Proximal Femur Fracture Repair Using Femoral Nail
This patient was quadriplegic and was wheel-chair bound. He had fallen from his chair while attempting to moved into bed or elsewhere. The proximal end of the femur (thigh leg bone) was completely detached.
A large incision (10-12 cm) was made in the hip of the patient, after have his leg placed in traction (tension, pulling) on a specialized table. This would allow for the nail to be placed (within the bone itself) and then put into a state of compression. A large (0.060") diameter pin was drilled into place along the axis of the femur, which would be used as a guide for the rest of the procedure. After correct placement was checked with a portable x-ray machine, a large drill was used to drill through t he top (proximal) end of the femur. This hole would be large enough to place the nail into the bone.
A measurement of the depth of the bone was made and repeated for accuracy, followed by the selection of the appropriately size femoral nail. This nail was attached to an insertion device and locked into place. This would allow for the nail to be positio ned properly and hammered into position while x-ray was used to verify correct positioning.
After the nail was hammered sufficiently into place, the initial pin was removed and a screw was driven sideways through the proximal end of the nail. This positioning was achieved by the insertion device, which is designed to accommodate the placement o f the final (lateral) screw. This screw would ensure the nails continued correct placement and orientation.
Reconnection of Thumb Bone Fragment
As seen from the x-rays of this patient, there was a bone fragment which was completely detached from the distal end of the medial bone of the right thumb. Once the patient was incised and inspected, it was determined that the ligament was still attached to the bone fragment, so re-attaching the bone fragment would restore motion and ability for this finger.
A single mattress suture was used on the dorsal side with a button placed on the palmar side of the thumb. A single 0.035" pin was used to immobilize this finger so that no motion would impede the healing process.
The skin was closed and lightly dressed with gauze (and adaptix near the skin).
Spinal Pain Stimulator Battery Replacement
Unlike most of the surgeries I have observed, the patient was awake for this one (though a little out of sorts from partial anesthesia.) Two incisions were made in the left and right side of the lower back, using the previous scars (from insertion of the batteries) as a guideline.
Local anesthesia was injected as the operation progressed, as pain was encountered. After cutting approximately one inch under the skin, the battery was found and pulled from the incision. The second battery (on the other side) was similarly removed.
A hard tissue covering each battery (a natural reaction of the body to a foreign object) was removed before the batteries could be fully removed from the incision.
An external pulse generator (equivalent to the batteries just removed) was then attached to test the stimulator leads. This was connected using a sterile wire which was only contaminated on one end, allowing for the sterile wires (protruding from the pat ient) and the non-sterile pulse generator to be connected. All eight leads (four left battery, four right battery) were tested and found to be operating correctly.
New (sterile) batteries were then connected and re-inserted into the patient, care was taken to ensure that the side with writing was placed skin-side up. This will ensure that the batteries would be able to be programmed using an external device on a la ter day. The batteries were once again sutured to the sub-dermal tissue to ensure no migration.
Insertion of proximal knee plate w/ ~9 screws
This is the first truly orthopedic case I have had the joy of witnessing. Although from my vantage point I could not see as much as previous surgeries, it was clearly the most interesting procedure.
The patient, a late-thirties male, had a shattered left femur resulting from a car accident. The right leg had already been given a plate, and on this subsequent day the other leg was being given equal treatment. Apparently, due to the severe compressio n caused by the knees impacting the underside of the dashboard, both of the patient's femurs had been broken (and shattered).
The patients leg was already open when I arrived in the OR. The top of the knee joint was exposed and the incision continued proximally up the leg about 14 inches. Through this incision, the plate could easily be positioned and attached with no trouble. Several pins (0.04" Dia.) were placed into the proximal part of the knee joint in order to find the appropriate position for the main screw (see figure). The attempt was made for the center pin to be exactly perpendicular to the bone, and therefore to line up with the axis of the joint. This will ensure good plate position when it is inserted.
Once the position of these pins was verified with a portable x-ray machine (note: all personnel in the OR were wearing lead shields to protect from excess radiation from this portable machine), the center pin was driven all the way into the bone, further than the screw would eventually go. This would allow for positioning to continue throughout the insertion of the main screw. The main screw was canulated (had a hole in the center), to allow it to slip over the pin which would give its position.
The main screw was turned in by hand, ending with the handle of the driver parallel to the patient's femur. This would give the proper position of the plate when it was attached to the femur. There are two flat edges on the main screw to allow it to fit onto the plate only in one orientation. This prevents the main screw from rotating and therefore backing out of its position.
