Plastics

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. 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.   The laceration was extended with two oblique incisions in order to gain more proximal access to the ulnar nerve and more distal access to the flexor tendons as they were entering the carpal tunnel. The wound was explored and the flexor tendons to the index finger was intact as well as the median nerve. The more ulnar sided structures had obvious injuries. Flexor carpi radialis has a 5% partial laceration. Flexor digitorum superficialis (FDS) of the long finger was lacerated, but the flexor digitorum profundus (FDP) was intact. The ring and small fingers had both FDS and FDP lacerated. The ulnar nerve was lacerated distal to takeoff of the dorsal sensory branch. Flexor carpi ulnaris was lacerated. The wrist and fingers were flexed in order to provide a tensionless repair of the tendons, nerves and artery.   The injuries were repaired from the radial to ulnar. The proximal muscle belly and tendon of FDS of the long finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the ring finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDP of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair. Next, the proximal muscle belly and tendon of FDS of the small finger was dissected bluntly and matched to the distal tendon. This was repaired with a 3-0 supramid using a modified kessler 4 strand repair.   The microscope was brought into the room and the distal and proximal ulnar neurovascular bundles were identified and the artery and nerve ends were bluntly dissected. The distal and proximal ends of the ulnar artery were clamed and the repaired with 9-0 nylon sutures in a 0-180 fashion repair. At this point, 2 hours had past and the tourniquet was released. The clamps were removed and there was pulsatile flow through the artery. Next, we turned our attention to the ulnar nerve. The nerve was lacerated distal to the branching of the dorsal sensory branch. Both the ulnar nerve and dorsal sensory branch were identified and bluntly dissected under the microscope. The ulnar nerve was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap. Next, the dorsal sensory branch was repaired with 9-0 nylon epineural sutures taking care to line up the fascicles followed by a 0.5cm diameter nerve wrap.   Finally, the microscope was removed and flexor carpi ulnaris proximal and distal tendons were identified and the ends bluntly dissected free. Flexor carpi ulnaris was repaired with a 3-0 supramid using a modified kessler 4 strand repair followed by a figure of 8 repair with a 4-0 fiberwire. The incision was closed with 4-0 nylon simple interrupted sutures. Xeroform, 8×8 were applied followed by a dorsal extension blocking splint with the wrist and the fingers in flexion.

Note about wrist flexors. Since the cross the elbow, the elbow should be immobilized as well in 90 degrees when you make the splint.
FDS flexors go through the carpal tunnel like spiderman.

PREOPERATIVE DIAGNOSIS: @ORLAT@ thumb CMC arthritis

POSTOPERATIVE DIAGNOSIS: same, * and trapezoid-scaphoid arthritis PROCEDURE PERFORMED: 1. Trapeziectomy with ligament reconstruction and tendon interposition * 2. Partial trapezoid excision

Surgeon: @ORSURROLE@

Assistants: @ME@

Anesthesia: @ORANEST@

EBL: minimal

Indications for Procedure: This is a @AGE@ @SEX@ who presented to clinic with @ORLAT@ hand pain. @HE@ had @ORLAT@ thumb carpometacarpal arthritis. @HE@ was wearing a splint for @HIS@ thumb pain, which exacerbated the pain and did not really help. Conversation was then had with the patient regarding @HIS@ options for treatment and clinically came to agreement stating that a trapeziectomy with ligament reconstruction and tendon interposition would be the best course of action.

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: Arthritic trapezium, suspension arthroplasty with ligament reconstruction and tendon interposition of flexor carpi radialis (FCR), * arthritic trapezoid-scaphoid joint 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. 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 Wagner longitudinal incision at the junction of the glabrous skin was made over the carpometacarpal joint, curving at the proximal wrist and stopping at the crossing of the flexor carpi radialis tendon. The incision was completed down to the subcutaneous tissue. The dorsal radial sensory nerve and its branches were identified and protected. The extensor pollicis brevis tendon and abductor pollicis longus tendon were identified and retracted radially. The joint space between the first metacarpal and the trapezium was identified using the c-arm and a subperiosteal longitudinal capsulotomy was made over the joint. Full-thickness flaps were raised using mixture of blunt and sharp dissection with scissors. The capsular incision extended for visualization of the base of the first metacarpal and full trapezium and part of the scapho-trapezial-trapezoid joint. Position was confirmed using a mini C-arm. Care was taken to preserve the capsule to facilitate later reattachment. The trapezium was then dissected circumferentially. A K-wire pin was then driven into the trapezium to use as a joystick handle to further help with retraction and movement to further facilitate fully dissecting free the trapezium. The FCR tendon at the base of the CMC joint was identified and care was taken to avoid injury to the tendon. The trapezium was removed piecemeal using the rongeur with careful attention not to injure the FCR tendon lying in the volar groove of the bone. * The trapezoid was evaluated and appeared denuded of cartilage. An osteotomy was made to remove the articulating surface with scaphoid.

