Surgery Flashcards
What are the eight general indications for surgical prophylaxis?
Implants (joint or internal fixation) Prolonged surgery >2 hours Trauma surgery Revisional surgery Immunocompromised patient Extensive dissection required Intra-operative contamination Endocarditis (SBE)
What are the three most commonly used antibiotics for surgical prophylaxis?
Ancef/Cephazolin 2g q 4hr >120 kg use 3g
Clindamycin if PCN allergy 900mg q8hr
Vancomycin if MRSA 1g weight based sliding scale
What are the indications for ordering a chest X-ray?
Over the age of 40
Smoker
Any pulmonary/cardiac disease
What are the indications for ordering a preop EKG?
> 40 years
Any history of cardiac disease
What is the most common post operative time frame in which an MI occurs?
Day 3
How long should elective surgery be suspended if the patient has incurred an MI or CABG?
6 months
How are daily fluid inputs calculated? (not IV)
100 x first 10kg =1000 mL/day
10 x second 10kg
Remaining kg x 20
Example: 70kg patient requires: (100x10) +(10 x10) + (50 x 20) = 2500
How are daily IV fluid inputs per hour calculated?
The 421 rule!
first 10kg x4 =40
Second 10kg x 20
Remaining kg x 1
Ex 70 kg patient: 40+200+ 50 = 110 mL/hr
What is the perioperative order for diabetics?
NPO after midnight
Start D5W1/2NSS in AM
Accu-check
If insulin is controlled hold regular insulin and give half the NPH dose. Cover with sliding scale insulin.
If orally controlled, hold oral meds and cover with SSI
If diet controlled cover with SSI
What should always be obtained in a RA patient before surgery?
Cervical X-ray to look for atlantoaxial fusion.
What are the risks that a patient with long term corticosteroid use faces when undergoing surgery?
Adrenal function is supressed
These patients face risk of poor or delayed wound healing with decreased inflammatory process.
Risk of infection, low WBC may mask an infection.
What is the perioperative management for chronic steroid use?
Periop IV steroid supplementation
Hydrocortisone 100 mg IV given the night before surgery, immediately before surgery, and then q8h until posto-op stress is releived.
What is the perioperative management for patients at risk for gout?
Begin colchicine 0.6 mg PO daily 3-5 days pre-op and continue 1 week post-op.
What is the big concern with surgery on patients doing long term diuretics?
Low potassium levels
Patient is to continue use with 1/2 NSS at low rate.
When should aspirin be discontinued prior to surgery?
Seven days prior due to irreversibly binding platelets.
When should NSAIDs be discontinued prior to surgery?
3 days prior due to irreversibly binding platelets.
When should heparin be discontinued prior to surgery?
8 hours prior
Monitor PTT levels.
When should Coumadin be discontinued prior to surgery?
3-4 days (Monitor PT/INR)
What should the INR be for elective surgery?
<1.4
What should be done prior to surgery if the patients INR is >1.4?
A high INR means you are at risk for bleeding.
Transfuse fresh frozen plasma (FFP)
One unit of FFP will decrease the INR by approximately .2
Vitamin K can be given but its very slow.
If a patient undergoes surgery with a high INR what needs to be closely monitored?
Hgb and Hct
30 and 10
Which Hgb and Hct levels require a transfusion?
Surgical rule is the 30 10 rule in which Hgb should be 30 and Hct should be 10 for elective surgery.
If Hg: <8 or Hct <24 then a transfusion should be done.
What should be done if a patient is thrombocytopenic?
Order a six pack of platelets which is a concentration of six pooled platelet units.
consult hematology.
How are relaxed skin tension lines usually oriented?
Perpendicular to the long axis of the leg and foot
How should a skin incision be made in accordance to the relaxed skin tension lines?
Should be made parallel to the relaxed skin tension lines.
Perpendicular incisions are at risk for gapping due to increased transverse forces.
What is an anti-tension line incision?
S-shaped or Zig-zagged incision when the exposure that is needed cannot be made parallel to the relaxed skin tension lines,.
To close a lesion with minimal tension, what should the ratio of length to width be?
3:1 length to width.
How much lengthening can be achieved with a Z-plasty that has 60 degree angles?
75% lengthening!
To correct a skin contracture, how should a Z-plasty incision be oriented?
The central arm of the Z-should be parallel to the contracture.
To correct a 5th digit adductovarus rotation, how should the skin incision be oriented?
Distal medial to proximal lateral
“DMU”
What is the 4 steps to wound graft closure?
Direct closure
Graft
Local flap
Distant flap
What are the four stages of skin graft healing?
