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--- resident:matt_iorio [2021/03/13 22:18] – krystle
+++ resident:matt_iorio [2024/12/20 11:14] (current) – jerry
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   * Resident - Plastic Surgery - Georgetown University (2008-2013)\\
   * Fellow - Hand and Micro-vascular Surgery - University of Washington (2013-2014)\\
+\\
+[[https://drive.google.com/open?id=1AC4dJNWcbqZyeyv7ScAuRqrUSojhLr3A|Dr. Iorio Publications]]\\
+\\
+[[https://drive.google.com/open?id=1dGsnXYy5elj9M99PHIWwcsRNOdcVdahJ|Dr. Iorio Recommended Papers]]\\
+\\
+General Notes:\\
+\\
+How to succeed on Iorio Thursday:\\
+Put tourniquets on in pre-op\\
+Ask Dr. Iorio which patients should get blocks and convey this to anesthesia. In general any bony, tendon or ligament work will get blocks. Soft tissue carpals, trigger fingers, ganglions get local. CuTR should go to sleep because the blocks tend not to work.\\
+The nurses tend to take a long time to prep, so feel free to put on sterile gloves yourself and get it done.\\
+Towards mid-morning, you will be way ahead of schedule and you need to harass the pre-op nurses to get the patients in "early."\\
+Use Amy's discharge instructions. Dotphrase .PRShanddischargeinstructions\\
+\\
+Clinic:\\
+It's busy. Between 40-60 patients on Tuesdays for Hand.\\
+You need to be extremely concise. "55 yo RHD woman with CTS. I want to order an EMG."\\
+Ask Kayla or Dan to pull meds for injections. He uses 1 cc dex and 1 cc lidocaine mixture for everything.\\
+You could potentially ask for pyxis access to do it yourself.\\
+\\
+How to roll a Dr. Iorio Bulky Jones:\\
+These are usually for lower extremity free flaps. Make sure you glue to vioptix down with dermabond. He holds it down and then cuts the tips of his gloves off. Roll the 1lb of cotton on. No need to break it in half. Next get the webril and use it to keep the cotton on. Now get the bias. Start at the heal. Once you get a roll around the heal, place a folded ABD under the heal for extra padding. Roll up the bias all the way up. Guess where the doppler stitch is and make a hole. Use the 1 slice of medipore tape to re-enforce the wall of the hole. Prop the heal up on blankets and pillows transversely at the foot of the bed. There should be no pressure under the popliteal fossa (the inflow).:\\
-[[https://drive.google.com/open?id=1AC4dJNWcbqZyeyv7ScAuRqrUSojhLr3A|Dr. Iorio Publications]]
+Stoma Revision Protocol (as of 3/20/23).\\
+- Biopsy culture stoma (bx for colonization data) "label screening culture" (Hayden/Damioli will work with lab to work up and grow to ID and susceptibility).\\
+- Vanc/tobra intra op around stoma (1 vial vanc/1 vial tobra).\\
+- Augmentin 875/125 PO BID x14 days.\\
+- If PCN allergy, the Bactrim DS 800/160 PO BID and Flagyl 500 PO BID x 14 days.\\
+\\
-[[https://drive.google.com/open?id=1dGsnXYy5elj9M99PHIWwcsRNOdcVdahJ|Dr. Iorio Recommended Papers]]
+OI soft tissue stoma superficial infection:.\\
+- Linezolid 600mg PO BID x10 days.\\
+- Cipro PO BIX x 10 days.\\
+Order pain buster orderset:\\
+Use Pain Buster order set. - In hospital use CADD pump set at 0.2 Ropivicaine dose, the day of leaving hospital need order the pain ball(400cc) and talk with pharmacy to set rate at 6cc/hr\\
+Do not ever use Keesler method for tendon repair. Use cruciate method (4-strands, 1 knot)
 ===== Operative Reports =====
@@ Line 19: / Line 52: @@
 \\
 Active IVDU do not get skin grafts.\\
+\\
+Doesn't like the suction. Thinks it traumatizes the tissue. Prefers raytec of lap pads.\\
+\\
+When using the knife, he doesn't want any adjustments. Don't grab anything new or move your hand. It changes the perspective.\\
+\\
+OI Stoma Revisions: Dc on Bactrim vs Doxy for 10 days; shrinkers are found in the equipment storage across from OR 2 (need to know length and circumference) as well as donning tubes to help put on the shrinkers. Helps to check chart to know what size patient was wearing before and may have to adjust from there. If you have questions, ask Maria Kouzmina (Stoneback's APP). Tell charge when you're taking them so they can keep track of inventory (Stoneback's request).
