Surgery Exit Exam, Study guide: Pre-Op Evaluation: o Steroid use and Supplementation: Surgery increases adrenal production

on of cortisol Patients taking steroids may have impaired adrenal function and be at risk for Addisonian crisis following surgery Maximum Cortisol production is approximately 300 mg/day Patients having minor surgery do not need supplementation, patients who have been on large doses of steroids or are having major surgery require maximal supplementation in the peri-operative period 300 mg of cortisol (or equivalent) over 24 hours: Hydrocortisone 100mg post-op & q8h o Insulin while NPO? Non-ketosis prone: may hold insulin Ketosis prone but short, early surgery and patient can eat soon after: may hold insulin Ketosis prone but longer, later surgery: half dose and treat BS Insulin: short, intermediate, and long acting injected subQ several times a day Oral agents: hold on day of surgery; if first gen, hold 48 hours- check fingerstick pre-op! Drugs to stop Pre-op: ACNOM ASA (>1 week before) Coumadin change to Heparin NSAIDS 5-7 days before Oral hypoglycemic drugs MAOIs Drugs to continue Pre-op: ACCAP Anti-hypertensives Cardiac drugs (CA channel blockers, BBs, anti-arrhythmics, nitrates) Chronic pain meds Antibiotics Psychiatric drugs Suture Materials: o Relative tissue reactivity: Synthetic materials less reactive than natural Monofilament less reactive than multifilament Greatest Reactive: SuSy SiCo PoSt(ed) NY Popo Surgical gut Synthetic absorbable Silk/Cotton Polyester Stainless steel wire Nylon Polypropylene Least reactive o Different types of absorbable sutures: Natural: Derived from collagen of healthy mammals, absorbed by enzymatic reactions o Surgical gut: Serosal layer of beef intestine Submucosal layer of sheep intestine Greatest amount of tissue reaction Plain gut: rapid absorbtion; loss of TS 7-10 days

Chromic gut (treated with chromium salt): loss of TS in 10-14 days Synthetic absorbable sutures Synthetic polymers, less tissue reaction than natural, longer rates of absorbtion st nd Absorbed by hydrolysis: 1 phase, loss of TS; 2 phase, loss of suture material Vicryl (Polyglactin 910) o Multifilament o Maintains TS until collagen formation occurs: p/o day 14: 65% TS p/o day 21: 30% TS Minimally absorbed until day 40, completed within 60-90 days Dexon (Polyglyocilic acid): same qualities as vicryl PDSII (Polydioxanone) o Monofilament material o p/o day 14: 70% TS o p/o day 28: 50% TS o p/o day 42: 25% TS o minimal absorption p/o day 19 o completed by 6 months Relative tensile strength of sutures: Greatest o Stainless steel o Polyester o Nylon o Polypropylene o Natural fibers Least Surgical needle: Local and Regional anesthesia: o How they work: Block ionic channels from inside the nerve Block changes in the membrane potential Block generation of an action potential o Metabolism: Esters: broken down by plasma cholinesterase Amides (have I in the name): broken down by liver enzymes o Allergies: true allergic reaction is rare, usually a reaction to epinephrine Allergic reaction to esters more common Can have reaction to preservative in amides (methylparaben) o Approximate toxic doses: Lidocaine: 300; 500 with epi Bupivicaine (Marcaine): 175; 225 with epi Chloroprocaine: 800; 1000 with epi Procaine (spinal): 1000 Mepivicaine: 400; 500 with epi Tetracaine (topical): 20 Etidocaine: 300/400 with epi Cocaine (topical): 150 o Short acting: Procaine (Novacaine), Chloroprocaine, Benzocaine o Long acting: Bupivicaine (Marcaine), Ropivicaine (Naropin), Etidicaine, Tetracaine o Ankle Block: saphenous nerve, sural nerve, superficial peroneal, deep peroneal, posterior tibial o Mayo: MDCN, deep peroneal, medial plantar, sometimes saphenous

