Smith Lecture: OR Protocol Surgical Procedures

Question 1

v-y flap

Answer 1

• žAdvancement Flap
• ž“V” shaped skin incision
• žSides of “V” advanced
• žClosed wound resembles a “Y”
• Technique: apex of v proximal or distal, incision to subcutaneous tissue, undermine outward, gently hold (retract) tissue, no tension, apical stitch *pictured*, suture

Question 2

y-v flap

Answer 2

• žAdvancement flap
• ž“Y” shaped skin incision
• ž“V” portion advanced
• žClosed wound resembles a “V”

Question 3

v-y island flap

Answer 3

Question 4

z-skin plasty

Answer 4

• žRotational flap
• ž“Z” skin incision
• žTranspose arms of “Z” to lengthen skin and relieve tension
• žLengthening along longitudinal axis and shortening along transverse axis
• Technique: central arm drawn in same direction as scar or contracture, lateral arms drawn with measuring device, lateral arms should equal central arm, full thickness flaps incised, undermine, flaps should transpose easily, prevent crushing of tips, suture base and central arm, apical stitch, suture remaining flap outside to inside

Question 5

instep fasciotomy

Answer 5

• žIncision in medial arch anterior to calcaneus
• žMedial portion of fascia released
• žAdvantages
  
  • Recovery
  • Visibility
• žDisadvantage
  
  • Resection of exostosis

Question 6

open fasciotomy

Answer 6

• žMedial incision (DuVries) to visualize the plantar fascia
• žFascia isolated superior and inferior
• žAdvantages
  
  • Visibility
  • Resection of exostosis
• žDisadvantages
  
  • Recovery
  • Wound complications and hematoma

Question 7

tarsal tunnel

Answer 7

• žMedial incision posterior to tibial artery
• žDissection to and release laciniate ligament
• žThird compartment of tarsal tunnel identified and released
• žSubcutaneous and skin closure only
  
  • Do not reapproximate laciniate ligament

Question 8

tendon lengthening

Answer 8

• žTendon lengthened to alleviate contracture and deformity or facilitate a repair
• žMost common lengthening is a “Z”
• žMedial half of tendon sectioned proximally and lateral half distally (start in middle)
• žTenon lengthened on itself and sutured

Question 9

Arthroplasty

Answer 9

• žSkin Incision
  
  • Linear or Semi-eliptical
• žTransection of EDL
• žRelease Collateral Ligaments
• žResect Head of Proximal Phalanx
• žSuture EDL and Skin
• Steps: transect tendon at pipj, release collateral ligament, remov head of bone, pin toe with k-wire (0.045” usually or 0.062” if cross the MPJ)

Question 10

steps for austin bunionectomy

Answer 10

• žDorsomedial Incision
• žSubcutaneous Dissection
• žLateral Release *
• žPeriosteal and Capsular Incision
• žResection of Medial Eminence
• žOsteotomy (check angles!!)
• žTranspose and Impact
• žFixation
• žResection Prominent Medial Cortex
• žClosure

Question 11

what is the hinge axis concept?

Answer 11

• žDetermines motion of distal segment about an axis created by a cortical hinge
• žTraditional Axis – perpendicular to long axis of first metatarsal resulted in elevation
• žAxis perpendicular to weightbearing surface results in transverse plane motion
• žHinge axis can be altered to create desired dorsiflexion or plantarflexion of distal segment
  • žPlantarflexion – Superior pole of axis angled lateral creating a dorsal-medial hinge
  • žDorsiflexion – Superior pole of axis angled medial creating a plantar-medial hinge

Question 12

Oblique osteotomy that extends from proximal-medial to distal-lateral creating an intact medial cortical hinge

Answer 12

closing base wedge osteotomy: Juvara