After the main screw was placed, the plate was positioned correctly with respect to the femur. Several distal screws held it in position while the break in the bone was set. Once the surgeons were satisfied with the proper positioning of the entire bone , the rest of the screws were driven through the plate, into the femur. Each screw was self-tapping, but a hole was drilled for each before the screw was driven.
1 - Skin Graft, Right Arm approx. 18 sq. in.
Both sides of this patient's right arm had become badly infected from a drug injection. The dorsal forearm would be grafted, while the ventral (palmar) side was simply stitched loosely closed to allow for air to aid in healing. After the palmar wound wa s stitched closed, the dorsal area was scraped clean, using a scalpel blade which was pointed away from the motion. This scraped off the dying epithelial cells to reveal the healthiest ones which were underneath.
The patients upper, right thigh had also been prepped and draped because this was the donor region for the graft. A pneumatically powered device which operated like a cheese slicer was used to retrieve and area of skin about 8 inches long. This was then supplemented with a second 3 inch section. Both were approx. 2.5 inches wide.
The skin was kept moist, and put through a "meshing" apparatus. This machine created a series of slices over the entire area of the skin, allowing it to stretch to a larger area than normal. The mesh used was a 1.5 mesh, meaning that the eventual area t he graft could cover would be 1.5 times the original area.
This was placed over the open wound, and stapled around the edges, along with several staples within the wound to help it conform.
The mesh also allows for bleeding to escape, while not lifting the graft off the receiving area, and allows for air to penetrate, along with the greater area advantage. The excess of the graft was trimmed and repositioned to cover another large area of t he wound.
Up to a 3:1 mesh (final:initial area) may be used for severe burn victims, allowing for a small donor area to be used to graft to a large, burned receiving area.
2 - Shoulder joint, follow-up, cleaning of infection
This patient had been given a partial (only ball) shoulder replacement approximately 2 years prior, which has been fending off infection ever since. This recurring infection would normally have been treated with amputation by now, but the patient insists on trying to keep the shoulder. Eventually and unfortunately, this shoulder will probably be lost.
1- Bone Spur Removal, Right Pinkie Finger
This was very similar to part of a previous surgery which had included the removal of small amounts of bone; during the follow-up case where the ring finger was removed, some bone was removed in similar manner to this surgery.
Due to a football injury, there was a small spike, made of bony material, which extended distally and palmar within the pinkie finger of the right hand. Motion of this hand was therefore retarded and the center joint could only be bent to a 40 degree ang le (from complete extension). The goal of the surgery was to remove this bony outgrowth and restore a normal range of motion, allowing the finger joint to bend to a 110 degree angle (from complete extension).
All went well in this case, and I was able to observe the details of the local anesthesia used. Similar to a dentist's local anesthetic, a mixture including litocane was injected near but not into the nerves leading to the pinkie finger. This nerve "blo ck" was performed after the tourniquet had already been placed, so that when blood flow was restored, the local anesthetic would be flushed out of the hand.
After a sufficient amount of the bone spur was removed to give an adequate range of motion, the patient's tourniquet was loosened, and the patient was allowed to test for complete range of motion by making a fist. 105 degrees of motion was returned to th e right hand, which was comparable to the left hand, as examined.
2- Reattachment of dorsal (anti-palmar) tendon, Right Hand, Middle Digit
This patient had (as viewed from the x-ray) a small chip of bone which had detached from the most distal bone of the middle finger of his right hand. This small bone chip was still attached to the tendon, but the action of the muscle would then only move the bone fragment, and not affect the finger itself.
In order to reattach this bone chip to the rest of the bone, it was necessary to first determine if there was sufficient amount of tendon to reach to its original position. If there was not enough, a tendon graft may have to be performed. After inspecti on, the tendon was seen to be long enough for the given treatment.
a non absorbent suture was used and placed carefully through the tendon, just proximal from the bone fragment. Both bone surfaces (the bone and the fragment) were roughed in order to achieve a fresh-healing region.
After the distal joint was stabilized with a 0.045" (Dia) pin, two holes were drilling through the distal bone at approximately a 45 degree angle distal. Immediately after each hole was drilled, a straight (non-cutting) needle was used to pull the suture through the bone. This left two suture ends on the palmar surface of the finger, while a loop on the dorsal surface caught the tendon and bone fragment. As the suture was pulled through the holes in the distal bone, the tendon was pulled into position. The bone fragment did not position itself correctly, so a smaller pin (0.035" Dia) was placed through the fragment holding it in the correct position.
On the ventral (palmar) side of the finger, the sutures were threaded through gauze and a button to provide a back to hold the bone fragment in position.
Skin was sutured shut, and a light dressing was put in place.