Plasmatic
Inosculation of blood vessels
Re-organization
Re-innervation
What are blair and humby knives?
These are knives used to harvest skin grafts
What is the most commonly used device to harvest skin grafts?
The dermatome.
What is the most common side effect of skin grafting?
Seroma/hematoma
How can hematomas/seromas be prevented in skin grafting?
Use mesh or pie crust graft and apply compressive dressings.
What are the advantages of using a split thickness graft?
Donor site heals spontaneously
May cover larger wounds.
What are the disadvantages of using a split thickness graft?
Grafts are fragile
Contraction of graft during healing
May be abnormally pigmented
What are the advantages of using a full thickness skin graft?
Minimal contraction of the graft
better appearance
What are the disadvantages of using a full thickness skin graft?
More difficult to take
Must close the donor site ({split thickness site self heals)
What is an advantage of using a muscle flap?
It brings immediate increased blood supply to the donor site.
What are the AO principles of internal fixation?
Anatomic articular reduction/adequate shaft reduction
Stable/biological fixation
Preservation of blood supply
Early ROM
What were the original AO principles published in 1958?
Anatomic reduction
Rigid internal fixation
Preservation of the blood supply
Early ROM
What are the steps to lag by technique?
Overdrill Underdrill Countersink Measure Tap Screw
How much of a screw thread should pass the far cortex in lag by technique?
One and a half threads
What is the purpose of tapping
Creates a path for screw threads
Why do you countersink for screws?
Prevents stress risers and soft tissue irritation
Provides compression from the land of the screw head.
What are the three sizes of the minifrag screws?
What type of screws are these?
1.5, 2.0, 2.7
These are all fully threaded cortical screws
What is the surgical screwdriver handle made of?
Pressed linen
What are the three differences between cortical and cancellous screws?
Cortical screws have a smaller pitch
Cortical screws have a smaller rake angle
Cortical screws have a smaller difference between thread diameter and core diameter.
What is unique about a malleolar scew?
4.5mm screw
Designed for fixation of the medial malleolus, partially threaded, same thread profile and pitch as a cortical screw.
Trephedine self cutting tip.
What type of screw is described as having a fluted tip?
Self tapping screws
What is the overdrill, underdrill, and countersink for a 1.5 mm screw?
Overdrill 1.5 mm
Underdrill 1.1 mm
Countersink 1.5 mm
What is the overdrill, underdrill, and countersink for a 2.0 mm screw?
Minifrag set
Overdrill 2.0
Underdrill 1.5
Countersink 2.0
What is the overdrill, underdrill and countersink for a 2.7mm screw?
Minifrag set
Overdril 2.7 mm
Underdrill 2.0 mm
Countersink 2.0 mm
What are the three small frag screw sizes?
What type of screws are in this set?
- 5 mm
- 0 mm fully threaded
- 0 mm partially threaded
(4. 0 for ankle gives both proximal and distal option)
What is the overdrill, underdrill, and countersink for the 3.5mm screw?
Small frag set
Overdrill: 3.5
Underdrill: 2.5
Countersink: 3.5
What is the overdrill, underdrill, and countersink for the fully threaded 4.0mm screw?
Small frag set
Overdrill: 4.0 mm
Underdrill: 2.5 mm
Countersink: 4.0
What are the four sizes of the large screw frag set?
- 5 mm
- 5 mm malleolar
- 5 mm partially threaded
- 5 mm fully threaded
What are the screw sizes found in the synthes modular hand screw system?
- 0
- 3
- 5
- 0
- 4
- 7
What are the Synthes cannulated screw sizes?
- 0
4. 0
What are the Smith and Nephew Cannulated Screw Sizes?
- 0
- 5
- 5
- 0
What are the steps for inserting a 4.0 mm cannulated screw?
Insert the 1.3 mm guide pin to the far cortex
Measure
Drill near cortex with a 4.0 mm cannulated bit
Drill the far cortex with a 2.7 mm cannulated bit
Tap
Countersink
Screw
What is a herbert screw?
A headless screw that can be inserted through articular cartilage.
There is a threaded portion proximally and distally with a smooth interpsace.
Proximal portion has a tighter pitch for compression.
What is a Reese Screw?
A headless screw used to create compression through an arthrodesis site.
Proximal threads run clockwise and the distal run counterclockwise.
What are the four K-wire sizes?
- 028
- 035
- 045
- 062
You are in surgery and the 1.5 mm underdrill for the 2.0mm screw falls on the floor.
What could be used as an alternative for the underdrill?
0.062 mm size K-wire could be used as the underdrill for the screw.
You are in surgery and the 1.1 mm underdrill for the 1.5 mm screw falls on the floor.
