Plastics

Operative Report   Pre-Op Diagnosis:

• Cubital tunnel syndrome on left [G56.22]
• Carpal tunnel syndrome of left wrist [G56.02]
• Arthritis of scaphoid-trapezium-trapezoid joint of left hand [M19.032]

  Post-Op Diagnosis: Same   Surgeon: Dr. Meryl S Livermore, MD   Assistants: Jonathan Freedman, MD - Resident   Anesthesia: General   EBL: minimal   Procedure: 1. Left Carpal Tunnel Release 2. Left Cubital Tunnel Release with subcutaneous subluxation 3. Steroid injection of left scaphoid-trapezium-trapezoid (STT)   Indications for Procedure: Mr. Timothy Paul Miller is a 55 y.o. man with EMG proven bilateral carpal tunnel and cubital tunnel syndrome as well as STT arthritis on the left. He has failed conservative therapy and wishes to proceed for operative release on the left. He was counseled that surgical intervention for his STT arthritis would require smoking cessation and at this time he has elected to try a steroid injection.   We discussed the nature and pathophysiology of the diagnosis. We discussed treatment options and expectations in regards to potential outcomes, including the need for secondary procedures or revisions.   Consent was obtained by discussion with the patient in regards to the risks and benefits, including possible injury to the 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 to the patient's satisfaction prior to completing the consent.   Complications: None   Operative Findings: STT joint identified by fluoroscopy, thickened carpal tunnel, subluxation of ulnar nerve   Operative Procedure: The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started.   Prior to prepping, the STT joint was identified with fluoroscopy. The site was cleansed with an alcohol swab and 1 cc of kenalog was injected into the joint.   The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.   The arm was exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg.   A 2 cm skin incision was made over the carpal tunnel.  This was carried sharply down to the palmar fascia.  The palmar fascia was then dissected bluntly to expose the transverse carpal ligament.  This was incised sharply under direct vision to expose the median nerve.  Distally the transverse carpal tunnel ligament was skeletonized and divided under direct vision until complete release and distal palmar fat was seen. Proximally the transverse carpal tunnel was skeletonized and divided continuing for two centimeters into the antebrachial fascia. At this point complete release of the ligament both proximal and distal was visualized. The wound was then irrigated and hemostasis ensured. The skin was closed with 4-0 nylon in an interrupted mattress fashion.   We turned our attention to the cubital tunnel.  A marking was made in between the medial epicondyle and the olecranon over the cubital tunnel.  The incision was made with a scalpel and was approximately 5 cm in length. Care was taken to protect the superficial nerves and veins and dissection was performed down to the fascia overlying the ulnar nerve. The nerve was identified proximal to osborne's ligament as the overlying fascia was thinnest at this point.  The Osborne's fascia was then divided sharply, taking care to protect the nerve underneath. The nerve was followed proximally and dissection continued releasing the arcade of Struthers and any involvement of the intermuscular septum. Next, the nerve was followed distally and the superficial fascia overlying the two heads of the flexor carpi ulnaris (FCU) was excised. The two heads were divided to reveal the deep fascia overlying the ulnar nerve and this fascia was divided.   The elbow was ranged and it was found to subluxate over the medial epicondyle. At this point, we decided to transpose the nerve. A wedge of intermuscular septum was excised to prevent a point of kinking of the transposed nerve. The posterior attachements of the nerve were released taking care not to disrupt small cutaneous branches and the branches to FCU. Once free, a subcutaneous tunnel was made by suturing the fascia adhered to the subcutaneous tissue and the fascia of the arm musculature superior to the medial epicondyle with a 3-0 vicryl.   Hemostasis was ensured using the bipolar electrocautery and the skin was 3-0 vicryl deep dermal sutures and a running 4-0 Monocryl subcuticular layer.   Exofin glue, xerforom, 4 x 8s, webril and a bias were placed for dressing.  The tourniquet was released and normal perfusion returned to the hand.   The patient was awoken and transferred to the recovery room in stable condition.  There were no apparent complications.   All counts were correct. Dr Livermore was present for the entirety of the case.      Post-Operative Plan: PACU discharge, Soft Dressing

Setup:
Check bed to make sure it sits up correctly. Many beds at DH are chair beds and are funny.
Anesthesia performs pre-operative pectoralis blocks.
Arms out at 90 degrees. Wrap arms in blanket and take. Place take over upper arm (avoid elbow) and over hand to help point thumb upwards.

Resident Notes:
Fellows mark the patient. Residents tend to watch. She marks IMF, meridian, breast footprint, pitanguy's point.
Starts with lower incision.

Discharge instructions:
No lifting greater than 10 lbs
No lifting your arms over your head (ie 90 degrees limit).
Okay to shower for 48 hours
Wear surgical vest at all times except showering until your follow up appointment.
No submerging in water (pool, hot tub, etc.) for 4 weeks
No underwire bras for 6 weeks
Keep scar covered from sunlight for 1 month