Plastics

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=====Dr. Iorio Introduction=====

  * Bachelor of Arts - Cum Laude - University of Chicago - 1998-2002\\
  * Doctor of Medicine - Magna Cum Laude - Georgetown University School of Medicine - 2003-2007\\
  * Intern - Plastic Surgery - Georgetown University (2007-2008)\\
  * Resident - Plastic Surgery - Georgetown University (2008-2013)\\
  * Fellow - Hand and Micro-vascular Surgery - University of Washington (2013-2014)\\ 
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[[https://drive.google.com/open?id=1AC4dJNWcbqZyeyv7ScAuRqrUSojhLr3A|Dr. Iorio Publications]]\\
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[[https://drive.google.com/open?id=1dGsnXYy5elj9M99PHIWwcsRNOdcVdahJ|Dr. Iorio Recommended Papers]]\\
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General Notes:\\
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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\\
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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.\\
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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).:\\

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.\\
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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 =====

General Notes:\\
General Dressing: adaptic, 4x4, kerlix, 2 inch ace\\
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REMOVE (some) STAPLES FOR HEMATOMA AT BEDSIDE. Save the flap.\\
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Active IVDU do not get skin grafts.\\
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Doesn't like the suction. Thinks it traumatizes the tissue. Prefers raytec of lap pads.\\
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When using the knife, he doesn't want any adjustments. Don't grab anything new or move your hand. It changes the perspective.\\
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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 ====

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Need op report. 6/1/20 Iorio

Operative Report:\\

The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
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Due to his prior radial nerve injury and multiple surgeries, we utilized an anterolateral approach. The nonunion site was marked with fluoroscopy, and an incision made and carried down through the brachialis. The access and fracture debridement was performed by Dr. Stoneback and will be dictated under separate cover.\\
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Following this, the humeral defect was visualized and a template of the bony defect was made with bone wax.\\
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Following this we turned to the ipsilateral knee. A longitudinal incision was made in line with the medial femoral condyle. The skin was incised, and the vastus medialis was retracted anteriorly exposing the condyle. The medial collateral ligament and Sartorious tendon were preserved.\\
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Following this, the DGA vascular pedicle was traced proximally from the condyle and circumferentially freed and side branches ligated.\\
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On the medial condyle, a bone flap was marked with the planned dimensions of 4x3x2cm. The periosteum was incised with the bovie, and the corticotomies were made with straight and curved osteotomes.\\
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Following this, the flap was elevated from the condyle, and reflected proximally on the vascular pedicle. Curettes were used to harvest cancellous bone graft.\\
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The flap was then islandized and brought to the arm. The flap was contoured to fit the humeral defect, and was compressed into place with an overlay plate. \\
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A side branch from the brachial artery was found, and an end to end anastomosis was completed, and the vein was coupled. The pedicle demonstrated a good signal.\\
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The site was irrigated and the brachialis was repaired. The skin was closed in layers with 3-0 pds and monocryl over a drain.\\
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The thigh was irrigated. The femoral defect was packed with allograft bone, and the vastus was secured over the defect and advanced to the sartorious with 3-0 pds. The skin was closed in layers with monocryl over a drain.\\
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A bulky dressing was applied. The patient was awoken from anesthesia and transported to recovery in stable condition.\\

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Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Attending Pearls (Learning points/Pimp Questions):\\

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==== CRPP/ORPP Metacarpal base fracture ====