 ==== Medial Femoral Condyle Free Flap ====
@@ Line 125: / Line 162: @@
-====Cubital Tunnel====
+====Cubital Tunnel with Transposition====
 <WRAP group>
@@ Line 149: / Line 186: @@
 Tourniquet: finger / forearm / arm\\
 Drain: Type of drain and placement\\
-Close: Deep dermal, running subQ.\\
+Close: Women :Deep dermal, running subQ. Old men: Nylons with a few deep dermals with monocryl.\\
 Dressing: adaptic, 4x4, webroll, ace. Off on POD#5.\\
+\\
 Anatomy: Pertinent anatomy should be listed\\
+\\
 Post-operative care: She will go home from the hospital today. Arrangements were made to follow up with me in clinic in 2 weeks for a wound check. she is to keep the hand elevated and remove the dressing in 48 hours and begin gentle range of motion as tolerated. If she has problems before followup, she has been told to contact me and I would be happy to see her sooner.\\
+\\
 Attending Pearls (Learning points/Pimp Questions):\\
+Prefers patient to have general anesthesia as opposed to nerve block. The cubital tunnel doesn't get the best spread with nerve blocks.\\
+\\
 What are the areas of ulnar nerve compression? Remember guyon's as well.\\
-What vessel runs with ulnar nerve in elbow? ??Superior ulnar collateral\\
+What vessel runs with ulnar nerve in elbow? ??Superior ulnar collateral, Posterior recurrent ulnar collateral. There is controversy if these should be cauterized because they are the primary blood supply to the nerve. Iorio does not believe this is true and is happy to cauterize them to mobilize the nerve.\\
+He prefers transposing as a primary operation because the revision rate is high for in-situ and it make is much harder with all the scar tissue. He does tend to do a lot of revisions.\\
+What are the points of compression of the ulnar nerve? Cubital tunnel (know these 5: Arcade of struthers, intermuscular septum, osborne's ligament, anconeus epitrochlearis, 2 heads of FCU), guyon's canal.\\
+\\
+Operates with the arm in a flexed elbow position. When he approaches osborne's ligament, he will straighten the arm.\\
+Marking: He marks like the hunt book. Just over the posterior border of the medial epicondyle.\\
+\\
+How he tackles each compression point:\\
+Usually starts proximally, however in the rare case that a patient is super thin or odd tissue will start distally,\\
+Finds nerve proximally to osbornes. Will go proximally and free up arcade of struthers bluntly with his finger.\\
+Next, will follow nerve and cut osborne's/anconeus.\\
+Continue following that proximally and cut the FCU fascia. Be careful around the muscle as branches may start coming off. Remember the first branch is the articular branch to the elbow, and then FCU branches. Dinging FCU branch not nice, but probably not a huge deal.\\
+Go back to medial intramuscular septum. This is between medial and long heads of triceps and brachialis. It's like strumming a guitar string. Cut that out and go down to just above periosteum. Like 1/2 cm wide and 4 cm logitudinal.\\
+Free up the nerve using a vessel loop. He uses combo of blunt with freer and scissors. Once free transpose. Check if you like it for kinks. Remember you can free up the distal half deeply off the bone using a freer. There are no branches going to the bone.\\
+Once you like how it lays, suture the old tract of the ulnar nerve closed with 3-0 monocryl. Then suture the lateral skin flap to the medial epicondyle with 3-0 monocryl.\\
+Close with 4-0 nylon horizontal mattress or 3-0 and 4-0 monocryl.\\
+\\
+</WRAP>
+</WRAP>
+====Cubital Tunnel Release without Transposition====
+Operating Report
+<WRAP Group>
+<WRAP half column>
+PROCEDURE:
+In situ decompression of ulnar nerve at the elbow\\
+She was identified In the holding area and the operative site was marked. She was brought to the operating theatre in stable condition, placed on a regular table in supine position with right arm on an arm board. Preoperative timeout was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. She received perioperative antibiotics. All bony prominences were well-padded. Her right arm was sterilely prepped and draped. \\
+I began the procedure by making a longitudinal incision centered between his medial epicondyle and olecranon. I dissected through subcutaneous tissue and protected branches of the medial antebrachial cutaneous nerve. The ulnar nerve was identified just posterior to the medial intramuscular septum. The nerve was then decompressed through the cubital tunnel, as well as between the 2 heads of the FCU fascia. Complete decompression was ensured, both proximally and distally. Full elbow range of motion showed no subluxation and hemostasis was revised. \\
