Sunday, June 25, 2006

Upper Extremity Procedures

Acromioplasty/5Mumford

ICD Impingement 726.2, AC Jt DJD 715.11
CPT Acromioplasty 23415, Mumford 23120
Sclein positioner, Intrascalene block
-Incision (for Mumford only) Just lateral to coracoid to just medial to AC jt to posterior border of clavicle (~6 cm) within Langer's lines
-Inc (for Acromio) just lat to coracoid to anterolat tip of acrmio
-Inc (combo) split the difference

-Infiltrate skin with epineph
-Gelpi retractor
-Dissect deltopectoral fascia transversely from distal clavicle
-Find bloodless plain to split the deltoid off the acromion edge.
-Stay stitch at 5 cm inf and tag sutures to fascia edges.
-Dissect circumferentially around distal 1-2 cm of clavicle. Sagittal saw. Bone wax.
-Saw to ant acromion in line with front of clavicle.
-Pineapple burr for acromioplasty, protect with cobb.
-Mets to bursa, Inspect for rotator cuff tear.
-Burr and OTL anchor sutures to trough for RCR.
(-Restore from DePuy for chronic tear. Repair first. Put Restore over repair. Baseball stitch and then tack down to bone.)


Biceps Tendon Repair

Indic: active, <3 weeks
Pos: Supine, arm table, sterile tourniquet
Inc: start on radial volar FA, just distal to elbow crease. oblique inc centered over radial tuberosity, thru subQ tissue. Use retractor to look proximally for biceps stump. If necessary, cross crease @ 60 degree angle to extend incision.
Tendon Preparation: Thin stump to fit into drill hole. Criss-cross one #5 and one #2 ethibond Bunnell sutures.
Use curved clamp to find previous tunnel to palpate radial tuberosity. Supinate for best view. Use wide reverse retractor to expose tuberosity.
High speed pineapple burr on long handle to excavate tuberosity. Do NOT penetrate dorsal cortex.
Thread ethibonds thru long Keith type needles from the ACL set. Tap thru dorsal cortex, 1 cm apart if possible. Should exit skin on dorsal FA, thru the extensor tendons. Second inc is centered over these needles. Pull thru and tie down to bone.
2-0 polysorb, 4-0 maxon
Posterior splint, Indocin 25 TID 10 days.
Postop check @ 10 days, Elbow brace with 30 degree extension stop x 6 weeks
May remove splint @ 9wks
Gentle Strengthening at 12 weeks
Full activity @ 6 months


Carpal Tunnel Release

Expected convalescence: 3 weeks
Work restrictions prior:wear wrist corset
WR post-op: no heavy lifting > 15 pounds
Full benefit time: 3-4 weeks.


Cubital Tunnel Release

ICD-9 354.2 CPT 64718

Supine on arm board, tourniquet
Folded towels under bent elbow
Inc- longitudinal 6-8 cm
Terminal branches of medial cutaneous nerve of the arm and crossing branches of the FA should be preserved just deep to the fat superficial to the fascia overlying the FCU
Release the aponeurotic origin of the FCU along with the cubital tunnel retinaculum.

IF symptoms are caused by a dislocating nerve, then transpose:
Inc centered on the medial epicondyle and 15 cm in length.
Protect the medial cutaneous nerves of the arm and FA proximally.
Release the Arcade of Struthers 8 cm prox to the epicondyle. This appears where the muscle fibers of the medial head of the triceps crosses superficial to the ulnar nerve.
Distally, protect the motor branches to the FCU and FDP while releasing the common aponeurosis.
Transpose straight anteriorly above the epicondye.
Sew the fascia of the skin flap to the antebrachial fascia just lateral to the epicondyle.

Fiberglass posterior splint. After 1 week, allow flexion and gradually increase elbow extension over next 2 weeks. D/C splint at 3 weeks and allow back to work. (6-8 weeks after transposition).

DeQuervain's Release

ICD-9 727.04, CPT 25000
pg 1990 Green's
Bier block or local
Request: tourniquet, hand table, sens, freer, 3-0, 4-0 maxon, bipolar, marcaine, irrigation
Incision: 0.5cm proximal to radial styloid. 2 cm transverse
Identify the 3 radial sensory branches that cross obliquely.
Expose the annular ligament, incise longitudinally with a knife.
Free the EPBr, and 2 slips of APL. Excise the thickened septa between the tunnels.
If the synovial tissue is thick and opaque, tenosynovectomy is performed.
Check decompression from MT junction to 1 cm distal to tunnel.


Distal Clavicle Fractures

Type 2, displaced, mediial to CA ligs
Request list: Mayfield headrest, my instruments, reduction clamps, bennett retractors, 18 gauge wires, osteotomes, wire cutter, heavy duty needle holders.

-Beach chair position with the Mayfield Head rest. Sit at 60-70 degrees from horizontal.
-Incision is Vertical! btwn the AC joint and the fracture. Start at the posterior margin of the clavicle, extend to superior lateral tip of the coracoid process.
-Mobilize skin above deltoid fascia.
-Deltotrapezial aponeurosis is incised transversely of the superior aspect of the clavicle from a point just lateral to the AC joint to a point 2-3 cm medial to the fracture.
-Expose fracture ends with knife and elevator. Expose circumfrentially.
-Mobilize and reduce anatomically.
-Use small osteotome to notch clavicle ant-sup, post-sup, ant-inf.
-Space notch 1cm apart
-Tighten wires, snip, retighten, bend twist under clavicle.
-Close fascia with #0 or 1 nonabsorbable suture to imbricate

-If type 2B vertical fracture, can't wire. Then use a 0.062 K-wire percutaneously fromlateral aspect of the acromion across the acromion, AC joint, the distal fragment of the clavicle, and into the proximal fragment.
-Cut wire 2.5 cm outside of the skin and bend back
-Dress the pin with a folded 4X4 gauze is wrapped around the pin, and another on top.

POSTop
-Sling and swathe for 6 continous weeks! (remove pin if used at 6 weeks.
-XR at 6 wks, start passive and active ROM by patient, PT at week 7. Avoid strenous or forceful efforts until strengthening exercises are started at 12 weeks.
-Once satisfactory fx healing radiographically, resistive exercises for the detoid and RC may be added.



Endoscopic Carpal Tunnel Release

ICD-9-- 354 CPT 29848
Pos: supine w/ armboard, tourn
Anesth: .25% Marcaine with epi in proximal wrist crease from palmaris longus -> ulnarly. Also some prox and distally. Usual prep.
Inc: prox wrist crease
Incise superficial fascia. Spread and incise proximally in usual fashion.
Narrow skin hooks.
Put thumb at distal end of transverse carpal ligament for rest of procedure.
Aim along 4th ray with other hand and stop at start of 1st web space level with scraper. Follow with small hamate finder/obturator, make sure it stops you ulnarly.
Then follow with standard size.
Follow with scope with numbers pointed up for right hand, down for left.
Incise distal most portion of Transverse Carpal ligament and then look again to insure complete cut. (Once you work more proximally, you lose your view.)
Check for separate limb movement of TCL.
Irrigate. 4-0 Maxon, Adaptic, 4 x4, 2 inch Kling.

Expected convalescence: 2
Work restrictions prior: wear wrist corset
WR post-op: No use of operated hand * 72 hours, then light assisted only or light duty work for four weeks
Full benefit time:2 months


Humeral IM Rod

Synthes Titanium Flexible Nail
Position-- supine, vascular table with free end up, scapular bump, fluoro from opposite side of table, arm board on backward so can rotate out of way
Danger--Axillary N 5 cm below acromion tip, Radial and MCN's distally
1. Incision-Lateral longitudinal incision thru the deltoid fibers just distal to the rotator cuff.
2. Place the tip of the medium awl centered in the greater tuberosity, 1 cm distal to cuff.
3. Check on fluoro, open the medullary canal
4. Insert the nail trial to confrim the size and shape of the entry hole.
5. Insert the 2.5mm Calibrated reaming rod
6. If neccessary, insert the 10.5mm flexible drill bit over the rod to enlarge the entry site to just below the surgical neck. Check with nail trial.
7. Reduce the fracture. Use the calibrated reaming rod and/or ruler to obtain the length of the nail. Use one size smaller than measured, the 15mm extention will comprise the rest.
8. To obtain the diameter of the nail, use the template or ruler with the humerus in the lateral view.
9. REAM to 1/2 size larger than nail. 7.5mm is the standard nail.
10. To assemble the nail, cut the peripheral wires flush with the 15mm extension piece using the percutaneous wire cutter.
11. Slide the connecting sleeve thru the insertion handle, tighten the screw. Attach the insertion cap and slide hammer to hammer.
12. Remove the gudie wire. Insert the nail into the canal. Use slap hammer prn
13. Seat the nail and confirm position by placing a 3.2mm drill bit thru the top hole in the arm.
13. Remove the insertion cap.
14. Stab hole thru stiff hole, Tension screw measuring gauge to pick purple screw length.
15. Insert trochar and protection sleeve
16. Remove trochar, replace with drill sleeve with bell. Drill to stop.
17. Insert 4.0 purple tension screw.
18. Extend incision form locking screw.
19. Drill with blue sleeve and 3.2mm calibrated drill bit. Can take measurement off this or with depth gauge.
20. Place 3.9mm bllue locking bolt.
21. Confirm fracture reduction.
22. Use perfect circle technique to lock distally from ant to posterior.
23. Place 15mm end cap. If too prominent, take off extention and place 0mm end cap.
24. Sling, start biceps contractions at one week.


Lateral Epicondylitis

-Supine, Bean bag, ipsilateral hip bump to work over-body.
-Long inc from 2-3 cm prox and anteromedial to the lat epic down to level of jt (~1cm distal to lat epic).
-Incise SQ fat & superficial fascia
-Look/feel interface btwn thin fascia over ECRL and firm, thick ant. edge of extensor aponeurosis
-Spliting inc 2-3mm deep btwn ECRL and aponeurosis
-ECRL released by scapel dissection and retracted anteromedially 2-3 cm
-ECRB lies underneath
-Pathology in ECRB and EDC, ant edge
-Excise path tissue
-May need to peel apon. of LE to ronguer any exostosis
-Brevis doesn't retract b/c connected to obicularis, distal apon, underside of ECRL
-Drill LE with 5/64th" drill for vascularity
-Simple running #1 Vicryl to close ECRL to aponeurosis
*Avoid the RCL

Expected convalescence: 2-7 days
Work restrictions prior: no repetitive lifting. No lifting > 10 pounds
WR post-op:one-handed work only
Full benefit time:2 months


Medial Epicondyle Avulsion

Request: Pronies, big C-arm at beginning, K-wire driver, 4.5 cannulated screw system.
Position -- Prone with affected arm down by side on C-arm as table
Incision -- Straight horizontal across epicondyle position
Watch for Ulnar Nerve
Find piece, hold with reduction clamp, get max. paralyzation, flex arm, hold in place with 0.062 k-wire. Check under fluoro.
Hold with guide wire from 4.5 cannulated screw system from center of piece headed up the column. Ideally head out anterior or posterior cortex (not lateral if possible).
+/- washer.
Posterior splint * 2 weeks, then encourage motion.


Medial Epicondylitis

(Fasciotomy, medial)
Provocative test: resisted wrist flexion
?PIN irritation?: resisted supination
Involved PT, FCR, PL, FCU
Check for ulnar n involvement
Pos: supine with arm board, tourn
Inc: curvilinear posterior to epicondylar groove, 2.5 cm prox and 5 cm distal to epicondyle. This avoids the MABCN. Carry dissection to fascia covering FCU. Progress anterolat towars med epic to expose common flexor origin.
Long. inc. at primary tenderness from origin, 5 cm distal. Spread and look for path tissue. Excise long. & elliptically.
5/64 inch drill bit for 3 holes in ME. Close defect with #1 vicryl, running
If needed, decompress ulnar N in zone 3 (distal to ME).
Posterior splint 4 x 15 fiberglass at 90 w/ FA in neutral x 2 days then start motion. Protect x 1 week. Medial CF brace until full FA strength.

