§ur V era Review Booklet

( & a f e w o t h e r i m p o r t a n t

i t e m s f o r e x t e r n s h i p s )

O C p M ' s f ^ C f f l l )

O f f i c e r s o f 2 0 0 5

% t y p j z d , e d i t e d . U p d a t e d b y t h ^ J p M d i f l i n 2 0 0 9

All pictures came from class notes / handouts.

Most of the pictures were referenced from Dr. Hetherington's book.

2

Tabliz of Contents:

Topic Page # Charting

Surgical Consult 6 Pre-Op Note 6 Post-Op Order 6 Admission Order & Note 6 Post-Op Note 7 Post-Op Visit 7

Layers of the Foot 8 Key Lab Values 8 Hospitalization Indications 9 Post-Op Fever Etiologies 9 Sutures

Types 10 Selection 11 Technique 11

Classification Systems Stewart, Salter-Harris 12 Gustillo-Anderson, WatsonJones, Freiberg 13 Berndt-Hardy, Hawkin 14 Sneppen, Watson & Dobas, Kuwada 15 Rowe, Sander's 16 Hardcastle, Dias, Danis-Weber 17 Lauge-Hansen 18

MRI 19 Anesthesia

Anesthetics 20 Dosing 20 Onset/Duration 20 Increasing Comfort 21 Ankle Block 21 Hemostasis = Tourniquet Pressures 21

3

Tablsz o j Contents (Continued):

Topic Page # Corticosteroid Injections

Types 22 Side Effects 22 Cocktails 22

Radiographic Data 23 Joint Deformities 24 Osteotomies

Proximal 25-27 Shaft 29-30 Distal 31-33

Internal Fixation Principles 34 Rule of 2's 34 K-Wires 34 Steinmann Pins 34 Monofilament Wire 35 Tension Band Wiring 36 Staples 37 Screws

Anatomy 38-39 Types 40-41 Fixation Technique 42-43 Selection 44

Soft Tissue Anchors 45 Plates 45-46

Table of Contents (Continued):

Topic Pase # External Fixation

Principles 47 Complications 48 Types 48-49 Dynamics 50 Care & Management 50

Forefoot Pathologies / Surgical Procedures Hallux Limitus/Rigidus 51-52 Hammertoes 53-56

Etiologies for Contracted Digits 5th Digit Arthroplasty 57

Rearfoot Surgery Plantar Fasciotomy 58 Haglund's Deformity 59 Keck & Kelly Osteotomies 59

Tendon Transfers & Indications Adductor Hallucis 60 Abductor Hallucis 60 Extensor Hallucis Longus 60 Jones Suspension 60 Hibbs 60 Tibialis Anterior 61 STATT 61 Cobb 61 Tibialis Posterior 62 Peroneus Longus 62

Bunions based on Angles 63 Other things to know... 67

CHARTING SURGICAL CONSULT

1. Chief Complaint 8. Primary Care Dr 2. HPI (NLDOCAT) 9. Hospitalizations 3. Allergies 10. RoS 4. Medications > Vitals / Vascular / Neuro / Derm / 5. Social History Musculoskeletal 6. Medications 11. Ancillary (x-rays, labs, ect...) 7. Family History

P R E - O P NOTE Surgeon Medications Pre-Op Dx Allergies Planned Procedure Diagnostic Data - Labs, x-rays, EKG, ect... Consent Form: Describe Procedure & Care / Complications /

Alleviations / Expected Outcomes / Arrange Pre-Op Testing "Consent form was reviewed with patient, signed and placed in chart." "All risks, possible complication and alternative treatments have been discussed with the patient in detail. All patients' questions have been answered to satisfaction. No guarantees to the outcome have been made."