3- Below Knee Amputation of Right Leg
This patient had been an ongoing case for approximately a month. She had diabetes, along with a rather sever case of Pulmonary Vascular Disease (PVD) which means that there is poor blood flow to the extremities. It was unknown at the beginning of the su rgery whether an amputation was to be performed and how extensive it would be. Whether several toes may be removed, or possibly a whole below-the-knee amputation.
As the dressings were removed, the foot was inspected. There were multiple large wounds; one large depression in the bottom of the foot, which exposed tendons, a large depression in the top of the foot, also exposing nerves and tendons, and a small wound on the back (dorsal) of the heel.
Upon further inspection, all of the large were noted to be infected, with little to no salvageable area of the foot-pad. The decision was made to amputate the entire foot. The surgeon in charge immediately addressed the conscious patient to discuss what had been previously only an option. She seemed very agreeable, and understood that there were no other options.
A large, sterile "sock" wrapped in plastic was placed over the infected foot, and both of the surgeons re-scrubbed to avoid contaminating the amputation site with infected tissue. All the instruments that had been used to inspect the foot were set aside and not used again, being supplemented with newly sterilized instruments.
A single, large incision was made approximately 12.5 cm below the distal edge of the knee joint. This incision was z-shaped, to allow for a flap of skin and sub-dermal tissue to be folded up over the exposed tissue, giving some padding to the end of the bone (soon to be exposed).
All of the soft tissue was incised in the same z-shape, with intermittent coagulation with a monopolar coagulator. This eventually revealed the Tibia and Fibia bones of the lower leg. A pneumatic saw was used to quickly (though loudly) cut through both bones (separately). With both bones severed, the distal portion of the leg could be completely removed, and was placed in a sterile bag to be sent for tissue cultures.
Both surgeons then immediately went to work on the bone, using the same pneumatic saw to bevel the edge to avoid a dangerous sharp corner. They then continued reshaping by removing soft tissue. This allowed for the flap to easily fold up to meet the ven tral (front) edge of the wound. After some blood vessel repair and nerve coagulation, the tourniquet was loosened and the wound was observed for bleeding. Several blood vessels were still bleeding, and they were either coagulated (electrically) or sutur ed shut. After inspection revealed no major bleeding, a drainage tube was inserted (away from the primary wound, to avoid its infection) and the (dorsal) skin flap was folded (ventrally). Several sutures were placed using both horizontal mattress and ve rtical mattress techniques.
Light dressing was achieved beginning with adaptix directly on the skin, followed by light 4x4's and fluff. A splint was created with a plaster-of-paris gauze pad, place dorsally, over the distal end, then ventrally. This would prevent the movement of t he knee joint for several days while the sutures were allowed to heal.
Tendon Transfer
The initial part of this surgery was intended to give the patient pinching ability by grafting (2) tendons from various other vestigial (unnecessary) regions.
This surgery involved the removal of several vestigial (unused) tendons from the patient's left arm (palmar) and left leg (inside), and reattaching these pieces for use on the anti-palmar(??) side of the right wrist. This was accomplished initially by cr eating several incisions on the target hand (right) and retrieving the part of the (right hand) anti-palmar(??) tendon which could be used. The distal end of this tendon was cut and a temporary suture was placed in the end. The tendon was pulled through and removed from the proximal incision, after some effort was needed to completely detach it from all connective tissue. This removal was followed by its immediate reinsertion into the same canal. Presumably, this will allow for the tendon to move free ly in its new orientation, without the restriction of any connective tissue.
Initially, the left hand was opened for removal of a vestigial ligament, and it was unknown whether there would be enough length in this tendon to supplement both target tendons in the right arm. The tendon removed from the left arm was approximately 7-8 inches in length. This was completely removed, along with a small part of the vestigial muscle to which it was attached (proximal end). This was then sutured to the end of the right arm's existing tendon with a technique known as the "horizontal mattre ss".
This horizontal mattress technique consists of using a sharp tipped instrument called a tendon retriever. The instrument has grip with the teeth, much like a normal hemostat, but also has a sharp tip, allowing it to be inserted through the old tendon in order to retrieve the end of the new tendon. This new tendon is then pulled through, followed by a suture being placed through all three layers; the bottom half of the old tendon, the new tendon (graft), and the upper half of the old tendon. This proce dure was repeated multiple times which allows for the new tendon (graft) to weave in and out of the old tendon, with a suture at each crossing. Very little excess suture was left in this tendon, to avoid the possibility of interference with future motion through the canal. The excess of both the old and new tendon (graft) were removed with a knife.