Expected convalescence: 2-7 days
Work restrictions prior: no repetitive lifting. No lifting > 10 pounds
WR post-op:one-handed work only
Full benefit time:2 months


Olecranon Cable pins

Zimmer
Bean bag, semi lateral, need to be able to bring the arm off the table to image
Sterile tourniquet
Drill across equidistant to fx
Reduction clamp
K-wire for length and direction
Trauma drill, chuck the CABLE ADAPTER from the set to the back of the pin
Place cable pin
Thread one thru the drill hole
Crimp on crimper, one squeeze to hold, thread cables thru loops, use blue handle to tighten, squeeze crimper, trim cables


Radial Head Fracture

Grade 2 fx, Mini Frag set
Supine, touniquet, work across the body
Kocher incision, distal J connecting the lateral epicondyle to the radial head obliquely. Enter the interval btwn the anconeus posteriorly and the ECU anteriorly. Elevate a portion of the ECU to allow exposure of the LCL complex.
Incision in the capsule anterior to the lateral complex.
Down onto radial head. Clear hematoma, find fractured pieces.
Reduce and hold w/ pointed tenaculum.
Place 0.45 K-wire anteriorly.
Pronate to show rest of fracture. Drill with 2.0 drill, measure, overdrill with 2.7 drill, tap, countersink and place screw. Don't go long.
Supinate, remove k-wire and replace with 2nd screw.
Loosely close capsule. Check for impingement with supination/pronation.
Postop: Posterior splint for 3 days then CPM. Avoid active ROM. XR's at 3 wks, if stable, then gentle active motion and passive pronation/supination. Avoid flexion in pronation.
Repeat xr's at 6 weeks.
3 months to heal.


Radial Head Replacement

Evolve Radial Head--Wright Medical
Supine, sterile touniquet, hand table, fluoro
Kocher incision, distal J connecting the lateral epicondyle to the radial head obliquely (this is fairly posterior!).
Enter the interval btwn the anconeus posteriorly and the ECU anteriorly. Elevate a portion of the ECU to allow exposure of the LCL complex.
Incision in the capsule anterior to the lateral complex.
Down onto radial head. Clear hematoma, find fractured pieces, remove if not salvagable. Place pieces in tray to check size. May need to go one size down for prosthesis head and stem.
Internally rotate shoulder, bolster elbow so hand is down, pronate forearm.
Use sagittal saw blade to prepare radial neck.
Use straight currette as awl down radial shaft.
Use successive size awls to prepare shaft (5.5,6.5, 7.5).
Place trial stem by hand or with pitch fork.
Trial head slides on and then turns 90 degrees to lock on. Another option is to place both in together as a unit.
Check reduction clinically and by fluoro.
Place components in together (after banging together on back table).
Close capsule and interval.
Splint including wrist.
Loosely close capsule. Check for impingement with supination/pronation.
Postop: Posterior splint for 3 days then CPM. Avoid active ROM. XR's at 3 wks, if stable, then gentle active motion and passive pronation/supination. Avoid flexion in pronation.
Repeat xr's at 6 weeks.
3 months to heal.


Radial Neck Fracture

Anterolateral approach
Start prox, lateral to biceps muscle, take in line with flexion crease and then medial to BR along biceps tendon.
Look for the lateral cutaneous nerve of the forearm, retract medial
Incise the deep fascia along the medial border of the BR.
ID the radial nerve prox btween the brachialis and the BR deep.Follow th4e Radial nerve along the intermusc interval until it divides into its three terminal branches: PIN into the supinator, sensory branch behind the BR, and the motor br to the ECRB.
Divide elbow capsule btwn the radial nerve laterally and the Brachialis medially.



Radial Nerve Release (posterior)

Supine, Arm board, Tourniquet
Pronate FA
Thompson spproach -- form in line with midportion of wrist and LE
ID the posterior cutaneous nerve of FA, preserve
*the plane = btwn ECRB and common extensor muscles
Supinator is deep
To expose the Arcade of Frohse, detach the ECRB and strip distal ECRL
Flex elbow and rotate to find the couse of the PIN by digital palp
Release the Arcade prox thru the entire supinator
5 x 30 fiberglass splint, include wrist


Sauve-Kapandji

CPT 25830
DRUJ arthrodesis with distal ulnar pseudarthrosis
Supine, hand table, tourniquet
Dorsoulnar incision centered over the ulnar head.
Avoid dorsal sensory branch of the ulnar nerve.
ID interval btwn the ECU and EDMin.
Open extensor retinaculum with a proximal flap based radially and distal flap based ulnarward.
Decorticate the radial and ulnar articular surfaces of the DRUJ.
Stabilize with a 0.045 K-wire.
Just proximal to the ulnar neck perform the ulnar osteotomy with an oscillating saw.
For patients with negative or neutral ulnar variance, remove 15 mm segment of ulna and surrounding periosteum. (larger with + variance)
Use 3.5 cortical screw with lag technique for permanent fixation.
Drill holes in proximal ulna to secure the pronator quadratus from the excised ulnar segment to the proximal segment for stabilization.
Use retinacular flaps to stabilize the ECU and to reinforce the capsule.
Splint or cast for 4 weeks.
Removable splint for 3-4 weeks for comfort.


Scaphoid NonUnion

Page 816 Green
Russe Method. Volar approach.
-4-5 cm longitudinal incision along the radial border of the FCR tendon, centerd at a level even with the tip of the radial styloid, which usually correcsponds to the level of the fracture itself. Extend the incision obliquely over the thenar eminece to expose the distal pole. The capsule is divided longitudinally, and the underlying deep volar radiocarpal ligaments are either divided partially and retracted, or completely severed and tagged for later repair. An egg-shaped cavity is created well into both fracture fragments without using power tools. A cancellous bone graft is then obained from the ipsilateral iliac crest and fashioned into an ovoid plug large enough to fit snugly into the scaphoid cavity. The graft is actually jammed into both fragments as these are forcibly distracted. Once the graft is in place, the fragments are impacted and you may elect for internal fixation.

Herbert guide puts the hook at the proximal pole end, and the drill guide firmly clamped to the distal pole. The length of the screw is read directly off the calibrated guide. The screw is fully inserted and the jig removed. Compression is secured by further turns of the screw.

Repair RC ligaments, SA Thumb Spica cast * 6 weeks.

? Synthes 3.0 cannulated titanium screws with threaded washers.
If you use that, guide wire, countersink, threaded washer, then measure, and place screw.


Septic Flexor Tenosynovitis

Kanavel: flexed potition, symmetric enlargement of the whole finger, excessive tenderness over the course of the sheath but limited to the sheath, and excruciating pain on extending the finger passively most marked at the proximal end.

Open drainage: Midaxial incision on the ulnar side (radial thumb and small finger). Start dorsal and distal to the distal flexion crease of the finger and extend proximally to the web space.
Keep the digital artery and nerve in the volar flap. dissect towards the tendon sheath dorsal to the NV structures. Inceise synovium btwn A3 and A4 to get pus. Irricage.
Second incisionin the palm over the tendon to drain the cul-de-sac: curved over the A1 pulley. Irrigate.
Remove tenosynovium, preserve pulleys.
Drains * 48 hours, compressive dressing, splint. Then saline soaks and active exercise.


Supracondylar humerus fx, CR&PCP

Pos: Supine, 12" tourn
Fluoro: Flip the 'C' over to use as the arm table
Long. Txn to get length. Then get medial/lateral alignment. Then, with thumb on olecranon, flex up & pronate. Rotate @ shoulder to check the lateral.
To pin use 0.062 K-wires. Put 2 pins radially first in case you need to remove the first one. Then go ulnar side w/ arm extended w/ finger in the groove. Should run up the medial column, cross, and out the lateral cortex.
Fiberglass cast @ 90 w/ FA in neutral.
Wires out in 3 weeks


Trigger Finger Release

ICD -9 727.03, CPT 26055
Request: hand table, lead hand, 11 and 15 blades, 3-0 and 4-0, splint

Incision: Index -- 1.5 cm proximal crease; long -- btwn creases; ring and small -- distal crease.


Wrist Arthroscopy

TFCC tear 824.02/ CPT 29846
Apple Hill set-up: Bar to table, bar to bar, tower, exsanguinate and tourniquet, strap to forearm comb, finger traps on 2/3/4th fingers, adjust height. 6-10 lbs traction on strap on upper arm.
*2.7mm, 30 degree scope with 5-8mm long shaft
*Small joint probe
*(need) suction punch from YH
*2-3.5 mm instruments
*Gator blade on dyonics shaver
1. Inject 5-7 ml marcaine with epi into 3-4 portal
*3-4 portal: wrist dimple 1cm distal to Lister's btwn ulnar border of ECRL and rad border of common ext's. Direct scope 10 degrees proximal.
Directly ahead is synovial tuft of lig of Testut.
2. 18 gauge needle into 4-5 portal for outflow.
*4-5 portal: 1cm ulnar to 3-4 btwn ulnar margin of common ext's and EDM. Directly ahead is LTL. At the jct of DR and TFC.
*6R portal: btwn EDM and ECU
*Order of structures: RSC, TLT, Tuft, UL, and UT.
* RMC portal: 1 cm distal to 3-4

Find thick proximal edge of A! pulley and cut with 11 blade ~1.5 cm.

Toe Procedures

AKIN OSTEOTOMY -- WGH

Indic: Persistent Valgus s/p HV correction
1. Continue incision distally to expose mid PP.
2. Use 0.062 K-wire to place angled suture holes as far from proposed osteotomy site as possible.
3. Osteotomy at flare, parallel to base.
4. Second cut to take dorsomedial wedge.
5. Close and check correction.
6. Ooh, Ah Stitch: Prepare holes with needle. Thread a 2-0 Chromic suture through distal hole.
7. Other end of stitch is doubled over and pinched, then loop is threaded outside to inside through proximal hole.
8. Place free end through loop and then pull free end through proximal hole. Carefully tie down suture.
9. Close with 4-0 Vicryl. Benzoin & Steristrips. Compressive Dressing.


BUNIONETTE

1. Inc- laterally from prox phal down shaft
2. Avoid dorsal/plantar nerves
3. L-shaped capsular incision, veer superiorly then down plantarly.
4. Dissect capsule off head
5. Saw to resect lateral eminence.
6. ?Need distal chevron?, proceed as with 1st MT. Fix with orthosorb pin.
7. Close capsule with 3-0 Vicryl-don't over tighten.
8. Close skin with 4-0 monocryl, steristrips.


CAPSULAR ARTHROPLASTY

Indic: Stage 2 or 3 H. Rigidus with equal length 1st & 2nd MT's
1. Medial midline longitudinal inc to capsule. Sens. Expose capsule, protect dorsal nerve
2. Incise capsule longitudinally. Free from underlying bone. Beware of FHL plantarly.
3. Rongeur osteophytes
4. Use towel clip-like bone clamp around distal PP to pull base up into the wound. Dissect off soft tissue, watch FHL. Remove clamp
5. Osc saw to resect prox 25% of PP (to flare). Bennett to protect FHL. Take care to cut perp. to shaft
6. Standard Cheilectomy.
7. Rongeur phytes. Irrigate.
8. Cut EDBr 3 cm prox to jt line
9. Check tension with finger. May need to open FHL sheath
10. DF foot to neutral to check for cockup. If so, lengthen EHL.
11. Tie EDBr and capsule down to FHBr stumps w/ 2-0 Ethibond,
12. 2-0 Chromic to finish capsule closure. Try to cover med eminence.
13. (Marty) Skewer w/ pin
14. Run 4-0 Vicryl. Compr dressing
15. DARCO shoe. WBAT.


Cheilectomy

Grading system:Coughlin and Shurnas
0-slight loss of motion, absence of pain during regular activity
1-mild loss of motion, small spur and sporadic pain
2-progressive loss of motion, 25% narrowing, spur, more pain
3-less than 10 degrees dorsiflexion,larger spurs and pain not in mid-range
(Fusion indicated for Grade 4-pain at the mid-range of motion)
1. Dorsal skin incision ~1 cm prox to IP Jt -> 5cm. Thru subQ -> extensor tendon & hood
2. Open ext hood and capsule, retract EHL medially
3. Full synovectomy. Inspect jt for loose bodies & osteophytes
4. MTPJt sharply dorsiflexed, 6mm osteotome used to resect dorsal 20-30% MT head, just dorsal to viable cartilage.
5. Remove lateral phytes along shaft
6. Finish synovectomy. Chk dorsiflexion, want 70 degrees.
7. PF MTPJt to inspect sesamoids
8. Bone wax. Close joint capsule and skin
9. APROM @ 10 DAYS

To add proximal phalanx dorsal closing wedge osteotomy:
8. Dissect further distally. Use 0.062 K-wire to create hole on either side.
9. 39 blade to create CW osteotomy.
10. Thread a long loop of 3-0 vicryl and 2-0 prolene thru the eye of a Keith needle. Pass the eye thru the prox hole. Grab each suture loop with a stat and pull up into the osteotomy site. Remove needle
11. Thread another 2-0 prolene thru the distal hole, into one of the loops, pull loop thru distal hole. Repeat with other. Tie down.
12. May need k-wire from dorsal-proximal to plantar-distal. Make sure it doesn't impinge on dorsiflexion.


