Plastics

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.

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

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

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, 4×4, webrill 2” ace.

Post-Surgery Time

Immediate Post Op Orders

Goals:

• Remove dressing at POD 5
• May move fingers, wrist, and elbow as tolerated
• OFF work x 2-3 days post-op

Work Restrictions

• Limited use of operative extremity to tolerance
• 0-2/3 days: OFF work
• 0-3 weeks: May use arm as tolerated; 5lb weight restriction
• 3-4 weeks: 10-15lbs as tolerated
• >5 weeks: no restrictions

10-14 Days Post-surgery

• Schedule 1st post op visit with Physician Extender
• Wound Check
• Suture Removal
• Review HEP for strengthening
• OT Order (PRN)

OT (if ordered beyond PE duties on 1st post op visit)

• Scar massage, desensitization, strengthening

8 Weeks

• F/U PRN: If patient has concerns or ongoing symptoms, 2nd follow up visit scheduled with MD/PA

DeQuervain’s Release

OR tips: Local w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 3-0/4-0 Monocryl, dermabond, 4×4, webrill 2” ace.

Post-Surgery Time

Immediate Post Op Orders

Goals:

• Remove dressing at POD 5
• Elevate wrist x 3 days
• May move fingers as splint allows
• OFF work x 2 days post op
• Follow up 10-14 days post op
• POST OP PROTOCOL ORDERS

Work Restrictions

• 2-3 days post op: OFF work
• 0-2 weeks: OK light use for typing and paperwork
• 0-2 weeks: 5 pound lifting limit, no pushing or pulling
• 2-4 wk.: no restriction

10-14 Days Post-surgery

• Schedule 1st post op visit with Physician Extender
• Wound Check
• Suture Removal
• OT Order (PRN)

OT (if ordered beyond PE duties on 1st post op visit)

• ROM, Scar massage, desensitization

6-8 weeks

• FU PRN: If patient has concerns or ongoing symptoms, 2nd follow up visit scheduled with MD/PA

Distal Radius Fracture s/p ORIF

Operating Report

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.

POSTOPERATIVE PLAN: Sonja will go home from the hospital today with arrangements made to follow up with me in clinic in two weeks. She will be transitioned into a short arm removal splint volar which will be worn continuously for an additional four weeks with protected range of motion of her wrist initiated by Hand Therapy. She has been told to strictly elevate her hand at all times as well as move her fingers to prevent stiffness. If she has any difficulty or concerns between now and followup, she has been told to contact me, and I would be happy to see her sooner.

Tourniquet: arm - elevation of the tourniquet to 250 mmHg
Drain: No
Sutures: 4-0 nylon
Dressing: sterile dressing

A1 Pulley Release

He was identified in the Holding Area, and the operative site was marked. He was brought into the operative theater in stable condition, with his arm on an arm board. Preoperative time-out was taken to ensure the patient's identity, operative procedure, as well as operative location.

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 over the volar A1 pulley was made. 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. Sterile dressing was applied. The tourniquet was released. Craig tolerated procedure well. There were no complications. Final instrument count was correct. He left the operating theatre in stable condition.

Tourniquet: arm - well padded tourniquet was inflated to 250 mmHg.
Drain: No
Sutures: 4-0 nylon horizontal mattress sutures
Dressing: sterile dressing

DIP Arthordesis

61 y.o. Female presents with a failed mallet repair and painful DIP joint. We will take her to the OR today for a DIP arthrodesis.

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.

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.

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

Axillary Hidradenitis Excision with Z-plasty

24 y.o. Female presents with a left axillary hidradenitis and scar tethering.

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 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.

Tourniquet: No
Drain: No
Sutures: 4-0 PDS
Dressing: bulky dresing

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.

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.

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