What could be used as an alternative for the underdrill?
0.045 mm size K-wire could be used as the underdrill for the 1.1 mm screw.
What are the color coordinations for K-wire pins?
Young Boys Wear Green .028 Yellow .035 Blue .045 White .062 Green
What are steinman pin sizes?
Everyone from 5/64th to 12/64
However, there is no 11/64!!
What are the different types of plate fixation?
Compression plates Dynamic compression plates Buttress Plate Neutralization Plate Bridge plate
What are the ways a compression plate can create compression?
Axial compression via an interfrag screw
Pre bending the plate
Eccentric drilling of hole adjacent to the fracture, remaining holes drilled centrally.
Plate placement on the tension side of the bone.
How does a neutralization plate work?
Protects against shear, bending, and torsional forces.
Allows interfrag compression via lag screws
All holes drilled centrally
What are the three forces a neutralization plate cancels?
Shear, Bending, Torsional
What is an antigluide plate?
Neutralization plate that is placed on the posterior aspect of the fibula.
What is a Butress plate?
A plate that maintains the alignment of unstable fracture fragments.
No interfragmental compression occurs here.
Should a plate be placed on the compression side or the tension side of a fracture?
A plate should be placed on the tension side.
In general, which side of a metatarsal is the tension side in fractures?
Plantarly!
Unfortunately because of soft tissue structures this normally cannot be reached.
What does a locking plate accomplish?
A locking plate acts as an extra cortex and does not rely on the bone for stability but rather forms a FIXED-ANGLE CONSTRUCTION
Excellent choice for osteoporotic, comminuted fractures, or revisional surgeries.
What is Hooke’s law?
For a material under load, strain is proportional to stress.
What is Young’s modulus?
After a load is removed, the material will spring back to its original shape, the resulting slope represents the stiffness of a material or its “Youngs modulous”
What is a Keith needle?
A straight needle used for suturing
What are three common needle point configurations?
Taper point for soft easy penetrable skin
Cutting tip on the inner edge or curve for skin
Reverse cutting: Cutting edge on outer curve for tough, difficult to penetrate skin.
What is Orthofix suture?
Polyglycolic acid
Also known as Dexon
How long does orthofix/Dexon maintain tensile strength?
6-12 weeks
Fully absorbed in 1-3 years
When is orthofix/dexon absorbed by the body?
Absorbed in 1-3 years.
What is “Orthosorb”?
polyparadioxanone (PPD) absorbable pins to be used in the foot and ankle
How long do Orthosorb pins last in the body?
Orthosorb pins lose strength at 4-6 weeks and fully absorb in 3-6 months.
What are the two sutures that are least reactive to tissue?
Prolene (Use instead of vicryl if there is an infection)
Stainless steel
What is Vicryl?
Polyglactin 910! 90% glycolide 10% lactide
Remember vicryl should not be used with infections (use prolene instead)
How is vicryl broken down?
Hydrolysis
How long does it take to absorb vicryl?
75% at 2 weeks
50% at 3 weeks
25% at 4 weeks
Fully absorbed in 10 weeks.
Should you use vicryl with infections?
NO
Avoid it if possible as vicryl is simply too reactive.
Who first described arthroscopy?
Takagi
Who were the first podiatrists to describe podiatric use for arthroscopy?
Heller and Vogel 1982
What are the three scope techniques?
Pistoning - In and out
Scanning - side to side up and down.
Rotating - 360 degrees
What are the five indications for an ankle scope?
Synovitis Osteochondral defect Soft tissue impingement Osteophytes Loose bodies
What is the most common complication following endoscopic plantar fasciotomy?
Lateral column instability leading to calcaneal cuboid joint pain.
What is the most common indication for the lapidus?
Hypermobility.
What is the order of the lateral release for a McBride procedure?
Extensor hood Adductor hallucis Fibular sesamoidal ligament Lateral collateral ligament FHB lateral head tenotomy Fibular sesamoidectomy
What is a Vogler osteotomy/
An offset V with its apex at the metaphyseal diaphyseal joint of the first metatarsal.
What is a Kalish osteotomy?
A long arm austin osteotomy in which the arms are 55 degrees for better dorsal screw fixation.
Normally the austin arms are at 60 degrees.
What is a Youngswick osteotomy?
An austin osteotomy with a slice taken dorsally to allow decompression and plantar flexion.
What procedure corrects an abnormal DASA >7.5 degrees?
An Akin osteotomy
What procedure corrects an abnormal PASA >7.5 degrees?
A Reverdin Osteotomy Peabody Biangular Austin DRATO Offset V with rotation
What procedure corrects an abnormal hallux interphalangeous angle?