Chevron Osteotomy

1. Skin inc over med aspect of 1st MTP Jt. Distally @ mid PP to 6 cm prox. Dissect to joint capsule. Create full thickness flaps, use knife inferiorly. Protect nerves -- Look for dorsal one early.
2. Capsule inc-- longitudinal cut down to bone-start to distal to ensure midline of shaft. Vertical cut 2 mm prox to PP base. Dissect capsule off bone to expose enough for the cut. Place bennets.
3. 38 blade 1mm med to sag sulcus, parallel to med border of foot.
4. Replace bennets to protect. Use 0.062 K-wire to drill across MT head 1 cm from tip.
5. 38 blade (or Zim 5053-232) @ 60 deg angle -- longer dorsal limb. Be cognizant of nerve dorsally. Make plantar cut proximal to sesamoids. Make sure cuts are complete.
6. Small towel clip to grasp MT. Grab toe, longitudinal traction, pull laterally. Measure change.
7. Impact oseotomy. Use Orthosorb pin (if correction greater than 5mm may need to use 2-0, accutrax, or herbert screw) to fix site -- one medial, one lateral. From just off articular surface, drop hand, drive into MT shaft.
8. Check image, measure pins.
9. Use sag saw to resect overlap. Go from dorsal to plantar. Concentrate on proximal end.
10. Take Orthosorb pin out of sleeve, measure on ruler, cut with 15 blade on ruler. Load back in sleeve with plunger in place.
11. Remove first pin, replace with orthosorb. Repeat with second pin.
12. Close capsule with #1 vicryl with raytec btwn toes. Run 4-0 monocryl. Steristrips. Compressive dressing.
13. Heel walk in DARCO Shoe.


Flexor to Extensor Tendon Transfer

Operative Techniques Jan 1999, 47
CPT 28270
Purpose: stabilize proxmal phalanx by FDL tendon dynamically stabilizes the MTp jt by replacig the intrinsics.
1a. (Clinics)Alternate dorsal incision is second incision just short transverse at mid PP level to expose extensor tendon for tie down. Need to make big incision in capsule release is necessary.
1. (Op Techniques/Lutter)First incision dorsally from proximal to the MTP and carried distally to the midproximal phalanx.
2. Soft tissue releases to achieve reduction of joint
3a. Alternate plantar incision is Z incision with first horizontal limb at proximal flexion crease, distal at distal crease.
3. Transverse incision made at the level of the proximal flexion crease.
4. Spread soft tissues bluntly to the level of the flexor tendon sheath and pulley. Protect NV structures.
5. Split sheath longitudinally and identify FDL centrally.
6. Pass mosquito clamp under and flex and extend DIP to check correct fendon.
7. Release FDL percutaneously at DIP level.
8. Split tendon into 2 tails.
9. At the level of the middiaphysis of the PP, a curved mosquito is passed deep to the extensor mechanism along the sides of the PP to exit on the plantar aspect of the wound
10. Pull tails dorsally to mid PP.
11. Hold MTP reduced and PF'ed 10 degrees and ankle neutral. Should get 30 degrees passive MTP DF.
12. Sew together and to EDL with nonabsorbable suture.
12a. (Myerson)Can set tension by tying knot in FDL limbs and take to one side or the other. Mann warns to be careful that it is not too bulky
13. Pass K-wire retrograde to protect repair.


Jones Procedure

CPT 28760
Extensor Tendon transfer and arthrodesis of the IP Joint used for HE of the MTP jt and flexion of the IP Jt.
1. Either a transvers elliptical incsion over the IP joint and a longitudinal incision over the MTP jt. alternatively, one longitudinal from MTP to DIP can be used.
2. Distally release EHL from DP.
3. Expose IP Jt, use saw to prepare surface for fusion.
4. Reduce to slight PF
5. Place screw from tip(30mm accutrax standard).
6. Dist MT shaft is cleared medially and laterally enough to allow an adequately sized hole to be drilled transversely in the shaft. DF foot to 10-15 degrees, suture tendon to self.

Post-op: PWB cast for 3 weeks, then WBAT cast * 3 weeks. Firm soled shoe once arthrodesis seen on XR's.


LAPIDUS

1. Modified McBride
2. Medial eminence resection-clear soft tissue Hamilton style.
3. 3rd inc. over 1st TMT joint. Avoid the vein. Retract tendon medially.
4. Expose joint. Use osteotome and curette to clear cartilage.
5. Laminar spreader, elevator to prop joint open may help.
6. Osc. saw to distal cuneiform- take more laterally and plantarly. Avoid taking too much bone.
7. Reduce, check on OEC
8. .062 K-wire to hold reduction
9. Pack bone graft.
10. 4-0 Cannulated drill guide from distal-dorsal to proximal-plantar.
11. Measure, drill, tap, countersink, screw.
12. Repeat from prox-dorsal to distal-plantar.
13. 3-0 Vicryl to cover joint
14. 4-0 Monocryl, steristrips to close

Postop options: Crutches until comfortable
SLC or postop shoe, If cast, 6 wks then DARCO shoe x 2 weeks. At 8-10 weeks, sneaker with unrestricted shoewear at 4 months
-or-
2 wks NWB, 2 wks PWB, 2-4 wks WBAT in cast


Lasso

modified mcbride
2*2-0 ethibond on grove needle. Dissect around 2 head. Dissect space btwn interosseous medially. Pass suture ~ 2 & btwn 2 & IOM. Put stich thru stump. Go to medial side, use mosquito to make pass ~ top & bottom of 1st. Grab suture ends. Tie ends while squeezing heads together.


Mann Bunionectomy

1. Dorsal inc 1st web space thru tkin and subq. Thumb bluntly dissects to adventitious bursa. Avoid super. br's of DPN
2. Weitlander btwn 1st and 2nd web space. This puts the ADD H on stretch. ID its insertion into the PP. Knife btwn MT head and lat sesamoid, dissect distally until hit PP, then turn laterally and plantarward to release from PP. Bring knife prox to complete release.
3. Dissect distal end of add from lateral sesamoid until jct of FHB and ADD Hal is reached.
4. Place weitlander deeper, protect CDN w/ freer and cut TML
5. Pie crust laterally, manipulate into H Varus. Sutures in web space.
6. Med Inc - mid portion of PP -> 1cm prox to ME. Dissect to capsule, raise full thick flaps. Protect the D&PMCN's
7. Capsular incision just prox to MTP jt. Expose ME
8. 2mm med to sagittal sulcus in line with long axis of 1st MT shaft. Smooth w/ ronguer.
9. Check correction for springback
10.3rd inc: dorsal base 1st MT. 0.5mm prox to MTC jt -> distal 3 cm. Retract EHL.
11. Osteotomy site 1cm distal. Screw site 1 cm distal to that.
12. 45 degree angle, 4.0 cannulated guide wire
13. Zimmer-Hall 5053-71crescentic blade with concavity towards heel (frown). Plane is 1/2 way btwn perp to MT shaft and floor.
14. Displace w/ freer. Push base medially, rotate head laterally.
15. Drill second side of screw hole.
16. K-wire for provisional fixation
17. Drill, Countersink, 26 mm 4.0
screw.
18. Tie web space sutures
19. Trim and repair medial capsule with raytec btwn toes.
20. Counterclockwise for R, Clockwise for L.


PIP Resection and Plantar Condylectomy

ICD-9 735.4, 838.05
CPT 28288, 28285
Indic: Hammer toe/ MP
Sublux/Metatarsalgia
1. Web Space incision. Cut EDBr, Z-lengthen EDL
2. Cut Longitudinally thru ext hood
3. Pull on toe to use Pucker sign to identify MTP jt. Mann takes capsule off the dorsal, medial and lateral base of proximal phalanx to enter joint
4. Flex toe down, place McGlamory MT head retractor
5. Small osteotome to resect plantar condyle. Check by palpation for prominence.
6. Elliptical skin incision over PIP
7. 15 blade to dissect off collaterals
8. Freer to protect plantar soft tissue
9. #39 osc. saw to resect PP head at flare. Scrape base of MP.
10. Awl to mark prox and distally
11. 0.045 K-wire distally thru toe and then manually reduce and advance pin retrograde across either just PIP or plus MTP Jt prn.
12. Suction tip and pliers to bend down end. Wire cutter
13. 2-0 Chromic to close capsules and PIP inc.
14. Run 4-0 Maxon, benzoin & steris
15. Check for cap refill after tourniquet


RHEUMATOID FOREFOOT RECONSTRUCTION

1. Closed osteoclasis of lesser toes.
2. Dorsal inc centered over 1st MTP Jt. Retract ext tendon laterally.
3. Synovectomy, jt capsule release
4. Cut distal 5 mm 1st MT, 5ovalgus, 15o DF
5. Free base of PP of soft tissue, cut prox 5mm parallel to to toe held in 15o DF/15o Valgus.
6. 0.062 k-wire to hold, check on OEC
7. 2 dorsal inc's--2nd/4th web spaces (3cm)
8. Find 2nd head. Long. inc along distal dorsal MT. Dissect head free, don't crank but use elevator.
9. 39 blade to cut just prox to art. cart. Cut more plantarly, check for sharp pts.
10. Similar procedure for 3rd-5th. Check length by palp and OEC to make nice cascade.
11. ?PIP resection? Dissect free sides of tendon then cut transversely thru jt. Dissect off collaterals then use elevator and cut off PP condyles.
12. (optional) Cut ext brevis prox 2 cm, z-lengthen ext longus tendons. Fix with 3-0 vicryl.
13. 0.045 wire to pin toes (4th/5th optional)
14. Interfrag 4-0 cann screw from distal med to prox lateral.
15. 1/4 tubular plate (5-6 holes) w/ 4.0 fully threaded screws.
16. Alternate fixation: two 1/8" steinmann pins thru tip of toe.
17. 3-0 vicryl to try and close something over the plate.
18. 4-0 monocryl, 3-0 nylon, steri's, dressing.



Ruiz-Mora Procedure

-For severe 5th cock-up toe
1. elliptical incision on the plantar aspect of the small toe and oriented along the longitudinal axis of the PP, deviating slightly medially to the base of the toe.
2. Ellipse of skin resected, flexor tendon is incised.
3. Proximal phalanx is resected (Janecki recommends partial)
4. Skin incision closed at right angles to the long axis to correct the plantar-medially. Use 3-0 chromic sutures


RVU Order

Chevron 28296
Akin 28298
Cheilectomy 28289
PC 28288
MT Osteotomy 28306
McBride 28292
Silver 28290
Moberg 28310
HT' s 28285


SCARF Bunionectomy

1. Dorsal inc 1st web space thru tkin and subq. Thumb bluntly dissects to adventitious bursa. Avoid super. br's of DPN
2. Weitlander btwn 1st and 2nd web space. This puts the ADD H on stretch. ID its insertion into the PP. Knife btwn MT head and lat sesamoid, dissect distally until hit PP, then turn laterally and plantarward to release from PP. Bring knife prox to complete release.
3. Dissect distal end of add from lateral sesamoid until jct of FHB and ADD Hal is reached.
4. Place weitlander deeper, protect CDN w/ freer and cut TML
5. Pie crust laterally, manipulate into H Varus. Sutures in web space.
6. Med Inc - mid portion of PP -> 1cm prox to ME. Dissect to capsule, raise full thick flaps. Protect the D&PMCN's
7. Capsular incision just prox to MTP jt. Expose ME
8. 2mm med to sagittal sulcus in line with long axis of 1st MT shaft. Smooth w/ ronguer.
9. Check correction for springback
10. Continue skin inc proximally along MT shaft.
11. Dissect btwn shaft and AbdH.
12. Osc saw cuts horizontally at 20 degree plantar angle, just inf to midline from 1 cm prox to artic surface to flare.
13. Prox, vertical cut down to plantar surface
14. Distally, vertical cut up thru dorsal surface.
15. Take wedge out of both ends of Z
16. Shift and hold with bone clamp
17. Check length and sesamoids on fluoro.
18. Place two 2.5 cortical screws from dorsal to plantar
19. Trim overlying bone.
20. Tie web space sutures
21. Trim and repair medial capsule with raytec btwn toes.
22. Counterclockwise for R, Clockwise for L.