+The wound was irrigated and skin closed using 4-0 Monocryl deep dermal and running subcuticular stitch.. Soft dressing was applied. She tolerated the procedure well. There were no complications. Marcaine 0.25% with 1% lidocaine and epinephrine was injected for postoperative anesthesia. She left the operating room in stable condition\\
 </WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Sutures: 4-0 Monocryl deep dermal and running subcuticular stitch\\
+Dressing: Soft dressing\\
+OR tips: OR tips: LMA. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon (sometimes 3-0/4-0 Monocryl), xeroform/adaptiq, 4x4, webrill 2” ace. \\
 </WRAP>
+</WRAP>
@@ Line 251: / Line 336: @@
 Attending Pearls (Learning points/Pimp Questions):\\
-Remember that FPL tendon is coming around thenar muscles. Hold hand in almost an intrinsic plus position with finger tips pointed to ceiling. The A1 pulley is posterior to thenar area in this position. Incision should NOT be over thenar prominence. If so, you are too far radial/anterior. Know what muscles attach to A1 and oblique pulley. Know innervation of thenar musculature\\
+Remember that FPL tendon is coming around thenar muscles. Hold hand in almost an intrinsic plus position with finger tips pointed to ceiling. With the thumb and fingers almost at a 90 degree angle. The A1 pulley is posterior to thenar area in this position. Incision should NOT be over thenar prominence. If so, you are too far radial/anterior. Know what muscles attach to A1 (FPB) and oblique pulley (Adductor pollicis). Know innervation of thenar musculature\\
+DO NOT HOLD THE THUMB EXTENDED. that brings the nerves up. Hold it with IP flexion in a resting position.\\
 \\
 OR tips: Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4x4, webrill 2” ace. \\
+Transverse spreads with scissors down to tendon. Only make 1 hole. Then longitudinal spreads with tips touching tendon sheath. Cut pulley with knife to open and then finish with scissors. You’ll go one way and he’ll go the other. \\
 </WRAP>
 </WRAP>
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 Attending Pearls (Learning points/Pimp Questions):\\
-OR tips: Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4x4, webrill 2” ace. \\
+OR tips: Local w/ sedation (inject into the tunnel, along the incision, and across volar wrist). Upper arm tourniquet w/ webrill, tourniquet, foam tape. Uses scalpel only for entire CTR operation (no Freer, no scissors). Close w/ 4-0 Nylon, xeroform/adaptiq, 4x4, webrill 2” ace. \\
 </WRAP>
 </WRAP>
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 </WRAP>
 <WRAP half column>
+Special Equipment: Suture passer, mini-mitek 3-0 or 4-0. 3.2mm cannulated drill bit. 3-0 fiber wire, 4-0 fiber wire. k-wires.\\
+\\
 Tourniquet: arm - well padded tourniquet was inflated to 250 mmHg. \\
 Drain: No\\
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 OR tips: OR tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 3-0/4-0 Monocryl, Dermabond, 4x4, Thumb spica plaster splint, webrill,  2” ace. \\
-</WRAP>
+Structures Dr. Iorio will ask you to identify: EPB/APL, Sensory branches of the superficial radial nerve, dorsal branch of radial artery.\\
-</WRAP>
+Will usually do something with EPB... either tenodesis to capsule or APB to prevent hyperextension of MP joint.\\
+Makes a bone tunnel with 3.2 mm cannulated drill bit. The tunnel should go dorsal-radial to volar-ulnar.\\
+Takes FCR at muscle belly for length. Make sure to identify all the bits so it comes out easy.\\
+Accordions FCR. Half of the tendon goes through bone tunnel and anchored in place with bone anchor. Also takes bite of volar capsule to prevent extrusion as the first bite of the 3-0 fiberwire.\\
-====Cubital Tunnel Release without Transposition====
+Uses suture passer to get (half) the tendon through the tunnel. And then anchors it in place with a bone anchor. Next he accordions the rest of that tendon and then the other half.\\
+Close the wrist capsule. Imbricate the capsule so it is tight. You will take a live fluoro shot in order to decide if the suspension is adequate. if not, you will k-wire the 1st MC to the 2nd MC. Decide what to do with the EPB. And then close skin.\\
-Operating Report
+Thumb spica splint.\\
+\\
-<WRAP Group>
