1. Orthopedic Procedures Operative Sequence
Bunionectomy

2. Foot - Anatomy -

3. Foot - Anatomy -

5. Bunionectomy Overall Purpose of Procedure:
The common bunion is a localized area of enlargement of the inner portion of the joint at the base of the big toe. The enlargement actually represents additional bone formation, often in combination with a misalignment of the big toe. The normal position of the big toe (straight forward) becomes outward-directed toward the smaller toes (Hallux Valgus.) The enlarged joint at the base of the big toe (the first metatarsophalangeal joint) can become inflamed with redness, tenderness, and pain. A small fluid-filled sac (bursa) adjacent to the joint can also become inflamed (bursitis) leading to additional swelling, redness, and pain.

6. Bunionectomy
Bunions are most often caused by an inherited faulty mechanical structure of the foot. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion.
Although wearing shoes that crowd the toes won't actually cause bunions in the first place, it sometimes makes the deformity get progressively worse.

7. Bunionectomy - Anatomy -

8. Bunionectomy - Anatomy -

9. Bunionectomy - Approaches
Austin Bunionectomy: This is the most common type of bunionectomy involving cutting the first metatarsal bone at the "head" and fixing the cut with a screw. There are other names for this type of bunionectomy including tricorrectional, chevron, etc. Typically, patients are able to put some weight on the heel of the operated foot immediately post-operatively.
Lapidus Fusion: This procedure is typically reserved for the more severe bunions and involves fusing the first metatarsal bone to the medial cuneiform bone. Recovery from this surgery is much more prolonged, requiring strict non-weight bearing with a cast for 6-8 weeks after surgery.
Fusion (arthrodesis) of big toe joint: Fusion of the bunion joint is for severe osteoarthritis.

10. Bunionectomy - Approaches
McBride Bunionectomy: removal of bone and repositioning of tendons.
Keller Bunionectomy: Removal of part of the big toe joint. This procedure is performed mostly in older patients.
Silver Bunionectomy: Simple shaving of the bunion "bump." This procedure can only be done in minor bunion cases.

11. Bunionectomy
A less common bunion is located at the joint at the base of the smallest (fifth) toe. This bunion is sometimes referred to as a tailor's bunion.

12. Bunionectomy Define the procedure:
A dorsal incision is made from the proximal phalanx to beyond the neck of the metatarsal.
Removal of excess bone and realign the great toe.

13. Wound Classification: 1
Bunionectomy
Wound Classification: 1

14. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application

15. Bunionectomy Instrumentation: Minor Bone tray
Positioning: The patient is in supine position, arms on arm boards. Foot, Ankle or Calf on bump.
Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from tourniquet to distal metatarsals, circumferentially.
Draping: Some surgeon like a sterile towel around the tourniquet, held in place with a towel clip. U-drape and an extremity drape.

16. Bunionectomy Begin your Operative Sequence
Incision:
15 kb on #3 handle for incision.
Some surgeons like multiple 15 kb’s for this procedure. Be prepared for this.

17. Bunionectomy cont. Operative Sequence
Hemostasis: Handheld Bovie and hemostats.

18. Bunionectomy cont. Operative Sequence
Dissection and Exposure:
Metz, Adsons.
Small Weitlander
Senn Rakes

19. Bunionectomy cont. Operative Sequence
Exploration and Isolation:
Apply plantar pressure to provide flexion of great toe.

20. Bunionectomy cont. Operative Sequence
Surgical Repair/Removal/Specimen Collection:
Depend on type of approach.
Bone can be shaved off with small drill.
Metarsal can be cut with TPS saw and held in straight position with small screws.
Ligaments can be lengthened (Z lengthening)
Have rasp available to smooth bone.
May have to make multiple incisions.
Bunion Vid

21. Bunionectomy cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
Take emeses pan with you.

22. Bunionectomy cont. Operative Sequence
Closure:
Small subcuticular stitch – 4-0 Vicryl
Skin is closed with surgeons choice of suture or staples.