Weil Osteotomy

Indic: long MT(metatarsalgia, dislocated MTP, pain at the base of a toe?)
1. Web space incision
2. Cut EDBr
3. Z-lengthen EDL
4. Cut longitudinally thru ext hood
5. Pull on toe to use Pucker sign to identify MTP joint. Mann takes capsule off the dorsal, medial and lateral base of proximal phalanx to enter joint
6. clear dorsal MT shaft
7. Flex toe down
8. Osc saw from 2mm plantar to the dorsal junction of the met head at an angle parallel to the bottom of the foot. Ideal angle is 25 degrees to avoid too much plantar flexion. Might consider taking a wedge out if metatarsalgia is a problem. Might angle cut opposite direction if you have a lot of medial or lateral angulation
9. Slide MT head to desired length
10. 0.062 K-wire to fix shaft to head piece.
11. Check on fluoro
12. Replace pin w/ 2.0 cortical screw or twist off
13. Rongeur excess bone
14. Reattach lengthened EDL w/ 3-0 chromic
15. Might consider pinning in plantar flexion as toes tends to sit dorsiflexed. Might have to miss the head and sink pin more proximal than head to get a bite.
16. Run 4-0 Vicryl, benzoin and steristrips
17. Postop shoe
18. PF exercises @ 2 wks

Procedures

ACL Reconstruction with BPB autograft
(Arthrex)


POSITION: Supine with leg holder and well leg stirrup. Thigh tourniquet. Don't drop bed until after graft taken
INC: long midline from distal 1/3 patella -> ~7cm to just med to TT.
-Make thick flaps
-Inc paratenon. Measure width of tendon
HARVEST: Measure central 10mm, mark, cut along fibers with kelly underneath to tension. Mark bone plugs, 25mm on each end if possible.
-Sag saw cuts trapezoid block from tibia first. Lever with curved osteotome. Drill three holes with 5/16th drill bit prior to removing.
-Sag saw to patella. Lift graft up, clear fat pad, make scary cut of patella to remove.
-Rongeur to excess tibia side to fill in patella defect. Also, curret to graft site.
-Wrap in wet raytec.
-Close tendon with #1polysorb, paratenon with #2-0 polysorb.
ARTHROSCOPY:Vertical portal laterally, 18 gauge to set medial portal. Diagnostic scope.
-Debride synovitis, ACL stump and floor. Protect PCL
-Notch plasty with 4.5 burr.
GRAFT PREPARATION: Trim plugs to 10mm, check with sizers. Drill hole in patella plug. Thread #1 PDS suture to lead, three #1 Ethibonds to follow. Clamp each and clamp to table. Mark plugs with pen. Wet raytec.
ARTHROSCOPY: Use Arthrex jig through medial portal set at 70 degress thru separate vertical incision at medial tibia.
-Sit just ant to PCL. Send guide pin through. check position.
-Use 10mm cannulated reamer to make tunnel. Use shaver to clear debris from opening.
-Flex to 90, use over-the top guide (11 oclock for R, 1PM for L). Send beath pin into femur. Check position.
-Push reamer thru tibial tunnel, past PCL and ream femoral tunnel to length of bone plug.
-Thread graft, deliver into tibial tunnel, pull past PCL and into fem tunnel with fibers posteriorly and markings visible.
-Make separate stab incision just medial to Patellar tendon in line with graft to pass the guide wire for the interference screw.
-First notch superior and lateral to plug, then place guide wire.
-Use clear sleeve to protect PCL and use 9x23mm bioabsorbable screw until flush.
-Cycle graft x 20 and check for stability.
-Raise foot of bed. Guide pin to tibial plug. Place screw with posterior drawer maneuver.
-Lachman, pivot shift
-Check stability and for impingement with camera. Take pictures.
-Close sites. Dress lightly.
-Polar care with ABD under hose.
-Donjoy brace locked in neutral.


BKA--ischemic limb

Level: anterior cut-- 10-12.5 cm distal to joint line; posterior flap--12 cm distal to that
Supine with thigh tourniquet
Anterior cut down to periosteum, outline other cuts thru skin.
Dissect around tibia, cut with Giggly saw.
Isolate neurovascular structure and clamp and tie with chromic ties.
Isolate fibula and cut 1 cm proximal to tibia.
Use amputation blade to cut distally between deep and superficial layers to finish amputation.
Finish hemostasis. Let down tourniquet.
Place med-large hemovac out prox-medial thigh.
Sew fascia of deep compartment to anterior tibia.
Close in layers with 2-0 vicryl and 3-0 nylon.
IPOP, change in 1 week. May ambulate in 6-8 weeks.


BKA -- NonIschemic Limb

Level: 12.5-17.5 cm (2.5/30cm height)
Position: supine with thigh tourniquet
Measure bone length from jt line. Measure leg diameter. Mark ant/post flaps of half the diameter.
Inc starts med/ant, curves convexly to point. Score the periosteum at the crest. Repeat post.
Deepen the post incision thru deep fascia.
Raise the ant flap off bone.
Use a curved hemostat to run up the IOM and over the fibula to emerge just anterior to the PBr.
Isolate the SPN btwn the EDL and PBr. Pull distal and divide high.
Divide ant musc's 0.6cm distal to bone cut.
Isolate and cut ATA&V and DPN.
Bevel ant tibia from 2cm prox to 1/2cm ant to canal. Cut tibia across. Round with rasp.
Cut fibula 1.2 cm proximally.
Divide the deep post musc's 0.6cm distal.
ID and cut the PTV, PerV, and PTN.
Bevel the gastrocsoleus so that it forms a long enough myofascial flap.
Release tourniquet. Hemostasis
Sew GS flap to ant fascia/periosteum.
Drain under flap, out 10 cm prox to stump end.
Interrupted, nonabsorbable sutures w/o tension.
Rigid above thigh cast. Avoid prox constriction.
Change 5-7days. Should ambulate in 6-8wks.


Chronic Patellar Tendonitis

(jumper's knee)-tendoosseous jct at inf pole of patella. Can have elongation of the anterior inferior patella surface ("tooth sign").
Inc- Incise the tendon sheath longitudinally and identify and excise the area of degeneration using longitudinal incisions in the tendon. The inferior pole of the patella can be curetted or drilled to incite a healing response. Suture the defect in the tendon with side-to-side interrupted 2-0 Vicryl sutures. Close the peritenon wit interrupted absorbable sutures and clse the skinand subq tissue.
Knee immobilizer * 3 wks, PWB.
Rehab: Stage 1-ROM, isometric strengthening. 2-closed chain when swelliing and tenderness have resolved. 3-activity specific avoiding eccentric overload.


Distal femur fracture (percutan)

Synthes distal femur locking plate, 4.5 LCP Condylar plate
-Vascular table
-Sterile thigh tourniquet
-Lateral incision at condyle
-Reduction maneuver intrartic first
-Hold provisionally with guide wire (drill) at lowest point possible
-Decide on plate length with fluoro
-Screw in 5 +1 2.5mm wire guides into distal end of plate
-Slide plate up percutaneously
-Make small incision proximally to center top of plate
-Put drill/pin into top spot to hold
-Lag screw pin parallel to joint axis and patellofemoral joint
-After placing lag screw site pin, measure with guide in place, remove guide and drill in lag screw. Hand tighten
-Place locking screws in the other 5 holes if possible
-Replace 7.3 lag screw with locking one.
-Proximally can use regular synthes 4.5 size screws for diaphyseal screws
-For compression mode, lightly place drill guide. For neutral, press down drill guide to center guide.
-Four cortices above with at least one locked to plate
-To lock proximally with 4.0 screws, 3.2mm drill guide, drill, remove drill guide, hook for measurement, lock in screw.

-Donjoy hinged knee brace


Fasciotomy for Chronic Exertional Anterior Compartment Syndrome

Anterior Compartment: ATT, EDL, EHL, PTer, interosseous membrane, fibula, anterior intermuscular septum laterally, deep fascia of the leg anteriorly. AT A&V AND Deep CPN run along the interosseous membrane, deep to the EHL.

Pedowitz criteria: resting pressure > 15mm Hg, 1-minute posterxercise > 30mm Hg, 5-minute postexercise > 20 mm Hg.

Incision: 5-6 cm in midportion of lower leg halfway btwn the anterior tibial crest and the fibula. Watch for superficial peroneal nerve as it pierces out thru the deep fascia at the junction of the middle and distal thirds of the lower leg (~10-15 cm from ankle mortise).
Incise deep fascia over the ATT. Identify the lateral intermuscular septum and incise horizontally. Undermine and fasciotomize anterior and lateral compartments both proximally and distally using 12 inch Metzenbaum scissors. May use lighted Dever retractor for help. Close skin only. Compressive dressing.

Without a muscle hernia, Schepsis et al. just did anterior compartment. Quicker recovery, less pain.

Postop: WBAT with crutches, immediate ROM knee and ankle. D/C dressing in 72 hours, D/C crutches in 5 days. Start stretch and strengthening.
Hold on jogging until 6 weeks. Full return 8-12 weeks or as symptoms allow.
Incise tr


Gamma Nail

Howmedica -- Daniel
Fracture table, C-arm
-Palpate tip of trochanter, incision 5 cm proximal-ward
-Starting point at tip of trochanter between the anterior 1/3 and posterior 2/3's
-Reverse curved awl to make starting hole down to below the lesser troch
-Beaded guide wire past the fracture site
-Select length of rod (all rods 11 diameter) and angle of lag screw
-Ream from 9 to 13 distally, up to 17 proximally to just past lesser trochanter
-Assemble nail to targeting device
-Do NOT mallet, wiggle rod down
-Check depth by flouro for the top of the nail and position of the lag screw track
-Drill pin for lag screw thru sleeves, measure length off inner sleeve
-Add 5 mm to measurement
-Drill, tap, insert screw, stop with handle parallel or perpendicular to targeting device
-Apply set screw through the top, don't overtighten
-If using 180mm short rod, lock distally through the targeting device, otherwise perfect circles distally


Hip Hemiarthroplasty

Lateral with peg board
-Stand at butt
-Mark out GrT and take incision one hand's breath proximal
-Thru IT band, GMax, bursa
-Charnley with short end at operator's side, for Left hip, retractor towards toes.
-Mark anterior 1/3 of Gluteus medius, often don't have to split it when you bovie the tendon off the Greater Trochanter.
-Externally rotate the leg to get around.
- Lift the GMin similarly
-T the casule across the bottom and along the neck and tag
-Into leg bag with knee straight up
-Femoral neck retractor, cut neck one FB proximal to lesser Troch
-Leg back up, bone hook to femur
-Corkscrew to remove head, measure, size head trial.
-Back into bag
-FN Retractor, box cutter, reamer, broaches
-Calcar reamer
-Trial
-Real prosthesis, trial, real head.
-Repair capsule
-Foot on padded mayo. Drill holes (3-4) across the GTr.
-#5 Ethibond thru drill hole then weave thru Minimus and Medius and back thru next drill hole. Repeat. For this, put knee on padded mayo.
Close fascia, skin in layers, staple.


Hip Spica Cast

Vascular table
Spica table
-Cut stockinette for body and 1.5 legs
-Adjust length of table so groin is on the round metal part and shoulders are on the pad. Need to get to mid chest with wrap.
-Get reduction, check with c-arm
-Try to flex hips and knees to simulate sitting in a car seat
-Two towels for lunch, make sure they're sticking out the top
-Webril
-3" fiberglass
-Reinforce spica part


IM Femoral Rod

Indic:shaft, subtroch fx
Preop prep: diameter of rod
Pos: Fx table, tibial traction pin below tubercle w/ middle threaded steinmann pin, adducted, good leg in well-leg holder or scissored down if possible with table, chk c-arm for circles
Get reduction on fluoro
Inc (percutaneous option) Use c-arm and metal guide wire to mark starting point on skin. Tends to be just distal to iliac crest, more posterior than you'd think. 3cm long
(standard opening) 2 fb post, 4 fb superior to greater trochanter, curvilinear thru skin, blunt thru subQ.
Use guide wire on drill to find the piriformis fossa. Check AP/lat. Drill to lesser troch. Over ream with 13mm reamer.
Place beaded guide wire across fx. Reduce fx.
Use ruler to determine length of rod. Start w/ #9 reamer. Use kocher and med cup to hold wire. Ream 1 size higher than chosen rod. Exchange tube, non beaded wire. If spiral blade, place correct blue sleeve over nail for angle. Tamp into place. (if spiral blade, do this step next) Pull out guide wire.
Perfect circle technique for distal interlock screws. Place trochars to determine length of screw.
Disengage trxn. Backslap prn to reduce/compress fx site.
Attach specialty arm. Send guide wire thru proper angle hole, separte incision. Measure guide pin for blade/screw length. If using blade, ream lateral cortex with 13mm. Tap blade across/place screw. Check. Take off proximal arm. Place end cap screw. Use silk tie around screw head so won't lose in soft tissue.

Postop: WBAT, coumadin


IM Femoral Rod for Impending Pathologic Fracture

Indic: Impending Pathologic Fracture
Preop prep: length, diameter, angle of spiral blade, blade length
Pos: Fx table, adducted, good leg scissored down, chk c-arm for circles
Inc (percutaneous option) Use c-arm and metal guide wire to mark starting point on skin. Tends to be just distal to iliac crest, more posterior than you'd think. 3cm long
(standard opening) 2 fb post, 4 fb superior to greater trochanter, curvilinear thru skin, blunt thru subQ.
Use guide wire on drill to find the piriformis fossa. Check AP/lat. Drill to lesser troch. Over ream with 13mm reamer.
Use ruler to determine length of rod. Diameter per preop template. Place correct blue sleeve over nail for angle. Tamp into place.
Attach specialty arm. Send guide wire thru proper angle hole, separte incision. Change depth of rod prn. Measure guide pin for blade length. Ream lateral cortex with 13mm. Tap blade across. Check. Take off proximal arm. Place end cap screw. Use silk tie around screw head so won't lose in soft tissue.
Perfect circle technique for distal interlock screw.
Postop: WBAT, coumadin


Knee Arthroscopy

Medial or lateral partial menisectomy
Expected convalescence: 3 days
Work restrictions prior: no repetitive bending or twisting of the knee
WR post-op: no work * 3 days, sit down work days 4-10, then no repetitive twisting or bending for 3-4 weeks
Full benefit time: 3-4 weeks.


