foot. Both feet were prepped and draped in the usual aseptic manner. The left foot was then elevated in an approximately 45-degree angle and exsanguinated using an Esmarch bandage.
Next, a semi-elliptical incision was made dorsally about the third distal interphalangeal joint. The skin was reflected and removed. The sharp and blunt dissection continued down to the subcutaneous tissue retracting all neurovascular structures and ligating all necessary bleeders. Dissection was carried down to the extensor digitorum longus tendon, which was identified and reflected both proximally and distally.
Next, all soft tissue attachments were reflected off of the intermediate phalanx head. An oscillating saw was then utilized to resect the intermediate phalanx head. Dissection was carried down plantarly to identify the flexor digitorum longus tendon, which was then tenotomized. The wound was flushed and irrigated using copious amounts of normal sterile saline.
Next, a 0.045 K-wire was inserted through the base of the distal phalanx and was inserted in the intermediate phalanx and to the proximal phalanx in a retrograde fashion. Fluoroscopy was utilized to confirm proper K-wire placement, which was noted to be adequate. Deep closure was obtained using Vicryl suture. Skin was closed and reapproximated using Novafil suture. The wound was dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4 gauze, Kling, and an Ace bandage. The left tourniquet was then deflated.
Next, the right foot was elevated at an approximately 45-degree angle and exsanguinated using an Esmarch bandage. Attention was then directed to the medial aspect of the hallux interphalangeal joint, where an approximately 2.5 cm incision was made. Sharp and blunt dissection was carried down to the subcutaneous tissue retracting all neurovascular structures and ligating all necessary bleeders. Careful dissection continued until the condyles of the base of the distal phalanx medially and condyle of the proximal phalanx distally was exposed. Dissection was utilized to free up all soft tissue attachments by paying careful attention to preserve the flexor and extensor tendons.
Next, an oscillating saw was utilized to resect the condyles at the interphalangeal joint. A rongeur was utilized to remove any other excessive hypertrophic bone. It was noted that no hypertrophic bony prominences remained. The wound was flushed and irrigated using copious amounts of normal sterile saline. Fluoroscopy was then utilized to confirm proper resection of bone. It was noted that adequate resection was achieved. Deep closure was obtained using Vicryl suture, and skin was closed and reapproximated using Novafil suture.
The wound was dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4 gauze, Kling, and Ace bandage. The tourniquet was deflated. The patient tolerated the anesthesia and procedure well, returned to the PACU with vital signs stable and hyperemia to all digits.