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 The skin was incised, and the vastus medialis was retracted anteriorly exposing the condyle.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. Decompression of ulnar nerve at the elbow with subcutaneous transposition:

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.
 
The arm was exsanguinated with an esmarch bandage, and the well padded tourniquet was inflated to 250 mmHg.
 
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.
 
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.

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: She will go home from the hospital today. Arrangements were made to follow up with me in clinic in 2 weeks for a wound check. she is to keep the hand elevated and remove the dressing in 48 hours and begin gentle range of motion as tolerated. If she has problems before followup, she has been told to contact me and I would be happy to see her sooner.

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

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

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 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.
 
The 4th A1 pulley was thickened and corresponded to her complaint of pain and locking, and the pulley was released directly with tenotomies.
 
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.
 
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.

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

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.

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. The A1 pulley is posterior to thenar area in this position. Incision should NOT be over thenar prominence. If so, you are too far radial/anterior. Know what muscles attach to A1 and oblique pulley. Know innervation of thenar musculature

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.

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.

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, 4×4, webrill 2” ace.

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.

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):
OR tips: Block w/ sedation; Upper arm tourniquet w/ webrill, tourniquet, 1000 drape. Close w/ 4-0 Nylon, xeroform/adaptiq, 4×4, webrill, Short arm splint, 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