Patella Subluxation

Madigan, proximal realignment, quadricepsplasty, when Q angle < 20
- Medial longitudinal skin incision to prepatellar bursa from 2-4 cm above the superior pole of the patella and inferiorly to the joint line.
- Expose the medial and lateral retinacula to the level of the intramuscular septae.
- Make the conventional superior portion of the medial parapatellar arthrotomy from 2 cm above the superior pole to midway. Leave a nice cuff of tendon on the bone and muscle flap.
- Inspect joint
- Continue incsion posteriorly at midlevel of patella, paralleling the posterior border of the vastus medialis obliquus until the medial intermuscular septum is reached.
- Leave this attachment to maintain the oblique pull.
- Transfer laterally and distally the the insertion of the vastus medialis so that it overlies the patella
- Fix the transfer with strong suture, range the knee to 60 degrees to asses the travel.
- ?'s -- smooth, excessive pull, lateral border of patella and lateral femoral condyle in line?
- If still tracks laterally, make an extra synovial lateral retinacular release.
- Suture the rest of the transfer. Attach the proximal corner to the quad tendon
- Close in layers
-?Cylinder cast/ knee immobilizer with knee in neutral position
- Straight leg raises POD#1. When able to maintain the leg in space, may start PWB.
- Start AROM and progressive resistive exercises

Campbells page 1342
Quadricepsplasty 27430
Lateral release 27425
Chondroplasty 29877 (2nd RVU)

Kyphoplasty-Prone on two transverse Prone positioners

2 pinks for knees
1010 across butt
Vascular table
-Bring in fluoro, 2 mag once centered, transversely mark affected vertebrae w/ skin markers
-Prep, square off w/ paper towels
-Localize 10 and 2 O'clock positions with Jam-Sheady needles (9 and 3 in thoracic, extra pedicular)
-Make transverse incision
-Check position on AP XR, Advance, Tap with mallet prn.
-Check on lateral, can readjust. -Advance to start of body
-Check on AP, should not be past the medial pedicle.
-Insert guide wire, check on lateral
-Use dilating cannula, working cannula.
-Drill
-Slide balloon in, fill to 50, then 100 to ~2cc of fluid.
-Pull back on handle to deflate balloon. Remove.
-Mix cement, pour into syringe, fill stylets. Fill 2 for each side. Not too runny. Tamp in. Not as deep with second.
-Let harden with tamp in to avoid back fill.
-Remove
-Horizontal mattress, bandaid
-No activity restrictions.


Popliteal (Baker's) Cyst

-Scope first, ?aspirate and cortisone
-Supine position with contralateral hip bump
-Externally rotate hip, flex knee 90 degrees
-Medial hockey-stick incision of the jt line. Vertical limb to medial side of tibial tubercle, Horizontal limb along top of tibia.
-Posteromedial capsular incision beginning btwn the medial epicondyle and adductor tubercle along the posterior border of the tibial collateral ligament.
-Retract the Posterior Oblique Ligament posteriorly and inspect the posteromedial compartment.
-ID the cyst usually in the area btwn the medial head of the gastrocnemius and semimebranosus tendon.
-Inspect the posteromedial joint and cyst lining for an intraarticular communication.
-Excise the base of the stalk and close the orifice with one or two nonabsorbable sutures.
-May need to advance the Posterior Oblique Ligament onto the medial epicondyle and TCL to restore tension to the posteromedial capsular ligaments.
-Knee immobilizer, WBAT
Straight leg raising and quad sets POD 1.
-D/C KI and begin active ROM once inflammation decreases.


Repicci Unicondylar Knee Arthroplasty

Indications: Ideally >50 years old, no flexion contracture (represents lateral disease), any varus deformity should be passively correctable, minimal lateral disease on arthroscopy, no inflammatory disease.

Positioning: Tourniquet, Supine on table with arthroscopic knee holder. Flex end of table down. Need to be able to get full extension and flexion to 115 degrees. Opposite leg in gyn leg holder. Ensure that femur is parallel to the ground by lining up the greater trochanter and the lateral epicondyle.

Prep/Drape: Prep (Stemach uses Duraprep), Mayo cover over contralateral leg. Impervious stockinette - holds foot while prepping, then roll all the way up to the leg holder. Put extremity drape up to the leg holder. Place extra sheet over opposite leg and ipsilateral arm. Cut stockinette verically over knee and transversely in each corner to tuck away from the field. Wrap coban from toe to below the opening. Put iodoform drape over skin. Mark intended incision: 3" (middle finger length) from top of patella to medial tibial plateau.

Arthroscopy: Esmarc, tourniquet. Make longitudinal medial portal in line with intended incision. Place scope. Examine medial compartment (quickly), ACL, lateral meniscus. Decide. Remove scope stuff.

Procedure: Make incision. Feel the top of the patella medially. Make 1 cm transverse cut. Make medial parapatellar arthrotomy. Do your medial release. Take out fat pad. Place weitlander. Remove medial meniscus. Reflect the periosteum overlying the medial patella. Remove 3/8" bone of medial patella with sagital saw blade.
Make sure tibial and femoral alignment is correct. Remove 5-8mm of posterior condyle with a sagittal saw blade and osteotome. 5/32" Steinmann pin in the midportion of the medial femoral condyle directed in line with the shaft of the femur. Same pin makes drill hole in proximal tibial ~ 1:1/2 inches below surface, directed medial to lateral. Remove weitlander. Place traction pins in holes. Place distractor. Place body of the distractor laterally with sponge clamped to secure it to the drape. This ER's the tibia. Replace weitlander.

Tibial Preparation: Finish medial menisectomy, flex knee to help. Use 5.5 round burr to burr the posterior condyle. This will help for the contour of the component and improve visualization. In center of tibial plateau, sink round burr to 5 mm posteriorly and anteriorly. Connect the trough with the burr. Make semi circle with the burr out to the medial edge. Keep anterior edge. Check smoothness and size with 32 mm trial. Expand laterally as necessary. Use cone burr to smooth surface. Use fissure burr on edges. Place trial, check for stabiltiy using a hemostat. Work on tibia until happy. May have neutral up to 10 degree varus cut. May have 5-10 degree posterior slope as well.

Femur Preparation: Remove distractor. Use femoral trial guides on the handle to determine the correct size. Methylene blue around the edge. Use the round burr to half depth to make 2mm deep test holes. Connect the holes to remove adequate bone.
Mark the weight bearing center of the tibia with a marking pen dipped in methylene blue. Then mark the desired center of rotation of the femur. Mark the femoral condyle at the desired mid-point of articulation with the tibial condyle. Also mark the femoral condyle corresponding to the the desired center point of the femoral prosthesis. Expect up to 15 degrees of medial tilt. Tap the femoral guide in, centered over the blue line. Use the guide as a gouge. Place steimann pins in the superior and inferior holes, angled slightly away from center. Bend them out of the way. Place the central bushing and drill to controlled stop. Remove guide. Use sagittal saw to make vertical keel-slot. Follow with fissure burr.

Component Insertion: Remove hardware, irrigate thoroughly. Tap femoral trial into position. Tap in trial tibial component. Go through range of motion, check for impingement, tibial component teetering, full contact through range.
Repicci Unicondylar Two
?Does the tibial component popup anteriorly? Then deepen the posterior tibia to improve flexion
?Is the ACL too tight? Then deepen either the posterior tibia or femoral prosthesis.
Do Not overstuff. It puts more pressure on the lateral side.
Remove components, thoroughly irrigate. Mix the Palicos cement. Inject posterior capsule and skin edges with 0.5% Marcaine with epinepherine. Place first sponge in suprapatellar pouch to absorb, then remove. Place second sponge to stay in until after cementing. Next sponge is twisted thin and stuffed posteriorly behind the femoral condyle. Stuff one into the femoral keel and one against the tibia. Remove the tibial one and cement the tibial component with a fingerful of Palicos cement. Use cobb to pressurize against the femur. Remove excess cement with freer and dental pick. Remove femoral sponge. Place cement on the femoral component and pack into distal femur with finger. Tamp into place. Remove excess cement. Cure the cement in full extension. Remove femoral osteophytes with osteotome.

Closure: Irrigate. Place 10 flat Jackson-Pratt drain out through superolateral stab incision. O Polysorb, 2-0 polysorb, staples. 4x4's, webril, 2x6" aces. Knee immobilizer.

Postop: Toradol, Demoral, home with vicodin and Bextra. WBAT with knee immobilizer for one day, then start knee motion. Should have 90 degrees by first week. Use walker for 4 days, then cane. May do stairs after one week. May drive 1 week after left, 2 weeks after right.

Wish list:
Arthroscopic leg holder
Arthroscope with set up
Opposite leg gyn leg holder
Space suits
Tourniquet
Headlight
Sagittal saw
Wire driver for 5/32" Steinmann pins (4)
2 bulb syringes
Stryker burrs 5.5mm round, core, fissure
Methylene blue
One Palicos cement
0.5% marcaine with epin
20 gauge spinal needle
10 flat jackson-pratt drain
Mayo cover for contralateral leg
Impervious stockinette
Extremity drape
4" coban
iodoform drape
6" esmarc
11 blade
bovie
Medium weitlander
Army/navy
Homan
Suction with frazier tip
Freer
Dental pick
Cobb
Flat osteotome
0 and 2-0 polysorb
staples
4x4's
webril
2 x 6" ace
knee immobilizer


Retrograde Femoral Nail

Indic: Supracondylar fx > 2 cm from art surface
Pos: Supine, hip bump, vascular table, fluoro, sterile thigh tourn
Inc: Midline over patella tendon
Split tendon, retract w/ gelpi, 2 ortho props under knee, use guide wire to find middle of trochlea on both planes.
Overream pin with reamer.
Close reduce fracture
Place guide wire. Ream to 1 cm above. Choose length rod from preop xrays. Insert rod with jig laterally.
For Trigen (Richards) nail, Y like jig to place straight horizontal, then one oblique screw. To place second oblique screw, take off jig and put in back on medially (optional screw).
Replace jig with long armed jig and place two proximal screws.
Close patellar tendon defect.
TTWB, easy, limited ROM


Spanning Ex-fix knee

CT scan
Howmedica ex-fix, call Brian
- Proximal pins thru ant. femur, use guide
- Distal pins thru ant-medial tibial cortex.
- Pull out to length, fix varus/valgus
-Outriggers to hold with knee flexed 20 degrees
- 7.0 cann screws to close down articular surface. Use large reduction clamps percutaneously.


STSG

CPT 15120
Use Mineral Oil and tongue depressor for skin tension with electric dermatome.
-Set dermatome between 10 and 12. Check with bevel of scapel for correct depth
-Place skin side up in 1:1.5 mesher
-Mesh the graft
-Attach with staples or suture, trim redundant edge
-Stent dressing or a Xeroform and hold in place with a bulky dressing secured by circumferential conforming gauze.
-Change dressing every 5-7 days, remove any necrotic graft with dressing change.

Donor area covered with a tegaderm for 2 days then changed to a new one for 1 week. May then leave open to air.

Campbell's 3299


Supra condylar femur fracture

Vascular table
Synthes 95 degree plate
(RIchard's guide is off)
- Incision centered btwn straight anterior and straight lateral, aimed towards Gerdy's tubercle distally.
- Split IT band
- Split btwn Vastus Lateralis and Rectus
- Split V Inter to expose condyles
- Mark lag screw site: Midpoint of the anterior half, parallel with the joint line
- If condyles split, use 7.0 screws to hold, reduce with large reduction clamp percutaneously. Place screws posteriorly and inferiorly to avoid lag screw track.
- Reduce condyles to shaft to gauge length of plate
- Do Not strip fracture anteriorly, avoid reverse retractors when possible
- Place lag screw and plate
- Short compression screw.