Nail disorders/pathology o Stages of onychocryptosis: Stage 1: little pain, edema, hyperhydrosis of area Stage 2: The free edge of the nail has penetrated the soft tissue Production of granulation tissue over the nail plate Painful, edematous, severe hyperhydrosis Seropurulent discharge and odor Stage 3: same as stage 2, granulation tissue becomes epithelialized o Get an XR to rule out OM o Chemical matrixectomies: Phenol/alcohol or Sodium hydroxide o Surgical Matrixectomies: Frost: L-shaped Winograd: elliptical Zadik: excision of the nail bed not necessary Kaplin: modified Zadik, excision of the nail bed and the nail matrix, H-shaped incision, exposure of distal phalanx left to close by secondary intention

DVT/PE: o Imaging gold standard: Contrast venography o Imaging first choice: ultrasonography o D-dimer: measures breakdown of fibrin, presence of which indicated thrombosis. Used to rule OUT DVT (negative = no DVT) o Treatment options: Warfarin, Heparin, LMWH, Fondaparinux, ASA o MOA of ASA: permanently inactivates the COX activity of PG-H, thus inhibiting platelet action. Antiplatelet but does NOT affect the coagulation cascade. o Direct thrombin inhibitors (Heparin/LMWH): inhibition of thrombin, enhances antithrombin activity and promotes tissue factor pathway inhibitors- affects the coagulation cascade directly o IVC filter: used when a patient cannot be anticoagulated because of an adverse complication or contraindication, can be permanently or temporarily placed below the IVC. o AACP guidelines for duration of therapy: DVT secondary to risk factor or first time distal DVT: 3 months Second episode or first time proximal: long term Compression stockings 30-40mmHg Maintain INR at 2.5 Hemostasis: Cuff pressure: Ankle: 100 plus systolic BP, no greater than 250mmHg Thigh: 300-350mmHg Do not leave cuff inflated >2 hours Exanguination via Esmarch bandage in order to eliminate the blood within the venous system that would otherwise be trapped in the tourniquet, reduces the amount of bleeding during the procedure MOA of Avitene (hemostatic material): attracts platelets

ANGLES:

Instruments:

Achilles tendon pathology: Diagnosis: o Palpable gap, bulbous segment o Thompson test: patient lies prone with feet hanging over the edge of the table and the clinician squeezes the calf muscle to stimulate contraction. Positive test (rupture) occurs when there is lack of plantarflexion o Matles resting tension position: patient lies prone on the examination table with the knee flexed at 90 degrees. Normally, flexing the knee causes the gastrocnemius muscle to shorten, leading to plantarflexion of the foot. With an AT rupture, the affected foot often lies in slight dorsiflexion compared to the uninjured side. Operative repair: standard of care, especially in chronic ruptures o End-to-end repair: need adequate length, Krackow suturing method is best. For defects measuring 1-2 cm o Augmentation: End-to-end with additional auto-, allo-, or synthetic grafts, MC is the plantaris tendon. o V-Y myotendinous lengthening with end-to end for defects 2-5 cm o FHL tendon transfer for defects 2-5 cm(PB and FDL have also been described but FHL is best) o Turndown or Rotational flaps: fascial turn down of proximal gastrocnemius fascia, covers and re-approximates the suture site, reserved for chronic rupture, for defect >5cm (can also do FHL plus V-Y) o Percutaneous repair

Hammer toes Three etiologies for hammertoes: flexor stabilization, flexor substitution and extensor substitution Extension of MPJ and Flexion of the PIPJ Mnemonic : HECAT o Head resection of the proxiaml phalanx o Extensor hood release: cut extensor expansion from the proximal phalanx and bring it back; do the kalikian test (push up test) to determine whether it is flexible or rigid o Capsulotomy : dorsal capsule is contracted while the plantar is elongated so you cut doral, medial and lateral at the MPJ; DONT cut the plantar capsule o Arthrodesis: fuse the proximal to the middle phalanx o Tendon transfer: transfer flexor brevis( cut far distal and bring back to shaft and split down the middle, those two flaps tie on to themselves so that they can pull down the proximal phalanx) o If the hammer toe doesnt reduce??? Partial met head resection Weil osteotomy: this will shorten the met without plantarflexing/dorsiflexing it Do a double cut: if you raiser the met head with the capsule intact, your dorsiflexing the met SIDE NOTE: never elongate a met unless you have brachymetatarsalgia ***Know the location of flexor brevis/ longus