Distal Akin
What are the complications associated with a keller resection arthroplasty?
Diminished propulsion of the digit
Loss of hallux purchase
Stress fracture of the second met
(Lateral release, removal of the medial eminence, and resection of the proximal phalanx)
Say you are performing a surgical osteotomy and the capital fragment falls on the floor. what do you do?
Rinse with saline Soak in Bacitracin for 15 minutes Rinse with saline Bacitracin soak for 15 minutes Rinse with saline Document and inform the patient.
What are the causes of white toe post operatively?
ARTERIAL IN NATURE!!! (Differs from blue toe)
Signs: Pain, pale, parasthesia, pulselessness
What are the treatments for a white toe?
D/C ice and elevation Loosed bandages Place the foot in a dependent positon Rotate the K-wire Apply a warm compress proximally Apply Nitroglycerine paste proximally Local nerve block proximally (stop the sympathetics) Avoid nicotine Consult vascular surgery
What are the causes of a blue toe?
POOR ARTERIAL FLOW: Toe is cold and doesnt blanch
OR
POOR VENOUS OUTFLOW: Toe is warm and will blanch with pressure
Important to note that unlike white toe, blue toe has two etiologies and can be venous or arterial in nature.
What are the treatments for blue toe due to sluggish venous outflow?
D/C ice (Not elevation) Loosen bandages Avoid dependency Dont attempt to increase vascular perfusion Consult Vascular Surgery
Describe a keck and kelly procedure
A procedure designed for a haglund deformity with a cavus foot and high calcaneal inclination angle.
Remove a wedge from the posterior superior aspect of the calcaneus.
The posterior superior prominence is moved anteriorly.
What is the Murphy procedure?
A procedure in which the achilles is advanced anterior for spastic equinus.
What are the surgical procedures for pes planus that act in the transverse plane?
Evans osteotomy
Kidner procedure (Excision of an accessory navicular)
CC distraction arthrodesis
What are the surgical procedures for pes planus that act in the sagittal plane?
Cotton osteotomy
Youngs procedure: Navicular tenosuspension with anterior tibialis tendon (Young procedure)
Lowman Procedure: TN joint fusion +/- TAL
Hoke Procedure: NC fusion
Miller Procedure: NC fusion + 1st met
Cobb Procedure:
What are the surgical procedures for pes planus that act n the frontal plane for a flexible deformity?
Koutsgiannis: Medial sliding calcaneal osteotomy Dwyer: Lateral wedge calcaneal osteotomy Chambers Gleich Baker-Hill Lord
Name the tendon procedures that can be done for pes cavus
Jones tenosuspension: EHL transfer
Hibbs Tenosuspension: EDL transfer
STATT
PT
What is an arthroresis?
A surgical procedure used to limit joint mobility by implanting in the sinus tarsi,
Typically want 2-4 degrees of STJ eversion with the implant.
How much STJ eversion do you want with an arthroresis
Want to fix at 2-4 degrees of STJ eversion.
What is a Valente procedure?
STJ block using a polyethylene plug with screw threads.
allows for 4-5 degrees of stj pronation.
Who first described the triple arthrodesis?
Ryerson
What order do you resect for a Triple Arthrodesis?
TN CCJ (Mid tarsal joints first) STJ (T-C) last
What order do you fixate for a triple arthrodesis?
STJ
TN
CC
What size screws are commonly used for fixation in a triple arthrodesis?
6.5-7.0mm interfrag compression screws.
What is the only FDA approved three component ankle replacement device?
STAR
What are the stages of primary bone healing?
Done with primary fixation!
Inflammation
Induction
Remodeling
What are the stages of secondary bone healing?
This is none-rigid bone fixation Inflammation Induction Soft callus formation Hard callus formation Remodeling
What are some factors that negatively affect bone healing?
Smoking Age Steroid therapy Anemia Osteoperosis
Name the three types of hypertrophic non-unions
Horse hoof
Elephant foot
Oligotrophic
Name the three types of atrophic non-unions
Torsion wedge
Comminuted
Defect
Atrophic
What clinical study can be done to distinguish betwee a hypertrophic and atrophic non-union?
Bone scan!
It will be positive for a hypertrophic non-union as there is blood flow in the area.
What is a pseudoarthrosis?
A type of non-union in which fibrocartilaginous tissue forms for an atrophic/avascular non-union.
What are the indications for bone stimulant use?
Non-union or failed fusion
What are the contraindications for bone stimulant use?
Pseudoarthrosis
Gap greater than 1/2 the bones diameter!
What are the four stages of avascular necrosis of bone?
Avascular - Loss of blood supply, epiphyseal growth ceases.