23. Bunionectomy
Major Arteries:
Ant. Tibial Artery

24. Bunionectomy
Major Veins:
Greater Saphenous vein
Major Nerves:
Plantar

25. Orthopedic Procedures Operative Sequence
Hammer Toe

26. Overall Purpose of Procedure:
Hammer Toe
Overall Purpose of Procedure:
A hammer toe is a deformity of the second, third, or fourth toe causing it to be permanently bent at the proximal interphalangeal joint, resembling a hammer. Mallet toe is another name for this condition when affecting the distal interphalangeal joint.

27. Hammer Toe - Anatomy - A Flexible Joint
You can straighten a flexible hammer toe with your fingers. Although they look painful, flexible hammer toes may not hurt.
A Rigid Joint
A rigid hammer toe cannot be moved, even with the fingers. Rigid joints may cause pain and distort foot movement. This may put extra stress on the ball of the foot, causing a callus (a corn on the bottom of the foot).

28. Hammer Toe

29. Mallet Toe

30. Claw Toe

31. Hammer Toe Define the procedure:
Resect the joint, release the soft tissue (ligaments) and place K-wire through joint.

32. Wound Classification: 1
Hammer Toe
Wound Classification: 1

33. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application

34. Hammer Toe Instrumentation: Minor Bone tray
Positioning: The patient is in supine position, arms on arm boards. Foot, Ankle or Calf on bump.
Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from tourniquet to distal metatarsals, circumferentially.
Draping: Some surgeon like a sterile towel around the tourniquet, held in place with a towel clip. U-drape and an extremity drape.

35. Hammer Toe Begin your Operative Sequence
Incision: 15 kb on #3 handle for incision.
Some surgeons like multiple 15 kb’s for this procedure. Be prepared for this.

36. Hammer Toe cont. Operative Sequence
Hemostasis: Handheld Bovie and hemostats.

37. Hammer Toe cont. Operative Sequence
Dissection and Exposure:
Metz, Adsons.
Small Weitlander
Senn Rakes

38. Hammer Toe cont. Operative Sequence
Exploration and Isolation:
Apply plantar pressure.
Senns or single tooth skin hooks.

39. Hammer Toe cont. Operative Sequence
Surgical Repair
The long extensor muscle, called the extensor digitorum longus (EDL), originates in the anterior leg. The EDL descends the leg crossing the ankle and continuing on to the tips of the toes. The EDL extends or lift the toes.
Excision of the EDL.
Resection of the articulating joint with a small saw.
The edges of the joint are lined up and a k-wire is run through the end of the toe, fusing the joint.
Reattachment of the EDL with suture like Supramid.

40. Post Op Vid: http://www.youtube.com/watch?v=VfCj_KX6h3w
The procedure:
Post Op Vid:

41. Hammer Toe cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
Take emeses pan with you.

42. Hammer Toe cont. Operative Sequence
Closure:
Small subcuticular stitch – 4-0 Vicryl
K-caps.
Skin is closed with surgeons choice of suture or staples.

43. Orthopedic Procedures Operative Sequence
ORIF Ankle

44. ORIF Ankle - Anatomy -

46. ORIF Ankle - Anatomy -
The leg bones form a scooped pocket around the top of the anklebone. This lets the foot bend up and down.
Right below the ankle joint is another joint (subtalar), where the anklebone connects to the heel bone (calcaneus). This joint enables the foot to rock from side to side. Three sets of fibrous tissues connect the bones and provide stability to both joints. The knobby bumps you can feel on either side of your ankle are the very ends of the lower leg bones. The bump on the outside of the ankle (lateral malleolus) is part of the fibula; the smaller bump on the inside of the ankle (medial malleolus) is part of the tibia.

47. Overall Purpose of Procedure:
ORIF Ankle
Overall Purpose of Procedure:
To stabilize the ankle so the patient can regain function of their foot.

