Orthopedic Procedures
Operative Sequence
Bunionectomy
Foot
- Anatomy -
Foot
- Anatomy -
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.
Bunionectomy
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
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.
Bunionectomy
- Anatomy -
Bunionectomy
- Anatomy -
Bunionectomy - Approaches
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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.
http://www.youtube.com/watch?v=aW17Eda291U
Fusion (arthrodesis) of big toe joint: Fusion of the
bunion joint is for severe osteoarthritis.
Bunionectomy - Approaches

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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.
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.
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.
Bunionectomy

Wound Classification: 1
Operative Sequence
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1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection
possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
Bunionectomy
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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.
Bunionectomy
Begin your Operative Sequence
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
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Incision:
15 kb on #3 handle
for incision.
Some surgeons like
multiple 15 kb’s for
this procedure. Be
prepared for this.
Bunionectomy
cont. Operative Sequence

Hemostasis: Handheld Bovie and
hemostats.
Bunionectomy
cont. Operative Sequence
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Dissection and
Exposure:
Metz, Adsons.
Small Weitlander
Senn Rakes
Bunionectomy
cont. Operative Sequence

Exploration and Isolation:
• Apply plantar pressure to provide flexion
of great toe.
Bunionectomy
cont. Operative Sequence
• Surgical Repair/Removal/Specimen
Collection:
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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
Bunionectomy
cont. Operative Sequence

Hemostasis and Irrigation:
• All bleeding is controlled with cautery.
• Use of warm Saline to irrigate.
• Take emeses pan with you.
Bunionectomy
cont. Operative Sequence

Closure:
• Small subcuticular stitch – 4-0 Vicryl
• Skin is closed with surgeons choice of suture or
staples.
Bunionectomy

Major
Arteries:
• Ant. Tibial
Artery
Bunionectomy

Major Veins:
• Greater
Saphenous vein

Major Nerves:
•
Plantar
Orthopedic Procedures
Operative Sequence
Hammer Toe
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.
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).
Hammer Toe
Mallet Toe
Claw Toe
Hammer Toe
• Define the
procedure:
• Resect the joint,
release the soft
tissue (ligaments)
and place K-wire
through joint.
Hammer Toe
• Wound Classification: 1
Operative Sequence
•
•
•
•
•
•
•
•
•
1- Incision
2- Hemostasis
3- Dissection
4- Exposure
5- Procedure (Specimen Collection possible)
6- Hemostasis
7- Irrigation
8- Closure
9- Dressing Application
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.
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.
Hammer Toe
cont. Operative Sequence
• Hemostasis: Handheld Bovie and
hemostats.
Hammer Toe
cont. Operative Sequence
• Dissection and
Exposure:
• Metz, Adsons.
• Small Weitlander
• Senn Rakes
Hammer Toe
cont. Operative Sequence
• Exploration and Isolation:
• Apply plantar pressure.
• Senns or single tooth skin hooks.
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.
• The procedure:
• http://video.google.com/vide
oplay?docid=687704531599
0173103&ei=qtK3San_OZG_AGhnN2EBA&hl=en
• Post Op Vid:
http://www.youtube.com/wat
ch?v=VfCj_KX6h3w
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.
Hammer Toe
cont. Operative Sequence
• Closure:
• Small subcuticular stitch – 4-0 Vicryl
• K-caps.
• Skin is closed with surgeons choice of
suture or staples.
Orthopedic Procedures
Operative Sequence
ORIF Ankle
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.

Overall
Purpose of
Procedure:

To stabilize the ankle so
the patient can regain
function of their foot.

Skate Boarding

Ankle break
 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
 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.
Wound
Classification: 1
depending on how long the ankle has been
fractured and if the bone broke the skin.
 1-
Incision
 2- Hemostasis
 3- Dissection
 4- Exposure
 5- Procedure (Specimen Collection
possible)
 6- Hemostasis
 7- Irrigation
 8- Closure
 9- Dressing Application

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.





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.
 Hemostasis:
Handheld Bovie and
hemostats.

a pneumatic thigh tourniquet is used for
hemostasis
 Dissection
and
Exposure:
 Metz, Adsons.
 Small Weitlander
 Senn Rakes
Exploration
 periosteum
and Isolation:
is reflected with use of a
periosteal elevator at the fracture
site of the fibula/tibia

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.


Cancellous screw:
A screw designed for
placement in cancellous
bone. The pullout strength
of a screw is proportional
to the amount of metalbone 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 metalbone contact and thus
have the same pullout
strength as cortical
screws.
 Cortical
Screw:
Cortical screws
have closelyspaced, shallow
threads.
 Cortical screws
are stronger than
cancellous screws
of the same outer
diameter.
 Drill
 Depth
 Tap
 Screw
Gauge

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.
 Hemostasis

and Irrigation:
All bleeding is controlled with cautery.
Use of warm Saline to irrigate.
 Take emeses pan with you.

 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.
 Three
simple steps to remember when
working with fractures:
 Find
the bone (fracture site)
 Reduce the bone
 Plate the bone