+Marking: just dorsal to 1st dorsal compartment. Mark halfway on the 1st MC and extend proximally over the TMC joint.\\
-<WRAP half column>
-PROCEDURE:
-In situ decompression of ulnar nerve at the elbow\\
-She was identified In the holding area and the operative site was marked. She was brought to the operating theatre in stable condition, placed on a regular table in supine position with right arm on an arm board. Preoperative timeout was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. She received perioperative antibiotics. All bony prominences were well-padded. Her right arm was sterilely prepped and draped. \\
-I began the procedure by making a longitudinal incision centered between his medial epicondyle and olecranon. I dissected through subcutaneous tissue and protected branches of the medial antebrachial cutaneous nerve. The ulnar nerve was identified just posterior to the medial intramuscular septum. The nerve was then decompressed through the cubital tunnel, as well as between the 2 heads of the FCU fascia. Complete decompression was ensured, both proximally and distally. Full elbow range of motion showed no subluxation and hemostasis was revised. \\
-The wound was irrigated and skin closed using 4-0 Monocryl deep dermal and running subcuticular stitch.. Soft dressing was applied. She tolerated the procedure well. There were no complications. Marcaine 0.25% with 1% lidocaine and epinephrine was injected for postoperative anesthesia. She left the operating room in stable condition\\
 </WRAP>
-<WRAP half column>
-Tourniquet: No\\
-Drain: No\\
-Sutures: 4-0 Monocryl deep dermal and running subcuticular stitch\\
-Dressing: Soft dressing\\
-OR tips: OR tips: LMA. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon (sometimes 3-0/4-0 Monocryl), xeroform/adaptiq, 4x4, webrill 2” ace. \\
 </WRAP>
-</WRAP>
@@ Line 505: / Line 571: @@
 Attending Pearls (Learning points/Pimp Questions):\\
-OR tips: Block w/ sedation; Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4x4, webrill, Short arm splint,  2” ace. \\
+\\
+Markings: start at proximal wrist crease and extend proximally 10 cm over FCR. \\
+OR tips: Block w/ sedation; Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4x4, webrill, Short arm splint,  2 inch ace. \\
+\\
+**How to rock a Dr. Iorio DR Fx ORIF using a volar locking plate.**\\
+\\
+Dr. Iorio uses Synthes Variable Locking DR plates. They come in the Synthes DR Plate Set.\\
+\\
+**Approach:**\\
+Mark 10 cm from proximal wrist crease extending proximally over FCR.\\
+Use the knife to incise the superior sheath of FCR. Once you are in, finish it proximally and distally with tenotomy scissors.\\
+Next, bring the tendon ulnar and use the knife to incise the deep FCR sheath. Remember the nerve is close, so just the sheath.\\
+Bluntly dissect FPL ulnar and clear off PQ.\\
+Make sure you identify approximately where the fracture is.\\
+Use the Bovie to incise PQ down to bone on the radial border. Watch for the radial artery.\\
+Use the brown handle elevator (push sub-periosteal) to elevate PQ from radial to ulna. Make sure you are distal enough that you uncovered the fracture.\\
+Distract the fracture and clear off the periosteum from the cortex so you can line it up nicely. Free your fracture.\\
+\\
+**Fixation:**\\
+Now you can reduce the fracture and place TWO radial styloid k-wires so that the fragments cannot rotate. Place the k-wire by hand and then drop your hand ulnar all the way so it doesn't go into the joint.\\
+Pick your plate and secure it with 2 k-wires through the plate.\\
+On the AP view:\\
+. Make sure you will capture the distal fragments.\\
+. Make sure the plate is centered on the axis of the radius.\\
+. Line up the dorsal and ulnar corners (he will "go live" to do this) so that the DRUJ is clear and make sure the screws aren't going into the DRUJ.
+On the Lateral view:\\
+. Make sure the genu of the plate is distal enough to capture the distal fragments\\
+. Make sure the screws do not go into the radial-carpal joint\\
+- Remember the "joint-view" is your radial inclination, so 10-20 degrees.\\
+\\
+Once happy with your plate placement, time for the screws. The guide fits into the holes like a cloverleaf.\\
+- First screw goes into the (radial) radial column hole. He always places a non-locking screw that is too long (24mm) into this hole. The concept is that it will bring the plate down to the bone.\\
+- Finish your distal row with locking screws and replace your non-locking screw.