Revascularization - Infiltration of new blood vessels, new bone deposited on dead bone, flattening or fragmentation of the articular surface.
Repair and remodeling - Bone deposition replaces bone resorption
Residual deformity - Restoration of epiphysis, sclerosis, deformed articular surface.
What is the best diagnostic study to evaluate avascular necrosis?
MRI
Wanting to look for decreased signal intensity within medullary bone in both the T1 and T2 images.
What are the three categories of bone graft?
Osteogenic
Osteoinductive
Osteoconductive
What makes a bone graft osteogenic?
The graft is able to synthesizenew bone.
Mesenchymal stem cells from autologous bone or bone marrow aspirate is used.
What makes a bone graft osteoinductive?
Contains factors that induce host tissue to form new bone.
Demineralized bone matrix
Bone morphogenic protein (BMP)
Platelet derived growth factors (PDGF)
What makes a bone graft osteoconductive?
This means the graft simply provides scaffolding for new bone growth.
Allografts from the calcaneus
Hydroxyapatite
calcium phosphate
calcium sulfate
these are all osteoconductive parts.
What type of bone graft is osteogenic, osteoinductive, and osteoconductive?
Autogenous!
Makes sense, it is your own bone :)
What are the 5 stages of bone graft healing?
Vascular ingrowth Osteoblastic proliferation Osteoinduction (BMP/PDGF) Osteoconduction (Scaffolding) Graft remodeling
What is an early radiographic finding of bone graft healing?
Initial radiolucency of the graft due to increased osteoclastic activity!
This is followed by osteoblasts laying down new bone.
(Think Hawkins sign in talar fx fixation)
What is creeping substitution?
Process in which the host’s cutting cone (Osteoclasts followed by osteoblasts) invade the bone graft.
Give me the 5 ASA classifications
1 healthy patient
2 Mild systemic disease
3 Severe systemic disease
4 Incapacitating systemic disease that is a threat to life
5 moribund patient expected not to live without surgery
Emergency
What is the maximum tourniquette time?
90-120 minutes
After that allow 5 minutes of profusion for every half hour over.
What are the eight contraindications to using a tourniquette?
Infection Open fracture Sickle Cell disease Peripheral vascular disease Recent arterial graft/stent Previous DVT Hypercoaguability Skin graft applications where you need bleeding
What is the classification system used to describe nerve damage?
Seddon Classification system
Neuropraxia: Nerve compression that recovers
Axonotmesis: Interuption of axons with distal wallerian degeneration. Connective tissue sheaths remain intact to allow for regeneration.
Neurotmesis: Complete severance of the nerve that is irreversible.
Describe the three stages of Seddons nerve damage classification.
Neuropraxia: Nerve compression that is gnerally recoverable.
Axonotmesis: Damage to the axon in which wallerian degeneration occurs. Connective tissue sheaths are intact so regeneration is possible.
Neurotmesis: Complete severence of a nerve that is irreversible.
What is the difference between an incisional and excisional biopsy?
Incisional: Only a portion of the lesion is being removed
Excisional: The entire lesion is removed
What is the principle by which bone stimulators work?
The Piezolectric principle!!
The side under compression makes a NEGATIVE CHARGE that leads to bone growth. Therefore, placing a CATHODE in a non-union site will stimulate growth.
REMEMBER: Bone stimulators are contraindicated when the bone gapping is > 1/2 the bones diameter or with a pseudoarthrosis.
What are the different skin biopsy techniques?
Punch
Shave
Curretage
Surgical excision
What is the direction of the cut for a reverse wilson of the fifth met?
Distal lateral
to
Proximal Medial
“Like a candle sliding”
Who was the first person to describe an arthrodesis?
Soule
What is the order for hammertoe surgery at the PIPJ?
PIPJ Extensor tendon Dorsal Capsule Collaterals Plantar Capsule Arthroplasty
What is the order for hammer toe surgery at the MPJ?
Hood
Tendon
Capsule
Plantar plate
Why are joint implants usd?
Maintain space between bony surfaces
Releive pain
What is the lag time for the presentation of osteomyelitis on an X-ray?
10-14 days.
Stress fractures present very similarly in time.
How should one culture osteomyelitis?
Take a cut from the infected bone and take a second cut proximal to the clearance margin to ensure remaining bone is not infected.
What is a Brodies abscess?
Subacute osteomyelitic lesion found mostly in children.
It is well circumscribed, lytic with sclerotic borders found in the metaphysis, epiphysis, and rarely the diaphysis.
It is often painful with periods of exacerbation and remission.
General treatment reccomendation is curettage and packing with autologous bone.