The flexor carpi radialis position was marked about 10 cm from the proximal wrist crease. A 2 cm transverse incision was made and using the scissors with blunt dissection through the subcutaneous tissues, the FCR tendon was visualized. Using a freer, dissection was carried over the FCR tendon superficially and deep to it, freeing it up as much as possible from the forearm incision as well as from the Wagner incision moving proximally along the FCR. The musculotendinous junction was identified, and the tendon was lifted into the incision using a right-angle clamp. The FCR was then transected. Then at the base of the FCR tendon, the FCR was pulled distally into the trapezial bed. The proximal forearm incision was closed with a 4-0 nylon suture.

Using a burr drill bit, the volar aspect of the base of the thumb metacarpal was burred down to cortical bone. Then a position onto the more dorsal aspect of the thumb base, the position for the Mitek anchor suture was chosen and predrilled. Then * two #2-0 mini-Mitek anchor were placed into the thumb metacarpal base. The FCR tendon was then pulled into its new anatomic position, and the suture of the Mitek anchor was then passed through the FCR tendon and tied. The remaining FCR tendon was then rolled up into an anchovy using 3-0 vicryl sutures. The capsule edges were re-approximated with 3-0 vicryl sutures. The tourniquet was deflated and hemostasis was obtained and the incision irrigated. The incision was closed with 4-0 nylon simple and horizontal mattress sutures. The incision was dressed with xeroform, 4×8 gauze and a thumb spica splint was applied. Dr. Malliaris was present for the entirety of the case. The patient tolerated the procedure well and was subsequently extubated and brought to the PACU in stable condition. Post-Operative Plan: The patient extubated and stable to PACU. Discharge home with thumb spica. Follow up in clinic as outpatient. ==== Distal Radius ORIF ==== Operative Procedure: The patient was taken to the the operating room and secured and following patient and procedure confirmation, anesthesia was started. 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 elevated and exsanguinated with an esmarch bandage and the tourniquet was inflated to 250 mmHg. An 8 cm incision was made over the flexor carpi radialis flexor tendon. The incision was continued down to the FCR sheath and the bipolar was used to achieve hemostasis of small vessels. The FCR sheath was incised and the FCR tendon retracted. The radial artery was identified and retracted radially. The antebrachial fascia was incised. Next, the pronator quadratus fascia was sharply incised in an “L” shape and elevated from radial to ulnar. The fracture line was identified and the periosteum elevated.   The fracture was freed with the dental pick and the freer elevator. The fracture still had some mobility.  Once all the fragments were free, the mini fluoroscopy was brought in and the fracture reduced with traction and dorsal pressure; we confirmed the reduction with multiple views. The regular * Acumed volar distal radius plate was chosen as the best size match. The plate was secured with *proximal (?distal) k-wires and fluoroscopy was used to confirm placement; the * distal radial screw was placed using a locking screw.   We then turned our attention to the shaft and placed the oblong screw, keeping this a bit loose, and removed the K wires. The radial styloid fragment was then reduced further, and another K wire was used to hold the ulnar two fragments. We then placed the ulnar distal locking screw followed by the remaining distal row, and then the distal most radial styloid screw.   We reduced the fragments to achieve more volar tilt and tightened the shaft screw, and then placed two more shaft screws.  Final fluoroscopy images were taken confirming reduction and plate placement.   The pronator quadratus fascia was closed with 4-0 vicryl, achieving almost complete plate coverage.  The skin was closed with 4-0 nylon locking horizontal mattress sutures. Xeroform was placed over the incision and a volar resting splint was placed with the MCP joints free.