+- Drill your oblong proximal hole, again use a non-locking screw in order to pull the plate to the bone and restore your volar tilt.\\
+- Now is the time to check your AP and lateral views. Adjust any screws that are too close to the joint. Make sure you aren't too long on any screws.\\
+- If you are happy, drill the remaining distal and proximal holes and take final images.\\
+**Closure:**\\
+Close skin with either 3-0, 4-0 monocryl with dermabond if there is adequate dermis. Otherwise, use horizontal mattress 4-0 nylons.\\
+Place a volar forearm based splint with the MCPs free.\\
 </WRAP>
 </WRAP>
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 </WRAP>
 </WRAP>
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 </WRAP>
-***
 ==== Distal Radius Vascularized Bone Graft for Scaphoid Nonunion ====
@@ Line 702: / Line 801: @@
 <WRAP half column>
-Tourniquet: Yes\\
+Tourniquet: Upper arm pneumatic tourniquet\\
 Drain: No\\
-Sutures: monocryl\\
+Sutures: 3-0 monocryl deep dermals and 4-0 monocryl subcuticular\\
-Dressing: bulky dressing with thumb spica\\
+Dressing: bulky dressing with thumb spica splint\\
+Post-operative Protocol:\\
+Splint for 4-6 weeks followed by progression of AROM to PROM.\\
 \\
 Iorio Tips:
@@ Line 728: / Line 831: @@
 </WRAP>
+==== Ulnar Shaft ORIF ====
 <WRAP group>
 <WRAP half column>
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 \\
-Indications: Ms.XXX　is a 53 y.o.　F that presents with a left forearm trauma involving an ulnar shaft fracture and radial forearm laceration.
+Indications: The patient presents with a left forearm trauma involving an ulnar shaft fracture and radial forearm laceration.
 We discussed the nature and pathophsiology of the diagnosis. We discussed treatment options and expectations in regards to potential outcomes, including the needs for secondary procedures or revisions.
@@ Line 767: / Line 873: @@
 Dressing: Sugar-tong in supination\\
-Anatomy:
+Anatomy:\\
 {{:resident:screen_shot_2021-03-13_at_8.13.26_pm.png?200|}}
 {{:resident:screen_shot_2021-03-13_at_8.13.32_pm.png?200|}}
@@ Line 782: / Line 888: @@
+==== Flexor Tendon Repair ====
+Uses cruciate 4-strand repair. Makes a point of you knowning what stitch you use and why. This minimizes the knot material buried in the tendon repair because it is 4 strands per 1 knot vs a modified kessler which is 2 strands per knot. He also says there no differential tension on the suture. Your bites should be the width of the tendon. Of course, you use an epitentinous repair as well. This is usually 5-0 prolene, 2 mm back from the edge of the repair, 2mm apart. You should cover the tendon blue. No need to do the back of tendon if it is difficult.
+==== Proximal Row Carpectomy ====
+Prefers a longitudinal incision unless it's a very young female patient for cosmetic reasons.\\
+Transposes EPL. Sutures wrist capsule back together with 3-0 monocryl.\\
+What extensor interval dose he use?\\
+After transposing EPL, will go longitudinally between DEC 2 & 4 and then elevate off the compartments. He is ALWYAS abele to close this. No stupid step cuts. Repair this at the end. 3-0 monocryl.\\
+Incise joint capsule and elevate off bones. Repair some of this at end with 3-0 monocryl.\\
+Take bone out with rongeur and freer and knife.\\
+Most important ligament to preserve is RSC (Radioscaphocapitate). All the ligaments that will support the wrist are now volar.\\
+Useful positions are flap and bumped up to flex the wrist using a blue towel bump.\\
+x-ray at the end. Take one image distracted to make sure the bone fragments are gone. Take the next image for stability. AP to show capitate sits in lunate fossa. Lateral flexed and extended to make sure the patient doesn't dislocate.\\
+Splint is very important. Volar dorsal. WRIST needs to be ulnarly deviated and the wrist in slight extension. MCPs free. Hand elevation pillow.\\
+This allows the capitate to stay in the lunate fossa of the radius.\\
+Special Equipment: Make sure to have finger traps and weights. 15lbs is a good start.\\