Plastics

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.
 
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.
 
Following this, the humeral defect was visualized and a template of the bony defect was made with bone wax.
 
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 The skin was incised, and the vastus medialis was retracted anteriorly exposing the condyle.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.
 
Following this, the DGA vascular pedicle was traced proximally from the condyle and circumferentially freed and side branches ligated.
 
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.
 
Following this, the flap was elevated from the condyle, and reflected proximally on the vascular pedicle. Curettes were used to harvest cancellous bone graft.
 
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.
 
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.
 
The site was irrigated and the brachialis was repaired. The skin was closed in layers with 3-0 pds and monocryl over a drain.
 
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.
 
A bulky dressing was applied. The patient was awoken from anesthesia and transported to recovery in stable condition.

Text in Column 2

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):

Operative Report:
1. ORIF right 4th metacarpal base fracture
2. ORIF right 5th metacarpal CMC fracture dislocation

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.
 
Following this, we attempted to reduce the fracture closed but were unsuccessful after several attempts.
 
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.
 
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.
 
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.
 
The joint capsule was closed with 4-0 pds, and the skin was closed with 4-0 nylon. Wires were clipped deep to skin.
 
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.

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):

Operative Report:
1. Exact name of Operative Procedure:

Only the operative report should go in this section in the left column.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Close: Deep dermal, running subQ.
Dressing: adaptic, 4×4, webroll, ace. Off on POD#5.

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Attending Pearls (Learning points/Pimp Questions):
What are the areas of ulnar nerve compression? Remember guyon's as well.
What vessel runs with ulnar nerve in elbow? ??Superior ulnar collateral

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
OR tips: OR tips: Block w/ sedation. Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 3-0/4-0 Monocryl, Dermabond, 4×4, Thumb spica plaster splint, webrill, 2” ace.

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.

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