  The incision was irrigated and then closed with 4-0 nylon locking horizontal mattress sutures. The incision was dressed with xeroform and a soft dressing of 4×4 gauze, webril and a volar resting splint. The tourniquet was released and normal perfusion returned to the hand.

Dr. Malliaris was present for the entirety of the case. All counts were correct. There were no complications. The patient was brought to the PACU and discharged without incident.

Operative Pearls Anatomy

Technical Steps Will do Lalonde approach in clinic. Only change is to include epi in the local instead of a tourniquet.
1. Inject local
2. Prep and place tourniquet sterilly on forarm if in OR.
3. Rolled blue towels under wrist.
4. Mark approximately 2 cm incision and incise with 15 blade.
5. Go through subcuatneous tissue with 15 blade.
6. Dissect with Ragnell scissors. She will retract with 2 Ragnells and a sharp Sen.
7. Once TCL exposed, sharply incise with beaver blade or 15 blade.
8. Go distally until you reach the distal fat.
9. Incise proximally with beaver blade or 15 blade and then spread above and below with ragnell scissors (not to wide as you only need a tunnel for your scissors). This is so you can ensure the next step is done under direct vision.
10. Slide ragnell scissors proximally. This is a translation of the scissor. The scissor tips are curved and the tip goes straight proximally while your hand is off to the side and you translate it forward.
11. Ensure complete release with the freer.
12. Close with 4-0 nylon. She prefers locked horizontal mattress sutures.

Postoperative Care Soft dressing
APAP/Ibuprofen
No Narcotics

The patient was marked in the pre-operative area and the patient was brought back to the operative suite, placed in supine position.  All bony prominences were padded.  SCD boots were placed. Perioperative antibiotics were given.  A proper timeout was taken, which all present parties were in agreement.  The preoperative markings were reinforced and remarked.   The surgery started with removing each nipple/areola complex, a 25 mm diameter cookie cutter was used to mark the new areola. It was then elevated as a full thickness skin graft. Both the right and left NACs were placed in saline moistened gauze in small containers and saved for use later in the case.  Hemostasis was achieved at these sites. An incision was made along the superior markings of the breasts. Using electrocautery a flap was then raised in the subcutaneous plane superficial to the breast parenchyma leaving adequate subcutaneous fat to perfuse the skin flaps. Next, the breasts were undermined to the inframammary folds. A demarcator was used to mark the inferior incision. The inferior incision was made sharply and using electrocautery, the subcutaneous tissues were dissected down to the pectoralis fascia and the breast was removed.   Then each side was copiously irrigated with warm saline and complete hemostasis was achieved using electrocautery Bovie.  A 15 french round Blake drain was placed in each wound bed and exited out in the inferior outer portion of the chest wall, they were secured with a 3-0 nylon. The incision was then temporarily closed with skin staples which demonstrated that there was a tensionless closure. The patient was sat up on the flexed bed to confirm symmetry and to choose the appropriate placement for the nipple graft. Using the 25 mm cookie cutter, the new positions of the nipples were marked along the lateral edge of the pectoralis muscle and at the level of the 4th intercostal space.  The circle were created into horizontal ellipses measuring 2.5cm x 1 cm and were then deepithelialized with a 15 blade on each side.  The nipple areolar complex grafts were defatted with the iris scissor and using an 11 blade they were pie crusted. They were then placed onto the bleeding dermal beds. They were inset using 5-0 chromic sutures circumferentially.   The deep tissue was approximated with 3-0 PDS suture. Deep dermals were placed with 3-0 monocryl stures. Lastly the subcutaneous tissue was closed using a running 3-0 V-Loc.      Bolsters were formed from xeroform, mineral oil soaked cotton, and sutured into place with 3-0 Silk, and placed over each nipple graft.   Exofin glue was placed on the inferior incision. A Biopatch was placed at each drain site. Telfa and tegaderm were used to cover the bolster. A compression garment was placed on the patient's chest.   All counts were correct. Dr. Malliaris was present for the entirety of the case.  The patient had pectoralis nerve block performed by anesthesia. The patient was then subsequently extubated and brought to the PACU in stable condition and was discharged home with outpatient followup.   Post-Operative Plan:  PACU discharge Compression vest Okay to remove outer dressings in 2 days and shower Keep bolster in place