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Operative Report:\\
1. ORIF right 4th metacarpal base fracture\\
2. ORIF right 5th metacarpal CMC fracture dislocation\\
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The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
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The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. \\
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Following this, we attempted to reduce the fracture closed but were unsuccessful after several attempts.\\ 
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A longitudinal incision was made over the base of the 4th and 5th metacarpals. EDC tendons to each finger were identified and protected, and the retinaculum was splint at this interval. The CMC joint to the 4th and 5th was then open with a transverse capsulotomy.\\
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There was a large amount of intervening granulation tissue and early bone healing and this was sequentially removed with a rongeur and freer. Following this, the 4th and 5th metacarpal could be reduced.\\
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A 0.062 kwire was placed transversely at the base of the metacarpals and anchored into the base of the 3rd metacarpal. An additional transverse and an oblique wire through the 5th metacarpal and hamate was placed. Reduction was confirmed with fluoroscopy. \\
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The joint capsule was closed with 4-0 pds, and the skin was closed with 4-0 nylon. Wires were clipped deep to skin.\\
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A bulky dressing was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.\\

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Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Attending Pearls (Learning points/Pimp Questions):\\
OR tips:  Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon (occasionally uses monocryl), xeroform/adaptiq, 4x4, Intinsic plus splint, webrill, 2” ace. \\

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====Cubital Tunnel with Transposition====

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Operative Report:\\
1. Decompression of ulnar nerve at the elbow with subcutaneous transposition:\\
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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. \\
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The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. \\
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I began the procedure by making a longitudinal incision centered between her 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. There also appeared to be a significant amount of adipose tissue within the epineurium and cubital tunnel, which was released. Complete decompression was ensured, both proximally and distally. Elbow motion demonstrated nerve subluxation and condylar perching. A subcutaneous pocket was made over the muscular fascia, and the nerve was transposed following excision of the IOM. The cubital tunnel was closed with 3-0 monocryl. \\
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The wound was irrigated and skin closed using 4-0 Monocryl deep dermal and running subcuticular stitch. Soft dressing was applied. The tourniquet was released and the hand demonstrated good perfusion. She tolerated the procedure well. There were no complications.. She left the operating room in stable condition.\\

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Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
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.\\
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Anatomy: Pertinent anatomy should be listed\\
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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.\\
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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.\\
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What are the areas of ulnar nerve compression? Remember guyon's as well.\\
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.\\
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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.\\
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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.\\
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====Cubital Tunnel Release without Transposition====

Operating Report

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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\\

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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. \\

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====Dupuytren's Contracture Release====

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Operative Report:\\
1. Limited palmar fasciectomy, right 4th finger to the level of the MP\\
2. Z-plasty, right palm, 3cm\\
3. 4th trigger release\\
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The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
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The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. \\
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A longitudinal incision was made over the palmar cord. The skin flaps were elevated with a scalpel. The neighboring palmar fascia to the 3rd and 4th palmar spaces were included, and the proximal 4th cord was transected. It was reflected distally, taking the vertical branches to the metacarpal as well.\\
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The 4th A1 pulley was thickened and corresponded to her complaint of pain and locking, and the pulley was released directly with tenotomies.\\
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The skin was then closed with 4-0 nylon. Given the contracture, she did appear to have an area of longitudinal tension, and a z-plasty was marked out with 1cm limbs at the level of the distal palmar crease. These were elevated with a scalpel, and transposed and closed with 4-0 nylon.\\
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A bulky dressing and splint was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.

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Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Attending Pearls (Learning points/Pimp Questions):\\
Know the cords.\\
Reviewed z-plasty. Measure out. All lengths should be equal. Measure angle by other side of triangle\\

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====Tigger Finger and Thumb A1 Release====

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Operative Report:\\
1. Right 1st trigger release\\
2. Right 3rd trigger release\\


The extremity was prepped and draped in sterile fashion. Local anesthesia was achieved with a mixture of 1% lidocaine and 0.5% marcaine. The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. 
  
An incision was made over the 3rd volar A1 pulley. Soft tissue was dissected, and the radial and ulnar neurovascular bundles were protected. The A1 pulley was released with a scalpel, and proximal and distal release confirmed, taking care to preserve the A2 pulley. The wound was irrigated and closed with 4-0 nylon horizontal mattress sutures. 
 