48. ORIF Ankle - Before

49. ORIF Ankle - Before

50. ORIF Ankle – How it happens
Skate Boarding
Ankle break

51. ORIF Ankle After Define the procedure:
The replacement of the bones into their correct position via plate and screws to stabilize the ankle.
Open reduction and internal fixation of bimalleolar fracture

52. ORIF Ankle
BIMALLEOLAR fracture: means that the lateral malleolus and the medial malleolus are broken.
Trimalleolar fracture: a fracture of the ankle that involves the lateral malleolus, medial malleolus and the distal posterior aspect of the tibia, the posterior malleolus. Strictly speaking, there are only two malleoli (medial and lateral), but the term trimalleolar is used nevertheless.

53. ORIF Ankle -Unimalleolar-

54. ORIF Ankle
Wound Classification: 1 depending on how long the ankle has been fractured and if the bone broke the skin.

55. Operative Sequence 1- Incision 2- Hemostasis 3- Dissection 4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application

56. ORIF Ankle
Instrumentation: Minor Bone tray Synthes Small Frag tray (or small frag of MD choice) Small drill system like the TPS or Stryker 4. Fracture reduction tray. (bone reduction forceps)
Positioning: The patient is in supine position, arms on arm boards. Foot, Ankle or Calf on bump.
Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from tourniquet to distal metatarsals, circumferentially.
Draping: Some surgeon like a sterile towel around the tourniquet, held in place with a towel clip. U-drape and an extremity drape.

57. ORIF Ankle Begin your Operative Sequence
Incision: 15 kb on #3 handle for incision.
Bone most often broken is the fibula.
Some surgeons like multiple 15 kb’s for this procedure. Be prepared for this. (bone dulls KB’s quickly)
incision can be made over the fibula with a ten blade as well as the tibia.

58. ORIF Ankle cont. Operative Sequence
Hemostasis: Handheld Bovie and hemostats.
a pneumatic thigh tourniquet is used for hemostasis

59. ORIF Ankle cont. Operative Sequence
Dissection and Exposure:
Metz, Adsons.
Small Weitlander
Senn Rakes

60. ORIF Ankle cont. Operative Sequence
Exploration and Isolation:
periosteum is reflected with use of a periosteal elevator at the fracture site of the fibula/tibia

61. ORIF Ankle cont. Operative Sequence
Surgical Repair/Removal/Specimen Collection:
Fibular fracture is manually reduced and maintained with the use of a bone clamp, the C-arm is utilized to view the reduction.
K-wire can be inserted through the fracture site and utilized as a guide wire or to hold the fracture together while proper plate is found.

63. cancellous screw vs cortical screws
A screw designed for placement in cancellous bone. The pullout strength of a screw is proportional to the amount of metal- bone contact. Because cancellous bone is porous, threads for cancellous bone screws have to be longer than for cortical screws to achieve the same degree of metal- bone contact and thus have the same pullout strength as cortical screws.

64. Cortical Screw
Cortical Screw: Cortical screws have closely- spaced, shallow threads.
Cortical screws are stronger than cancellous screws of the same outer diameter.

65. Full vs Partial Thread

66. Screw Procedure
Drill
Depth Gauge
Tap
Screw

67. ORIF Ankle cont. Operative Sequence
Surgical Repair / Removal/Specimen Collection:
A cannulated interfrag cortical screw can be inserted perpendicular to the fracture site of the fibula (over the K-wire)
A 1/3 tubular plate (most common plate) can be bent to the shape of the fibula, placed over the fracture and stabilized with the screws.
The C-arm will again be utilized to check placement of screws and plate.

69. ORIF Ankle cont. Operative Sequence
Hemostasis and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
Take emeses pan with you.

70. ORIF Ankle cont. Operative Sequence
Closure:
Subcutaneous tissue will be reapproximated and sutured with use of 2-0 Vicryl.
The skin will be closed with staples or Monocryl.
Patient to maintain strict non-weight bearing status of the extremity.

71. Remember Three simple steps to remember when working with fractures:
Find the bone (fracture site)
Reduce the bone
Plate the bone