Post-op:
Hinged knee brace to protect varus/valgus
AAROM, AROM, NWB 8-12 weeks



TFN--Synthes Titanium Trochanteric Fixation Nail

Fracture table/fluoro
Inc: oblique from tip of trochanter
3.2mm guide pin from just lateral to the tip of the GT to past the lesser troch
Lateral angle is 6 degrees
Protection sleeve and wire guide
17.0mm cannulated drill bit to the stop
Assemble nail to insertion handle
To insert, start with handle anteriorly and rotate laterally
Place correct angle connecting sleeve
Blade guide sleeve with buttress compression nut down to bone
3.2mm wire guide to approp position
(could use miss-a-nail attachment here prn)
Measure for length of helical blade
Open lateral cortex only
Tap in blade
Lock from top
Turn nut for compression
Remove insertion sleeve
Drill guides to place distal bolt (obliquely)
Read length directly, insert


Tibial plateau Arthroscopically Assisted
For facture reduction for Type 2


Vascular table, kidney rest, c-arm
Scope, Arthrex ACL guide, "crouton" bone chips, tamp, Ace-Depuy cannulated titanium screws

-Scope
-Use Arthrex ACL guide to target depressed area
Place pin below the surface
Use drill to open up cortex only
Use tamp to push fracture up to reduce
-"Crouton" bone chips to pack
-Ace cannulated screws across with washers


Tibial Plateau Fracture

Medial side is larger/concave
Lateral side is higher/convex
Most common, valgus compression force
SCHATZKER
I - wedge/split fx of lat - lag screws
II - split depression lat - butress
III - depression lat - butress/BG
IV - split/split-dep medial - look for avul of intercondylar eminence; disloc, peroneal N. or popl A. injury
V - split med and lat - axial load - span then plate
VI - metaph fx separates shaft

II approach:
CT Scan
- Split the difference btwn Gerdy's tubercle and fibula head, curve around lateral patell
- Incise the capsule below the meniscus horizontally, use rake to retract up
- Open split like book, only strip periosteum at edge
- Lift depression up en masse
- Bone graft
-Zimmer small (3.5) periarticular plate with 4 screw on top, can put pins thru plate for provisional fix.

Post-op: Hinged knee brace for AAROM, AROM. NWB 8-12 weeks

V approach:
CT scan
Howmedica ex-fix, call Brian
- Proximal pins thru ant. femur, use guide
- Distal pins thru ant-medial tibial cortex.
- Pull out to length, fix varus/valgus
-Outriggers to hold with knee flexed 20 degrees
- 7.0 cann screws to close down articular surface. Use large reduction clamps percutaneously.


Total Hip Replacement

Position: Supine on hip bump (2 x 6 x 12") centered under umbilicus.
Foot rest 40*
5 deg trendelenberg, 5-10 deg away
Prep: nonsterile U and 1010, wrap foot w/ 1010
Leg length check
Candy cane to prep

Downsheet
Impervious stockinette to midthigh
U-drape
Cross drape
Outer gloves off
Coban, fold stockinette back
Marking pen - Greater Troch, shaft, anterior 1/3 centered at tip of troch, cross hatch
Ioban drape - one large, one cut 2/3's for perineum
Attach drain pouch

Skin incision down to fascia lata
Sponge and hibbs to top
Sponge to bottom, bovie
Knife and mayo's thru distal fascia lata
Abd leg, mayo's thru proximal fascia, superficial to Gl. Max
Split Gl. Max w/ thumb, bovie, sponge
Move hibbs up to anterior flap to expose Gl Med.

Thumb to split anterior 1/3 of GlMed
Lift up, bovie tendon to troch
Blunt homan/cobra anterior and posterior to neck
Split the GlMed muscle to greater troch to visualize the capsule
Clear the capsule. Split transversely w/ bovie, just posterior to muscle split, from troch to acetabulum, remove retractors
Cobb to lat femur below ridge, bovie 2 inches, Bennet anteriorly
Semicircle anteriorly to connect splits w/ bovie (cut current).
Lift w/ hibbs, ER to expose to medial neck and lesser troch
+/- Bone hook, ER, lateral pull to dislocate hip
Cross leg (Adduct), ER

Really cross leg over the other to expose, knee straight up
Rasp and bovie to mark fem neck cut
Blunt homans to protect, sag saw cut, broad osteotome, towel clip
Save head for bone graft

Ankle to ankle adduction
Cobb up and over anterior labrum (12 o'clock), tap hole, replace with blunt homan
Spiked Mueller acetabular retractor for superior capsule (3 or 9 o'clock) aimed slightly cranial to avoid tip exposure and reaming.
Use impactor and mallet to seat and give to 1st assistant
Double footed, double angled Mueller retractor goes up and over cut femur to seat below inferior acetabulum. Holds femur out of way. Lift femur with ring and long, direct with index finger. Second assist reaches around knee to hold this one.

Excise labrum with hemostat and long knife.
Find teardrop with cobb, this will be where the inferior rim of cup sits
Rongeur prn, avoid excessive resection inferiorly to protect retractors

Ream. Start w/ 44-48. Medialize. Can't retrovert (run into shaft). Keep handle resting on femur, elbow on table.
Neutral to 5 deg of anterversion, 35-40 degrees from horizontal
Check acetabular floor continuously. Go up by two until two less than template.
Check for bony coverage
Irrigate, curette, bonegraft
Seat component (2 sizes bigger than ream, 1 if really sclerotic) with 3 holes superior lateral
Impact directly and from 1st assistant's side (medialize) on an impactor
Check with hemostat to be down.
? screw? Superior lateral, drill, measure, screw
Tap in liner with 10 degree offset posterior lateral.
Check for stability
Remove inferior retractor, ?osteophytes?
Irrigate, sponge in poly

Flex and adduct leg to expose prox femur, knee up
Wooden handled, double footed retractor to lesser troch
Bennet beneath greater
Rongeur, curette as canal finder, box cutter
One reamer to start
Broach to pitch and template
Neutral head and neck to reduce and trial
Longitudinal (less than 1-2 mm)
Flex to 90 degrees, adduct, IR/ER
Check leg lengths
Dislocate, place real femoral component, careful about version
Trial reduce for neck length
Clean off taper, real head, reduce

Drain thru separate anterior stab
Close capsule #1 Polysorb
Close Gl Med/Min tendon with #1 polysorb
Run muscle split and vastus lateralis with #1 polysorb
Fascia lata with fig 8 #1 polysorb
3-0 Polysorb, staples
Abduction pillow
XR in PACU


Total Knee Replacement

NextGen Zimmer
-Place Beanbag (or knee holder if only one assistant)
-Disposable Tourniquet, foley, 1010 to foot, Blue U, hip bump
-Check for knee contracture, ?take off plate
-Midline incision, dissect medially
-Medial parapatellar arthrotomy: cut Quad tendon, medial to tib tubercle and parapatella
-Cut out fat pad, patello-femoral attachments
-Medial release
-Evert patella, notchplasty, excise ACL/PCL
-Fork and lateral homan, excise menisci, save popliteus, superficial geniculate artery
-Cutting guide, spike just lateral to posterior spine, center over tibial crest with bottom in line with medial ankle gutter for varus knee, tamp down, pin, check depth, cut
-Spacer with rod to check cut
-Size tibia
-Punch and reamer to femur
-5 degree, correct side to sink sword
-Drop anterior guide on, fix with pins thru zeros.
-Take out sword, protect tibia, cut
-Check extension gap and alignment with 10 block plus rod
?Cut more
-Check tension, more medial release?
-Size femur, place correct size put anterior smooth pins in slots, spring pins
-Cut anterior, anterior chamfers, posterior, posterior chamfers.
-Smooth posterior osteophytes
-Notch guide, centered, chain saw blade
-Tamp in trial, don't let it flex by holding a homan around the rung.
-Trial poly for fit and rotation, mark rotation with bovie
-Prepare tibia, trial
-Assess patella for resurfacing
-Remove trials, power irrigate
-Put cement on tibial and femoral components
-Tamp in tibia first, protect and place femoral.
-Slide in poly, hold axial pressure with 10 degree flexion to pin down back.
-While cement hardening, take osteophytes off patella, rasp, bovie
-Irrigate remove cement
-Trial, place poly, check for patella tracking.
-Close in layers over orthopat drain

Ranawat's concotion for prior to closure:
Marcaine 80 mg
Depo-Medrol 40 mg
Morphine 4 mg
Epinephrine 300 mcg
Zinacef 750mg
Clonidine 100 mcg


Unicompartmental Knee Arthroplasty 1

Zimmer M/G Uni, MIS
Best indications: old pt, low demand, low weight. Flexion of at least 105 degrees, <10 deg varus, 13 deg valgus.
93% survivorship at 16 years
Average 125 degrees motion

Surgical Technique
Spinal with Duramorph for 36 hours pain relief
1000units IV push Heparin just before the tourniquet goes up
Tape one sandbag at 30degrees flexion, other at 100.
In flexion, cut mini arthrotomy from 1cm proximal to superomedial border of patella, to proximal tip of the tibial tubercle, or 1cm below the joint line centered over the medial condyle, centered about just medial to patellar tendon. Length is about 10-12 cm. Need to cheat proximally if anywhere.
Put knee in extension to raise flaps, especially proximally
Cut thru retinaculum. At the top, go from straight vertical at 6o'clock to 2 o'clock (R knee) along the fibers of the vastus medialis to help exposure (other option is to T it here) to expose proximally. May need to take some fat pad down.
Elevate off the joint line with the bovie for medial release of deep MCL.
Place headed pin superomedially as retractor for VMO
Take down osteophytes on femur
Flex to 30 to loosen patella, drill the femur with 8mm drill. Expand hole with curette
Place S retractors
Tap in IM femoral resection guide (check side and compartment) to sit onto distal condyle. Have to sweet talk and flex and extend knee to get jig into soft tissue envelope. Set bottom to be parallel to intended tibial cut, predrill and place headed pin (or rachet in threaded pin).
Orient top jig- distal femoral resector block (lateral one is gold) to be perpendicular to intended tibial cut, place pin, ?4 degrees?
Reciprocating or oscillating saw to cut distal femur. Take out pin before finished, take jig off., place patella retractor in IM hole, complete cut free hand. Make sure it's nice and flat.
Size the femur. Have flush against the cut surface and the posterior condyle. Aim to have 1mm perimeter of bone showing. Make it vertical. Cheat the guide towards the intercondylar notch if necessary. If between, go smaller
Drill superior hole, fill with headed pin
Drill the anterior post hole and insert a holding peg
Drill the posterior post hole
Drill a side hole and fill with headed pin
Cut the posterior condyle.
Remove the holding peg (lug) and cut the posterior chamfer.
Trial femur on handle for fit. Remove

Cut the tibia:
Place sharp narrow Hohmann around the medial tibia.
Place tibial resector so distal tip is over 2nd MT.
Position top of resector proximal to the tibial tubercle.
Adjust posterior slope to 4 degrees, less than halfway.
Want neutral (no 7 degrees valgus in totals)
May need to release posteromedial joint corner
Check with tibial depth 2mm tip of the stylus at the deepest portion of the plateau, tighten bolt
Just medial to ACL insertion fibers so reciprocating saw doesn't cut them
Predrill and place headless pins into 0 slots on cutting platform.
Check with finger and 10mm side for medial border.
Check sagittal position.
Place spring pins.
Mark the sagittal cut first with bovie and osteotome and then cut with reciprocating, leave blade in cut
Protect MCL and cut transverse tibia.
Size the tibia with the metal lollipops (usually 1 or 2)
Osteotome for posterior femur osteophytes, ?arthroscopic basket works well

Put femur trial back in and trial poly lollipop sizer for size and alignment with rod
Check with 2mm side of tongue blade in both flex/extension (or trial the next poly size up)
Take out trials
Use reciprocating saw to cut lateral keel for tibial trial
Place tibial trial, use shoe horn to knock down and back
Drill and place headed holding pin anteriorly
Drill tibial pegs, angled 20 degrees
Snap in poly, check tracking.
Remove trials, pulse lavage, mix cement

Place cement on tibial component.
Place raytec in back.
Put down posterior edge first then bring down anteriorly to keep cement from oozing out the back so much.
Cement and impact femur
Extend to place plastic, snap in

Place regular drain for one day
WBAT
Coumadin 2-6 weeks

For lateral, mirror incision. Don't T, just higher straight proximal
Get component as lateral as possible to avoid patella

Foot Procedures

Anterior Process Fx Excision

MOI: plantar flexion/inv
Treat conservatively, can inject
Location: Thumb on tip of fib, long finger on tip of 5th MT tuberosity, crooked index finger equidistant between the two should lie over it.
Ollier incision: from 1 cm distal and anterior to the tip of the fibular malleolus, obliquely across the sinus tarsi, and ends at the superolateral margin of the TN Jt.
Post-op: LPW, NWB *4 weeks
Non-op acute: LPW, compression stocking, NWB *4 weeks


Baxter's Nerve Decompression, partial PF

1st branch of the lateral plantar nerve, Nerve to the Abd Dig Minimi
ICD-9 956.4 CPT 64704, 28060 (list first)
Inc- Oblique medial heel incision in a superior posterior to medial distal direction is used. Along the course of the PTN from just distal to the top of the calcaneus, aimed at the medial calcaneal tuberosity.
-Deepen to the fascia of the abductor hallucis muscle.
-Avoid the branch of the medial calcaneal nerve that is superficial to the fascia.
-Visualize the whole abd muscle from superior to inferior border and incise the fascia in line with the skin incision.
-Elevate the muscle superiorly to expose the deep fascia.
-The lateral plantar nerve and the NAbdDigQ located here. Identify at the superior border and follow.
-Follow distally and inferiorly to the point where it passes btwn the flexor brevis and quadratus plantae.
-Resect a small rectangle of the plantar fascia, medial 1/3, and lower 1/4 of the deep abductor fascia here as well.