Following this, an incision was made over the 1st volar A1 pulley. Soft tissue was dissected, and the radial and ulnar neurovascular bundles were protected. The A1 pulley was released with a scalpel, and proximal and distal release confirmed, taking care to preserve the A2 pulley.
 
Sterile dressing was applied. The tourniquet was released. Stephen tolerated procedure well.  There were no complications.  Final instrument count was correct.  He left the operating theatre in stable condition.

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Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

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. 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.\\
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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. \\
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====Completion Amputation====

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Operative Report:\\
1. Amputation, right 3rd finger, proximal phalanx level with direct closure\\
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The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.
 
A fishmouth incision was marked proximal to the area of ongoing tissue changes and distal gangrene. This corresponded to the PIP level. The incision was made full thickness with a scalpel, down through skin and tendon. The joint was disarticulated and the finger passed off the field.

The head of the proximal phalanx and cartilage was removed with a rongeur. The wound was loosely closed with 4-0 chromic suture.
 
A bulky dressing was applied. The patient was awoken from anesthesia and transported to recovery in stable condition.

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Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Learning points/Pimp Questions:\\
Fishmouth or cut 2 ovals, cut out the middle and then sew together

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====Carpal Tunnel Release====

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Operative Report:\\
1. Carpal Tunnel Release:\\
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The patient was identified in the holding area and the operative sites were marked.  He was brought to the operating room and placed supine. The extremity was prepped and draped in standard sterile fashion. A preoperative time-out was taken to ensure the patient's identity, the operative procedure, as well as the operative location.
  
Local anesthesia was achieved with 1% lidocaine mixed with 0.5% Marcaine. The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. 
 
A longitiunal incision was made over the transverse carpal ligament at the level just distal of the volar wrist crease, in line with the 3rd webspace. We dissected through the subcutaneous tissue and palmar fascia, and the palmaris brevis muscle fibers.  Care was taken to protect the ulnar neurovascular bundle in Guyon's canal.  Next we identified the transverse carpal ligament which was divided longitudinally from the palmar fat pad and proximally into the antebrachial fascia. Complete release was ensured and the wound was irrigated with normal saline. The skin was closed using 4-0 nylon stitch.  

A soft dressing was applied. The tourniquet was released. He tolerated the procedure well. There were no complications.  Final instrument count was correct.  He left the operating room in stable condition. 

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Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Attending Pearls (Learning points/Pimp Questions):\\
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. \\
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====CMC Arthroplasty====

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PRE-OP DIAGNOSIS:
Right 1st CMC OA
Right 1st MP hyperextension deformity
 
POST OP DIAGNOSIS (required):
same
 
ESTIMATED BLOOD LOSS: 0-50mL
 
Procedure (preliminary CPT codes for reference):
1.  Right 1st CMC arthroplasty
2.  Right EPB tenodesis
3.  Right MP joint capsulodesis
 
Indications: 69 y.o. female. presents with a painful right thumb and ongoing arthritis, with an MP extension deformity.
 
We discussed the nature and pathophysiology of the diagnosis. We discussed treatment options and expectations in regards to potential outcomes, including the needs for secondary procedures or revisions.
 
Consent was obtained by discussion with the patient in regards to the risks and benefits, including possible injury to nerve, vessel, tendon, the need for secondary or revision procedures and occupational therapy. The patient had adequate time for discussion, and all questions were answered prior to completing the consent.
 
Operative Procedure: The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.
 
The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. 
 
A longitudinal incision was made over the 1st CMC joint. The interval between the EPL and EPB was identified, and the tendons were freed from their associated sheaths. Following this, a capsulotomy into the 1st cmc was made. The trapezium was circumferentially dissected, and removed in piecemeal.
 
The FCR tendon was visualized at the base of the wound and freed distally. A counter incision over the volar forearm was made, and the FCR tendon was verified and transected. This was then brought into the wound.
 
A cannulated drill was utilized to make a bone tunnel in the 1st metacarpal base exiting at the volar ulnar corner to recreate the AOL ligament. The FCR tendon was then split, and one-half was brought through the bone tunnel.
 