After the new tendon (graft) was attached to the old tendon, a long hemostat instrument was used to reach back from the target position of the new tendon (with graft) back to the incision from which the tendon was protruding. It was then pulled through a nd under ?????. Correct placement of the hand and fingers was necessary before suturing of the tendon end was performed. This consisted of having the thumb pressed lightly against the index finger, and light tension being placed on the tendon (with graf t). The tendon was then sutured into position, and the excess removed with a knife.
This same procedure would be followed for attachment of the second tendon graft going from the inside of the forearm across and attaching to the index finger, but the remaining new tendon (graft) from the first graft was not of sufficient length to comple te the second graft. A second vestigial tendon was removed from the left leg of the patient, near the Achilles tendon. This smaller tendon graft was then similarly attached to the second tendon.
After both grafts were complete, a second problem of the patient was addressed, as the tourniquet time approached 1:45. The fingers of the right hand had a tendency to curl, due to unnecessary flexion of the volar ligaments on the palmar surface of the f ingers. The pinkie and ring fingers were incised and the volar ligament cut to alleviate this condition. Only time will tell what kind of improvement will occur due to this cut. This is now in the hands of the physical therapists. Incisions were close d, total tourniquet time on the right arm 2:06 (approx.).
Presumably, the volar ligaments of the other two fingers would be cut at a later date.
1 - Ligament Repair, Left Hand
This was a good introductory surgery by the fact that the patient began with the hand normal (not opened). I saw the surgeon make the incision slowly along the outside of the thumb, while using his opposite hand fingers to spread the skin as he went. Th is allows the depth of the incision to be observed while it is performed. I felt the slightest bit queasy when the first incision was begun, but this feeling went away after 3-4 minutes and has not returned through any of the other surgeries.
The purpose of the surgery was to repair a ligament which had been torn in an accident. This ligament runs from the outside of the thumb across the palm and attaches somewhere near the middle of the hand. After the hand was sufficiently open in order to allow for visualization of structures, the ligament was retrieved. In order to attach this ligament to bone, it was necessary to place a suture anchor within the proximal bone of the thumb. This anchor is a small metal device which was placed within a pre-drilled hole in the bone, and had suture extending off in both directions.
Once the proximal joint of the thumb was immobilized with a 0.045" (Dia) pin, a hole was drilled for the suture anchor. This hole was approximately 0.05" in diameter. The suture anchor was placed into this hole with its own device, which had a plunger t o push the anchor sufficiently below the surface of the bone. The protruding suture was then sown to the ligament in multiple positions.
2 - Pinkie finger reattachment
This surgery was a little bit touch and go, whether to reattach (attempt) or simply amputate the patient's pinkie finger. Due to the following conditions:
Having gotten prior consent from the patient, no external fixators were able to be located, and a sample was used instead. This fixator sample was the exact same device as would be actually used, constructed of the same materials. When the decision was made to reattach the finger, it needed to be sterilized (being simply a sample). There was a slight confusion, and later on in the surgery it was noticed that the external fixator had not yet been sterilized (flashed). This only takes a couple of minute s, but the patient was ready for the device to be attached when the problem was realized.
I was proud to have been able to help the surgeon to figure out the exact arrangement of the external fixator. It had been disassembled in order to sterilize, but the exact placement of each of the screws and several small pieces was not apparent to the surgeon. After resolving this problem, the fixator was immediately sterilized while the surgeon inserted pins into both the distal and the proximal bones of the finger. Using a single center pin for alignment, all other pins were placed parallel to the center pin. These were then given a quick x-ray to confirm that they were all correctly positioned.
Right about the time that all of the pins were confirmed in their positions, the lightly assembled external fixator was brought back from sterilization. It was attached quickly and easily. Some small sutures were placed to hold the skin closed, and the excess of the pins was remove with a wire-cutter device.
The external fixator itself has a worm gear which allows for the adjustment of the critical joint by manual rotation. This allows physical therapists to regain motion in this joint by repositioning as the finger heals.
3 - Follow-up, Multiple digit reattachment (amputation of necrotic ring finger)
This was probably the quickest of all the surgeries I had seen. It involved checking the condition of a multiple finger re-implantation, of which three fingers were complete re-implants and one was a partial implant. When the dressing was removed from t he patient's left hand, it was found that the ring finger had become necrotic (not survived). The part of this finger which had initially been re-implanted was then amputated. After removing the necrotic portion of the finger, there was a slight amount of bleeding, but instead of using the bipolar coagulator to stop the bleeding, the amputation was simply completed quickly, allowing the body's natural blood clotting to work its magic.
Some notable points:
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