Postop- Compressive dressing, NWB 10-14 days, increase to WBAT at 3 weeks.

Lutter 186, Baxter 13


Calcaneal Malunion

Sanders article in SF Advanced Foot course manual. FAI 395-401, 1996.
Type 1,2,3


Calcaneus ORIF

Vasc table, ICBG, tourniquet, blankets, peg board, pinkies, ax roll, fluoro
Inc-lateral extensile approach just ant to achilles, curve @ corner, jct of skin & plantar surface. Full thickness flap w/ no touch technique. Careful @ both ends for sural n and peroneal tendons, otherwise, straight to bone. Use k-wire in f ib shaft, cuboid and talus.
4.0 schantz pin in corner of wound.
Evaluate lateral wall. Take off @ angle of Gissane and save to see articular surface. Rotate the depressed fx fragment out from w/in the body

Type 3 with articular comminution or Type 4? Primary subtalar fusion with bone graft. If evidence of early fusion might beging PWB in LPW at 8 weeks. Only 3 months until back to work.

Norian after done takes 10 minutes to set up.

Dave Levine's postop: splint two days only. then CAM walker at 48 hours. and begin a/aarom
ankle/subtalar/circumduction. at best 50-66% normal side.


Charcot Arthropathy

Stage I: acute inflammatory process. Dissolution, fragmentation and dislocation. Hyperemia, swollen, hot and red. Elevation, NWB at least 8 weeks.

Stage II: Coalescence, reparative process. Less Edema, warmth and redness. New bone formation.

Stage III: Consolidation and healing. Enlarged wotj exiberamt fracture healing. Edema resolves.

TCC or TCCBrace for at least 6 - 12 months. Might move to a plastizote lined AFO Diabetic shoe at 6 - 12 months.



Compartment Syndrome Foot

ICD-9 Crush foot 928.20, Early complications of trauma 958.8
CPT 28008, Skin closure 1200x (depends on size), STSG 15120

Medial - ABH, FHBr
Central - FDBr, Lumb, QP, AddH
Lateral - FDM, ADM, OppDM
Interosseous
Calcaneal - QP, LPNerve

Dorsal plus Medial approach:
-Incisions over 2nd and 4th MT
-Use Kelly around 5th and 1st MT's
-Incision medially for ABH superficial and deep fascia

Meyerson's Medial approach:
-Inc immediately beneath 1st MT
-Release super and deep fascia of ABH
-Retract the AHL muscle inferiorly, the take kelly up into interossei and thru Central in two layers

Leave open plan to close in 3-7 days. May need STSG

Soft dressing until swelling subsides and ambulation comfortable (at least 2 weeks)


CUBOID EX-FIX

Indic- Comminuted cuboid fracture, used for lateral column lengthening
EBI mini fixator
1. Inc -- transverse to expose ant neck of calcaneus, across cuboid to TMT jt.
2. Check TMT jt for comminution.
3. Load EBI fixator with two clamps with distraction nuts btwn each clamp.
4. K-wire thru most prox clamp hole (top or bottom pair) into ant. calcaneus. May cut and spread skin first.
5. Check on OEC.
6. 2nd K-wire thru distal clamp hole into 5th MT base, check on OEC
7. Put 3rd K-wire thru other and opposite proximal hole.
8. Remove 1st k-wire and replace with half pin. Don't over penetrate -- will get loose if have to back out.
9. Replace 3rd pin w/ half pin.
10. Place 4th pin in distal clamp. Replace 3rd/4th with half pins.
11. Freeze OEC picture to compare after distraction.
12. Tighten everything except one distraction nut. Distract one side then the other.
13. Check on OEC.
14. Open window in lateral cuboid just under distal art surface. Use curette to lift up art surface. Fill defect with tibial graft or collagraft.



Double Hindfoot Arthrodesis

Indic: AVN collapse of the talus
Pos: Lateral decub of peg board, tourniquet, prep out PICBG
Remove any previously placed hardware from talar body.
Inc: Posterolateral along achilles thru fatty tissue. Move FHL medially. Expose and excise PTiFL, and TFLig's.
Flex knee and ER hip to place femoral distractor with 5.0 Schantz pins in medial mid- tibia and superior posterior calc body.
remove necrotic talar bone until talar neck bleeds. Remove articular cartilage from distal tibia and posterior calcaneal facet.
Make sure foot is in neutral
Place first screw: guiding hole with 4.5mm drill from posterolateral distal tibia --> middle of remaining talar neck -->cross the anteromedial portion of the tibial plafond. Continue with 3.5mm drill into talus. Use long threaded (32) 6.5mm screw.
Get XR to check position and placement.
Measure gap. Drop the tourniquet.
PICBG: Vertical incision over the posterosuperior spine ~ 4 cm long. Dissect thru fat --> lumbrosacral fascia. Straight inc thru fascia onto periosteum over the spinous prominence. Extend prox ~ 3 cm towards crest.
Remove fibers of the glut max and erector musc's from med and lat sides.
Insert Taylor retractor 3cm down on lateral side, Cobb medial.
Parallel cuts with osc. saw at correct width. Use curved osteotome to complete horizontal cut. Take some cancellous bone before closing.
Pack wedge and cancellous bone graft. Remove distractor.
2nd screw sent from heel --> calc--> graft --> use 3.5 drill thru anterior tibial plafond (~95 mm).
3rd screw from lateral calcaneus vertically thru graft and distal lateral tibia. Use ~ 130mm fully threaded cancellous screw.
Pack any addition graft and close.


FDL Tendon Tx

Saltzman post op:
SLC w/ perc pin in TN, SLC PF/Supin
3 weeks, pin out, mold for UCBL, SLC in neutral.
6 wks, check XR for WB in LPW w/ UCBL.
10 wks, transfer UCBL to shoe.
6 months, remove UCBL.
Suzette,
Thanks for your note. I apply a splint ( U and posterior) in the OR with the foot in 10 degrees of plantarflexion and ten degrees of inversion to take strain off the transfer. I tell patients to keep their "toes above their nose" for 5 days and then nwb with elevation when possible. At 2 weeks ( now) I am taking off the splint, molding the foot in a talonavic neutral position for a ucbl. We use with trilam (ACOR) for slender patients and poly backing with pelite for bigger patients. We then put them into a SLC at neutral for 3-4 more weeks. Mark Myerson, I am told, doesn't use a cast anymore but simply uses a boot. If you use a boot you may want to use an aircast boot and a warm and form insert (wrymark, st louis) or plaster/felt to hold position. I do all this with an orthotist who has an office in our hospital and comes to my clinic at the time of cast change.
Hope that helps
I will try to attach photos of our box for the hindfoot alignment view. It costs around $500 to make. A large piece of solid foam might also work.
Thanks

Charlie



Haglund's Syndrome

ICD 726.7/ CPT 28118
Position: Supine with contralateral hip bump, kidney rest, thigh tourn
1a. Pfeffer -might consider going laterally because attachment is stronger laterally. Prone.
1b. Anderson -Might consider going posteriorly through the tendon especially if lots of calcific deposits the problem. Prone.
1. 4 cm linear sikin inc 1 cm ant and parallel to the medial border of the Achilles tendon. Extend distal onto the calcaneus
2. Carry inc to fascia
3. ID medial border of Achilles and retract medial calcaneal nerve
4. Expose and excise retrocalcaneal bursa
5. Subperiosteal dissection at the insertion of Achilles, 50-70% from medial to lateral
6. Excise calc prominence with saggital saw, ?reciprocating rasp
7. Drill holes in medial and superior calc to reattach achilles insertion
8. Irrigate, close in layers
9. Splint
10. NWB cast in neutral * 2 weeks
11. CAM walker, NWB * 2 weeks, then WBAT


Jones Fracture

Fracture extends into articulation of the 4th MT
Nunley -Recommend surgery to all active patients. Use big noncannulated 6.5 screw


Kidner Procedure

CPT 28238
Mann 485
Indic: Accessory navicular
Pos: Supine, thigh tourniquet
Inc: Long, parallel to the upper border of the PTT starting 1 cm ant to tip of the MM and extending to the medial cuneiform.
Dissection: Down to the sup border of the PTT along the inc until the tendon courses plantarward beneath the navicular.
ID the accessory nav and excise it sharply.
If the tendon is to be rerouted, detach it as distally as possible.
If there is significant prominence to the medial tuber., osteotomize and resect.
If the PTT is to be advanced, a dorsal/plantar drill hole is placed through the navicular. The tendon is the passed in a plantar-to dorsal direction thru the drill hole and sutured back to itself with the foot in maximum inversion/equinus.
If not to be advanced, suture to the navicular with a #1 ethibond or suture anchor.
Postop:3wks NWB, 3wks WB or 4 wks equinus/add NWB and 4 WB.


LATERAL SESAMOID EXCISION

1. 1st web space incision, dissect thru soft tissue like modified McBride.
2. Use small tenaculum or K-wire to spear sesamoid.
3. Free one end and shell out
4. Protect FHL


Ludloff

-modified McBride
-medial incision. Don't do medial eminence yet.
-inverted L capsule - apex dorsal/proxim
-begin cut 3mm distal to dorsl edge of MTC joint. 25 degrees. Cut 2/3 of way at right angles.
-use 2mm fully threaded pin as drill starting at least 8 mm from osteotomy start, directed proximal and plantar.
-reverse ruler
-switch to smooth pin
-place screw, don't sink
-complete the osteotomy distally
-rotate the osteotomy with screw as axis
-once desired correction is achieved, place second screw from plantar medial to dorsal lateral across the distal segment. start with 2mm guide pin.
-trim excess bone from prox dorsal and plantar distal fragment with edge of saw.
-resect medial eminence from dorsal to plantar
-capsulorrhaphy
-WBAT in postop shoe until at least 4 weeks.


MEDIAL SESAMOID EXCISION

1. Supine, ankle tourniquet
2. Inc along medial eminence, more prox than usual bunion one
3. Watch for dorsal nerve, dissect inferior flap
4. Incise capsule btwn sesamoid and met head.
5. Protect FHL while dissecting sesamoid free
6. Reattach Brevis tendon
7. 4-0 Monocryl, dressing, DARCO


Navicular Stress Fractures

Vague symptoms, activity related
?Short 1st MT, MT adductus
Bone Scan
CT scan: 1.5 mm Axial cuts, 3mm Coronal cuts
Fracture occurs between medial 1/3 and lateral 2/3's because of blood supply and repetitive loading
-Non-op tx for incomplete fx's:
6 weeks NWB in cast, then WB exercise, ROM, strengthening * 4 weeks
-ORIF +/- bone graft, screw lateral to medial


Os Trigonum excision

@ the posterior process of the talus.
Usually gradual pain exacerbated by PF
Ddx from retrocalc bursitis and bipartite talus
1. Lateral decubitus position w/ thigh tourniquet
2. Long incision ~5 cm over the retrocalcaneal space posterior to the distal aspect of the fibula
3. Retract skin, incise fascia, Protect the Sural Nerve, retract the peroneal tendons
4. Denude the os trigonum from its attachnents
5. Smooth remaining articular surface
6. Close fascia and skin in layers
7. Compression dressing. TTWB X 1 week.