The metacarpal was then placed on maximum longitudinal traction, and secured with a suture anchor. Both halves of the tendon were then imbricated upon themselves with 3-0 fiberwire. The capsule was closed tightly with 4-0 fiberwire. The skin was closed with deep dermal followed by a running monocryl.
 
Intraoperative fluoroscopy was utilized to verify position of the trapezium, complete excision of the trapezium, and then following closure to verify the stability of the arthroplasty against subsidence against axial compression. A 0.045 k wire was placed from the base of the 1st to the 2nd metacarpal and clipped deep to skin.
 
The EPB tendon was then identified and the MP joint was brought into flexion. The tendon was then tenodesed to the capsule and base of the metacarpal with 3-0 fiberwire to limit MP motion and extension.
 
A counter incision was made over the MP crease with a brunner incision. The ulnar digital nerve was identified and protected. The A1 pulley was released, and the volar plate was recessed. An anchor was placed at the base of the metacarpal head, and the joint was brought to flexion and the anchor tied down to the volar plate. The skin was then closed with 4-0 nylon.
 
A bulky dressing was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.

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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.\\
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Tourniquet: arm - well padded tourniquet was inflated to 250 mmHg. \\
Drain: No\\
Sutures: 4-0 nylon\\
Dressing: bulky dressing\\
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. \\

Structures Dr. Iorio will ask you to identify: EPB/APL, Sensory branches of the superficial radial nerve, dorsal branch of radial artery.\\
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.\\
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.\\
Thumb spica splint.\\
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Marking: just dorsal to 1st dorsal compartment. Mark halfway on the 1st MC and extend proximally over the TMC joint.\\

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====DeQuervain’s Release====

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<WRAP half column>

Operative Report:\\
1. Right 1st dorsal compartment release\\
\\
The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
 \\
The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. \\
 \\
A longitudinal incision was made over the radial styloid. The cephalic vein and DRSBN were identified and protected. The retinaculum was incised on the dorsal rim, and full proximal and distal release of the APL and EPB was confirmed. The wound was closed in layers with monocryl\\
 \\
A bulky dressing was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.\\

</WRAP>

<WRAP half column>

Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Attending Pearls (Learning points/Pimp Questions):\\
OR tips:  Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 3-0/4-0 Monocryl, dermabond, 4x4, webrill 2” ace. \\

</WRAP>
</WRAP>




====Distal Radius Fracture - Volar ORIF ====

<WRAP group>
<WRAP half column>

Operating Report:\\
1. ORIF Distal Radius with volar locking plate

The patient was identified in the Holding Area and the operative site was marked. She was brought to the operating theater in stable condition and placed onto a regular OR table with her operative arm on an arm board. A preoperative time-out was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. Her splint was removed and a tourniquet was placed onto her arm which was then sterilely prepped and draped. An Esmarch bandage was used to exsanguinate the limb before elevation of the tourniquet to 250 mmHg.\\
 
We began the procedure by making a 10 cm incision longitudinally over his FCR tendon extending from his wrist crease and proximally. We dissected through subcutaneous tissue and identified the FCR tendon. We incised the tendon sheath, retracted the tendon ulnarly, and incised the subsheath. The distal aspect of the FPL origin was released with cautery and the FPL was retracted ulnarly to expose the pronator quadratus which was incised along its radial and distal borders and elevated subperiosteally. We identified the fracture site and cleaned the fracture of callus.  We then used fluoroscopic imaging in order to confirm the ability to reduce the fracture.\\ 
 
We then selected an Acumed Acu-Loc 2 volar radius plate. The plate position was provisionally stabilized using 0.054 K-wires and then secured to the proximal fragment using a 3.5 mm compression screw. We then reduced the fracture onto the plate and stabilized the distal fragment using additional 0.054 K-wires. The position of the plate and the fracture reduction were confirmed using fluoroscopic imaging. We then secured the epiphysis and articular fragments to the plate using 2.8 mm locking screws. We completed stabilization of the plate to the proximal fragment using 3.5 mm locking screws. The final position of the plate and fracture reduction were confirmed using fluoroscopic imaging and we were happy with both. Clinical examination showed no impingement of her wrist range of motion and good stability of the DRUJ. \\
 
A longitudinal incision over the volar palm was made. Skin, palmar fascia were sequentially divided. The transverse carpal ligament was divided proximally and distally. The incision was closed with 4-0 nylon.\\
 
The forearm incision was washed. The skin was closed in layers. A sterile dressing and volar splint were applied. General anesthesia was reversed. She tolerated the procedure well. There were no complications. Final instrument count was correct.  Sonja was taken out of the operating theater and to the PACU in stable condition.\\
 
</WRAP>

<WRAP half column>

Photos\\

Tourniquet: Upper Arm\\
Drain: none\\
Sutures: 4-0 nylon\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Attending Pearls (Learning points/Pimp Questions):\\
\\

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:\\
1. Make sure you will capture the distal fragments.\\
2. Make sure the plate is centered on the axis of the radius.\\
3. 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:\\
1. Make sure the genu of the plate is distal enough to capture the distal fragments\\
2. 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>




====Dorsal/Volar Wrist Ganglion Excision====

<WRAP group>
<WRAP half column>

Operative Report:\\
1. Excision of Left Dorsal Wrist Ganglion\\
\\
The patient was identified in the holding area and the operative site was marked.  She was brought to the operating theater in stable condition and placed onto regular OR table with hers arm on an arm board. A preoperative timeout was taken to ensure the patient's identity, operative procedure, as well as the operative location. Local anesthesia was achieved with 0.25% Marcaine mixed with 1% lidocaine with epinephrine. The hand was sterilely prepped and draped. \\
 \\
A transverse incision was made over the ganglion. We dissected through subcutaneous tissue and exposed the extensor retinaculum which was divided longitudinally over the ganglion.  The ganglion was identified and traced to the radiocarpal joint.  A portion of the dorsal wrist capsule was excised around the stalk and this specimen was sent for pathology.\\
 \\
The wound was irrigated and hemostasis was assured. Skin was closed with 4-0 Monocryl deep dermal sutures. A sterile dressing was applied. She tolerated the procedure well. There were no complications.She left the operating room in stable condition.

</WRAP>

<WRAP half column>

Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Learning points/Pimp Questions:\\
OR tips: Upper arm tourniquet w/ webril, tourniquet, 1000 drape. Close w/ 3-0/4-0 Monocryl, Dermabond, 4x4, webrill 2” ace. Send specimen for permanent. Sometimes will place short, short arm splint and have remove after 5 days. \\

</WRAP>
</WRAP>


====DIP Arthordesis====

<WRAP group>
<WRAP half column>

Operative Report:\\
1. DIP arthrodesis after failed mallet repair\\
\\
The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
 
The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. \\
 
A dorsal incision was made in the prior incision overlying the 5th DIP. The suture anchor was visualized and removed entirely.\\
 
The cartilage from the head of the middle phalanx and base of the distal phalanx was removed including subchondral cortical bone with a rongeur.\\
 
A provisional K wire was placed across the site and confirmed with fluoroscopy. The track was then tapped, and an accutwist compression screw was placed. The screw position was confirmed on fluoroscopy with good compression. The site was irrigated and closed with 4-0 nylon.\\
 
A bulky dressing was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.\\


</WRAP>

<WRAP half column>

Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Learning points/Pimp Questions:\\

</WRAP>
</WRAP>
====Axillary Hidradenitis Excision with Z-plasty====

<WRAP group>
<WRAP half column>

Operative Report:\\
1. Axillary hidradenitis excision with z-plasty
\\
The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
 