Peroneal Tendon Tears

Brodsky - SF Advanced Foot Course
Swelling most reliable finding
If tear > 50% of tendon, tenodese
Superior Peoneal Teinaculum Teconstruction?
?Groove deepening?
NWB * 6 weeks
WB brace * 6 weeks, AROM
PT at 10 weeks


PES CAVUS

Equipment: mini c-arm, bean bag, 7.0 cann screws, richards staples, 3.5 stataks, drill, sagittal saw with wide and narrow blades, k-wire driver.
Lateral decubitus on bean bag
Plantar fascia release:
1. Oblique incision from med border of foot just distal to fat pad
2. Dissect down to PF, release. Protect LPN.
3. 3-0 Vicryl, 4-0 mononcryl
Dwyer Osteotomy (if cavovarus calcaneus to make closing wedge)
1. Lateral inc from post to tip of fibula to plantar calccuboid joint
2. Protect sural nerve and dissect peroneals off the calcaneus
3. Homan's to protect sup/inf borders. Check on image
4. Long oblique cut from 0.5 cm post to post facet to 1 cm prox to CC jt
5. Second cut plantar and parallel takes out the wedge
6. Close osteotomy and fix w/ 7.0 cann screws
PL tenodesis to Pbr
1. Extend inc to sheath
2. Identify tendons, vessel loop
3. 0 Ethibond together, cut Peron Longus
1st Metatarsal Osteotomy
1. Dorso-Medial inc@ TMT jt or 1cm distal thru base of 1st MT
2. 1st cut thru jt, 2nd cut distally takes out dorsal wedge
3. Check orientation on flat plate
4. Fix with dorsal staple (medium Richards)
PTT tendon Transfer
1. Short medial incision over navicular to excise PTT from insertion.
2. Another short inc 10 cm prox to MM tip just behind tibia to identify and pull up tendon
3. Another incision, at the same level, on the lateral side of the tibial crest.
4. Retract the anterior compt and the NVB laterally to obtain access to the IOM.
5. Make a 3cm window to pass the PTT posterior to the tibia and then subcutaneously down to the 4th incision over the cuboid.
6. Use 3.5 statak to anchor tendon at correct tension to the cuboid.
1st toe Jones Procedure
(When hyperextension of te 1st MTP joint secondary to ATT weakness to make the EHL overwork to DF the ankle.)
1. Skin incision is elliptical over IP joint
2. Cut collaterals
3. Prepare the IP joint for fusion
4. 4.0mm screw thru toe tip
5. Dorsal longitudinal inc over MTP joint -> 5 cm proximally
6. Isolate extenson tendon
7. 3-4mm drill bit to make transverse hole thru distal 1st MT
8. Pass tendon thru hole, hold ankle in 15 degrees of DF and suture tendon to itself


Plantar Fascia Release

-Supine with contralateral hip bump
1. Oblique incsion from med border of foot just distal to fat pad
2. Dissect down to PF, release. Protect LPN.
3. 3-0 Vicryl, 4-0 mononcryl


Plantar Fibromatosis

ICD-9: 728.71, CPT - 28062
Orthoses! Shoewear failure
Inpt overnight for drain.
Position -- prone, thigh tourniquet
May need total or near total resection b/c resection with less than 2 cm bridge leads to worse recurrence (57%)
Page 120, Lutter
Incision -- S from 2 cm prox to lateral aspect of 1st MT head, to just prox to lateral calcaneal bony prominence
Meticulous handling and full thickness to prevent edge necrosis.
Expose medial border of plantar fascia.
Proceed proximally, make take down fascia from calc insertion (or however proximally you need to go, ) and then dissect distally.
Watch for M&LPN's at about midpoint of medial border.
Hemostasis, let tourniquet down, ? hemovac, interupted sutures
Compression dressing, splint, NWB 10-14 days.


Subtalar Arthodesis

Pos:Lat decubitus on bean bag, thigh tourniquet, fluoro
Inc: Oblique from fib tip across dorsum to CC Jt. Weitlander. Protect Sural N and peroneals. Incise ext. retinaculum long & retract ext tendons superiorly prn
Incise EDBr origin, expose sinus tarsi
Incise T-C capsule, cervical ligament IO ligament
Expose ant. calc process
Use 39 blade to make parallel cuts just prox to CC Jt as BG from ant calcaneus prn
Use laminar spreaders in ST.
Use straight/curved currettes; osteotome to feather.
Reduce. Run guide wires from 7.0 cannulated synthes set from post. inf calc thru to talar neck. Check on fluoro.
Pack bone graft
Place appropriately sized, short thread screw.
Close in layers, Jones dr, splints
NWB at least 3 weeks.


Subtalar Arthroscopy

See ICL # 1
-Lateral decubitus on beanbag, kidney rests
-Bump
-Ankle scope, no distraction, no strap

-Portals
ANTERIOR: 2cm Ant and 1cm distal to tip of lateral malleolus
POSTERIOR: 1 cm proximal to tip of lateral malleolus and anterior to Achilles tendon
MIDDLE: Just distal and inferior to tip of lateral malleolus

Identify anterior portal with 18 gauge needle. Inflate joint with 50cc 0.5%Marcaine With Epinephrine. Other portals under direct visualization.


Talar Neck Fx's

Page 505 Fracture- Masters
Anterior reduction, posterior screw fixation
-Remember bone is softer medially so you get more comminution and liklihood for varus malunion. Might consider plating medially if a lot of comminution.
-Big Fluoro, Ace Titanium Screw, Bean Bag, Pelvic Reduction Clamps, Shantz screws
-Shantz screw in calc, plantar flexion to reduce
-Canale XR view: Oblique, pronated 15 degrees, XR beam 75 degrees from floor, ankle plantar flexed.
-Anteriormedial incision from medial malleolus, curved to Nav Tuberosity btwn PTT and ATT. Avoid deltoid branches.
-MM osteotomy, predrill 2.5 drill
-Protect deltoid
-Dorsiflex foot to hold reduction
-ANteriorlateral incision (may need, esp if comminuted neck) -Curvilinear 2 cm anterior to fib --> base of the 4th MT, thru ext retinaculum, lateral to the extensor tendons. Exposes the sinus tarsi and talar neck.
. Alternatively. Tip of fibula towards ant process of calc. Retract EDB superiorly.
-Can place screws ant-post thru these incisions
-Postererolateral approach - 3 cm vertical incision 1 cm lateral to the Achilles.
-Dissect btwn FHL and Peroneus Brevis, open the posterior capsule
-Could use 4.5 cannulated screws here
-Enter the body of the talus inferior lateral if possible. Wire should be perpendicuar to the fx site.
-Use the oblique,pronated XR view to check the TN joint.

-NWB until appears healed. NO evidence of decreased AVN with prolonged NWB beyond that.


TALONAVICULAR ARTHODESIS -- WGH

Indic: Isolated TN arthrosis
Postion: Epidural, Supine, thigh tourniquet
1. Dorsal incision over talonavicular jt
2. Weitlander, sharply dissect down to jt.
3. Confirm the distal navicular border by penetrating nav-cun jt with scapel blade
4. May need to take down dorsal half of PTT to fully access jt. Tag end with 2-0 ethibond
5. Drill thick threaded Steinmann pins divergently into navicular tuberosity and talar neck
6. Use laminar spreader btwn Steinmann pins to access jt
7. Small straight and curved currettes to remove cartilage down to subchondral bone
8. Irrigate
9. Small curved osteotome to feather surfaces
10. Check reduction. Distal tibia for graft prn
11. ORIF. Staples --If bone sclerotic, predrill w/ K-wire before tamping down staples
12. -Or- crossing compression screws
13. Resuture PTT stump with 2-0 ethibond
14. 4-0 nylon as vertical mattress sutures
15. A/P splints. NWB x 6wks, Protected WB x 6 wks.


Talus AVN

Canale XR view: foot in 15 degrees of pronation, ankle plantar flexed, beam at 75 degrees.

T/C PTB brace, core decompression, drill and microfracture, OATS procedure, and cadaveric allograft,


Tarsal Coalition Resection - Calcaneonavcular

ICD 755.67/ CPT 28116, 27690
Schedule: mini c-arm, ankle block with sedation, 90 minutes, OPS/AH, f/u 1 week for cast
8-12 y/o. Dx w/ oblique XR vs. CT
Conservative: SLC, orthotics
1. Oblique incision centered over the coalition (fullness in the sinus tarsi) starting @ peroneals -> 4cm long across the dorsum to the TN joint.
2. Mark out the SPN, protect that, the peroneals and Sural N.
3. Reflect the skin and subQ in one layer
4. Elevate the entire EDBr origin off the ant. calc process.
5. Weave a #0 chromic catgut thru the detached origin of the EDBr and strip the muscle from the area overlying the coalition
6. ID the coalition, TN, TC and CC joints with a freer.
7. Remove coalition as one rectangular piece of bone with a cm wide osteotome.
8. Osteotomy should be in line with the neck of the talus at the plantar aspect of the TN joint. Should be rectangular.
9. Clear any remaing bone and soft tissue
10. Thread strands of chromic thru 2 Keith needles
11. Pass needles thru resection and thru medial side of foot thru NWB portion of arch. Pass thru layer of foam and button from pull-out suture kit.
12. Pull tight and secure.
13. Splints, cast NWB *3 weeks, then remove button and start protected WB for additional 3 weeks.


Tarsal Tunnel Release

EMG/NCV data: > 1ms latency diff or > 6ms
Schedule: GA, 2 hours, OPS
ICD-9 355.5, CPT 28035
Position: supine, thigh tourniquet, loupes, bipolar
Incision: start 6 cm proximal to tip of MM, ~2cm post to posterior tibia, along the NVB, curve distal and plantar to TN jt/mid Abd Hall Longus muscle.
2. Thru skin and subQ
3. Thru thin lacinate lig/flex retinaculum with clamp beneath.
4. Beware of branch of med calcaneal N which is superficial to Abd HL fascia
5. Expose and free nerve proximally.
6. Incise superficial fascia of AbdHLM to mobilize superiorly
7. Trace the medial plantar Nerve (MPN) distally, beneath the AbdHL, thru the fibrous tunnel near the TN joint.
8. Develop the plane btwn the AbdHL and its deep fascia. Carefully release the deep fascia to expose the LPN and its 1st branch.
9. Retract the Flexor Dig Brevis laterally to expose any potential tunnels.
10. Follow the first branch btwn FDBr and Quadratus Plantae. Release any sharp edges.
11. Release tourniquet, bipolar bleeders.
12. Don't close retinaculum.
13. Splint * 1wk, cast NWB *2 more wks, LPW WBAT * 3 weeks.

Expected convalescence: 2-7 days
Work restrictions prior:0
WR post-op: Splint * 1wk, cast NWB *2 more wks, LPW WBAT * 3 weeks.
Full benefit time:3 months


TENOLYSIS OF FHL/EXCISION OF OS TRIGONUM -- WGH

Setup: Supine, thigh tourniquet, foot bump
1. Curvilinear inc centered over NVB from above sup border of os calcis to jus posterior to tip of med mall. Be careful, lacinate ligament is thin here
2. Divide deep fascia. Dissect anterior to NVB to avoid post branches.
3. Dissect and retract NVB w/ army/navy. Examine for anatomic anomalies
4. ID FHL sheath by moving toe. Open fascia prox first, continue distally. Careful distally esp.
5. Retract tendon and inspect for nodules, loose bodies
6. Retract FHL w/ NVB. Os trigonum just on lateral side of tunnel. May need capsulotomy. ID sup border of os calcis for help
7. Dissect subtalar jt med to lat to get underneath. Remove w/ circumferential dissection. Inspect post jt
8. Irrigate wound, check for impingement. Close w/ chromic in neutral.
9. WBAT w/ crutches. Early motion. Recovery 8-12 weeks



TMT ARTHODESIS W/ DISTAL TIBIAL GRAFT

CPT 28730, 20900
1. Center longitudinal incision over affected TMT joints or oblique incision from navicular medially to second webspace at the level of the midshaft of 2nd MT.
Neurovascular bundle is btwn 1 & 2
2. Expose jts, check on OEC.
3. Curette, burr, k-wire to prepare surfaces to bleeding bone.
4.Determine whether to harvest distal tibial bone graft vs ICBG
5. Inc- travel proximally from medial malleolus to flat part of distal tibia. 3 cm long inc. along midline.
Protect saphenous vein
Dissect down to periosteum.
6. Use 0.62 K-wire to outline an oval
7. Small osteotome to connect the dots, take out cortical piece
8. Small currette to scoop out cancellous bone and pack.
9.Use 3.5 cannulated guide wires to hold reductions. Cross one from !st MT to middle cuneiform, medial cuneiform to 2nd MT and 3rd MT to lateral cuneiform. Check OEC
10. Drill, tap, screw each.
11. Close in layers. Ankle block for post op comfort?
12. Splint, NWB 6-12 weeks.


Triple Arthrodesis

1, Position-bean bag so can work on lateral side and get bone graft. Thigh tourniquet.
2. Incision-tip of fibula to base of 4th MT (1" dorsal to 5th tuberosity, 1/2" distal). Deepen thru subQ and fat. Protect Sural N. plantarly.
3. EDB dissected up or off proximal insertion.
4. Remove fat and interosseeous ligament from sinus tarsi
5. Place laminar spreader in sinus tarsi, under talar neck.
6. Use a cobb to peel cartilage off posterior facet. Use curettes, rongeurs, burr to clear.
7. Crank open CC joint with elevator and prepare in similar manner.
8. Use 0.62 K-wire and smallest osteotome to prepare surfaces.
9. Dorsal medial incision -- along the ATT over the talar neck and talonavicular joint. Open the TN joint. Remove dorsal osteophytes. Lever open with cobb, prepare surfaces. Irrigate.
10. Manipulate into plantigrade foot with ST joint in 5 degrees valgus
11. Run 7.3 screw guide wire from talar neck laterally to calcaneal tuberosity. Measure, tap, screw
12. Check position
13. ICBG?
14. Staples to TN and CC joints
15. Repair EDB, 2-0 and 3-0 Vicryl, 4-0 Nylon
16. Post and U-splints, NWB * 6 weeks