The area of left axillary hidradenitis was marked. It was then incised with a scalpel down to axillary fascia and subcutaneous tissue to ensure removal of the glandular tissue. The specimen was sent to pathology. The wound was irrigated, hemostasis was achieved, and it was provisionally stapled closed.\\
 
Given the scar tethering across the axillary dome, we marked out a z-plasty with 4cm limbs. These were then incised and similarly carried down to fascia. The flaps were transposed. The deep tissue was closed with 4-0 PDS and the skin was closed in layers.\\
 
A bulky dressing was applied. The patient was awoken from anesthesia and transported to recovery in stable condition.\\
</WRAP>

<WRAP half column>

Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Learning points/Pimp Questions:\\
ALWAYS does z-plasty\\ 
Will make you draw the z-plasty\\
Sometimes places "z" in the middle of incision\\
</WRAP>
</WRAP>

==== CPN Decompression at Knee ====
<WRAP group>
<WRAP half column>

Procedure:\\
1. Right DPN neurolysis and decompression
  
Operative Procedure: The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
\\
The leg was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg. \\
 \\
A curvilinear incision was made over the lateral right knee at the fibular head. Skin and subcutaneous tissue was divided.\\
 \\
The DPN was identified proximally, and traced distally to the fibular tunnel. The anterior fascia was released, and the DPN and individual motor branches were traced out. The posterior and innominate crural fascias were released, and the DPN was traced into the substance of the anterior compartment.\\
 \\
We ensured no proximal or distal residual compression. There was a slight hourglass effect of the nerve at the fibular head, but otherwise the nerve appeared to be intact without signs of hemorrhage or bruising.\\
\\
The site was irrigated. The skin was closed in layers with monocryl.\\
\\
A bulky dressing was applied. The tourniquet was released and the foot demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.\\

</WRAP>

<WRAP half column>


Tourniquet: Yes\\
Drain: No\\
Sutures: monocryl\\
Dressing: bulky dressing\\

[[https://www.youtube.com/watch?v=PFhcchWfdKY&t=652s|Mackinnon CPN Video]]\\

Makes a backcut incision laterally to extend incision proximally.\\
Make sure you are a finger breadth below the fibular head or you will be too proximal to the nerve.\\
Make sure you know borders of adductor canal.\\
There are 3 branches at the knee. Articular (which you cut), superficial and deep peroneal branches.\\

</WRAP>
</WRAP>


==== Distal Radius Vascularized Bone Graft for Scaphoid Nonunion ====
<WRAP group>
<WRAP half column>

Procedure:\\
1. Repair right scaphoid nonunion repair
2. Right wrist pedicled vascularized bone graft
3. Right PIN neurectomy
  
Operative Procedure: The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.\\
\\
The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg.  A dorsal incision was made ulnar to lister's tubercle. The EPL was transposed, and the 4th compartment was opened and retracted. The PIN was visualized proximally, ligated, crushed and transposed proximally.\\
 \\
The 4+5 extracapsular artery was identified and traced to the proximal radius, in a retrograde circuit. Osteotomes were utilized to harvest a bone graft approximately 11x8x10mm. This was kept in continuity with the 4+5 vascular pedicle and reflected distally.\\
 \\
The scaphoid was stabilized with a longitudinal k-wire, and the fracture site identified. A curette and rongeur was used to remove the intervening necrotic bone or fibrous tissue. The proximal and distal scaphoid was curetted back to punctate bleeding bone and the deep spaces were packed with autograft cancellous bone from the distal radius site.\\
 \\
Following this, the bone flap was contoured to press fit into the scaphoid defect, and this was stabilized and compressed with a headless compression screw. K-wires were removed and screw position and bone graft confirmed. The capsule was closed with PDS.\\
\\
The dorsal radius was then bone grafted with cancellous allograft and tamped into position. The extensor retinaculum was split and interposed between the radius and the 4th compartment and secured with PDS.\\
\\
The site was irrigated and the skin was closed in layers.  A thumb spica bulky dressing was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.\\

</WRAP>

<WRAP half column>

Tourniquet: Upper arm pneumatic tourniquet\\
Drain: No\\
Sutures: 3-0 monocryl deep dermals and 4-0 monocryl subcuticular\\
Dressing: bulky dressing with thumb spica splint\\

Post-operative Protocol:\\
Splint for 4-6 weeks followed by progression of AROM to PROM.\\

\\
Iorio Tips:
Uses retrograde 4+5 ECA\\
\\
Expose 4th compartment and ulnar-ward retraction of the tendons will reveal the posterior interosseous artery & communication with the 4th and 5th extracapsular arteries\\
\\
Bone graft centered 1 cm proximally to the radiocarpal joint & overlying the ECA is marked and raised with osteotomes\\
\\
Do NOT perforate the far or volar cortex\\
\\
As with the 1,2 IC SRA , the flap should be elevated with osteotomes, taking care to prevent foreshortening of the graft by using curved osteotomes, and a small trough osteotomy proximal to the graft may aide in harvesting appropriate depth\\
\\
Beyond the distal osteotomy, the pedicle should be elevated with sharp periosteal or Freer elevators\\
\\
The flap is reflected with a wide cuff capsular tissue around the retrograde ECA\\
\\
{{:resident:iorio_1.jpg?400|}}
{{:resident:iorio_2.jpg?400|}}

</WRAP>
</WRAP>



==== Ulnar Shaft ORIF ====
<WRAP group>
<WRAP half column>

Operative Report:\\
1. Left ulnar shaft ORIF\\
2. Repair left forearm laceration, 15 cm\\
\\

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.
 
Consent was obtained by discussion with the patient in regards to the risks and benefits, including possible injury to nerve, vessel, tendon, the need for secondary or revision procedures and occupational therapy. The patient had adequate time for discussion, and all questions were answered prior to completing the consent.
 
Operative Procedure: The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.

The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg.　　The laceration was covered with ioban.
 
An incision was made on the ulnar side of the forearm over the fracture. The plane between the FCU and ECU was developed. The ulnar nerve was visualized and appeared contused with some hemorrhage, but was intact without apparent discontinuity.
 
The fracture was visualized and confirmed with fluoroscopy. The fracture was comprised of approximately 5 large fragments that precluded direct reduction due to the obliquity of the fractures. As such, the central fragments were reduced and 2 lag screws placed with good compression.
 
A volar forearm plate was selected and bent to shape. This was secured proximally and distally with locking screws, however due to the distal nature the plate could not be advanced beyond the ulnar neck without DRUJ impingement, and as such the lag screws remained and the plate was left to bridge the intercalary fragments. Bone allograft was packed into the fracture recess.
 
The periosteum and ECU/ FCU was closed with monocryl. The wound was closed in layers and dermabond applied.
 
The ioban was removed. The radial laceration was irrigated and the nonviable tissue including the edge of nonviable skin was sharply excised, down to and including fascia. No apparent tendon, nerve or artery laceration was present. The wound was then closed with horizontal mattress nylon sutures.
 
A bulky dressing was applied. The tourniquet was released and the hand demonstrated good distal perfusion. The patient was awoken from anesthesia and transported to recovery in stable condition.

</WRAP>

<WRAP half column>

Tourniquet: Arm\\
Drain: None\\
Sutures: 4-0 Nylon horizontal mattress\\
Dressing: Sugar-tong in supination\\

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|}}
{{:resident:screen_shot_2021-03-13_at_8.13.37_pm.png?400|}}
\\

Post-operative care: Sugar-tong in supination until follow-up in clinic in 1 week. Make sure splint is well padded!\\

Attending Pearls (Learning points/Pimp Questions):The deep dissection should be carried out in the interval between the flexor carpi ulnaris and the extensor carpi ulnaris muscles. Know anatomy for approach to ulna, as in photos above.\\

</WRAP>
</WRAP>



==== 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.\\