POST-OPERATIVE ADMISSION ORDERS & ORDERS: NOTE: VANDIMAX ADC - V A AN DILM A X Vitals Date/Time/Signature Date/Time/Signature Activities Vitals Admit to Allergies Activities Dx Nursing Nursing Condition Diet Diet - Ins/Outs Ins/Outs Labs Meds Meds Ancillary Ancillary X-ray X-ray

6

P O S T - O P NOTE: S A P P A I T E M I F C 2 P 3

Surgeon Hemostasis - type Assistants Estimated Blood Loss Pre-Op Diagnosis Materials - sutures/hardware Post-Op Diagnosis Injectables - any post-incision Procedure Anesthesia - type /

how much "Patient tolerated procedure and anesthesia well. Patient transported to recovery by anesthesia with vital signs stable and vascular status intact." Also may include.. Pathology - bone, ST; Condition - stable, guarded, fair, poor; Prophylaxis

Findings Pathology Prophylaxis Complications Condition

P O S T - O P VISIT: S O A P Subjective

1. POV# , PVD # 2. Procedure 3. N,V,C,F,SOB 4. Activity status 5. Pain / How controlled 6. Other Complaints

Objective 1. How patient presents - walking, wheelchair 2. Vascular, Neuro, Derm, Musculoskeletal

Assessment 1. Status Post-Op 2. Compliance

Plan 1. Treatment 2. Dr & Residents

7

L A Y E R OF THE F O O T

1st Layer 1. Abductor Hallucis M. 2. Abductor Digiti Minimi M. 3. Flexor Digitorum Brevis M.

2nd Layer 1. Quadratus Plantae M. 2. Lumbricales M.

3rd Layer 1. Flexor Hallucis Brevis M. 2. Flexor Digiti Minimi M. 3. Adductor Hallucis M.

4th Layer 1. Dorsal Interossei M. (4) 2. Plantar Interossei M. (3)

K E Y L A B V A L U E S

Chem 7 (136-145mEq/L)

Na

K

(97-107mEq/L)

CI

CO (3.5-5mEq/L) (23-29mmol/L)

(5-20mg/dL)

BUN / Glucose (<13 Omh/dL) Cr

(M: <1.2 W:<l.lm'g/dL)

CBC

WBC (4500 -11,000/LV,

(M: 14.4-16.6g/dL) (W: 12.2-14.7g/dL)

HgB

HCT (M: 43-49%) (W: 37-43%)

Platelets (150.000-450,OOOpL)

INDICATIONS FOR HOSPITALIZATION P O S T - O P

1. Fever >101.6° 2. Ascending Cellulitis / Suspect Osteomyelitis 3. Lymphangitis / Lymphadenopathy 4. Immunosuppressed 5. Virulent / Resistant Organisms 6. Need for I&D Procedure 7. Need for IV Antibiotics 8. Failed response to outpatient therapy 9. Need a consult

P O S T - O P FEVER ETIOLOGY

1. Wind - Pulmonary a. Aspiration / Pneumonia b. Occurs 24-48h c. Get chest x-ray

2. Water-UTI a. Occurs in 2-6d

3. Wound a. Occurs in 3~5d

4. Walk - DVT / Pulmonary Embolism a. Within l s lweek b. Virchow's Triad

i. Hypercoagulation ii. Venous Stasis

iii. Endothelial Damage

5. Wonder - drugs / fever / benign / medicines

SUTURES

Absorbable Sutures Filament Type Total Absorption Chromic Gut 70d Monocryl Monofilament 90d Maxon Monofilament 90-120d Vicryl Monofilament 56-70d

or Braided Dexon Mono- or 90-120d

Multifilament Dexon Plus Mono- or 90-120d

Multifilament Dexon S Multifilament 90-120d PDS Monofilament 180d Non - Absorbable Sutures Filament Type Advantages Stainless Steel Mono- or High strength, low

Multifilament tissue Rxn Ethilon Nylon Monofilament Elasticity/Memory Prolene Monofilament Minimal Tissue Rxn Novafil Monofilament Elasticity/Tensile

strength Silk Multifilament Good Handling Nurolon Nylon Multifilament Mersilene Multifilament Consistent Tension Ticron Braided Minimal Tissue Rxn Ethibond Multifilament Good Handling

•—N

10

1. Bone a. Stainless Steel

2. Tendon a. Prolene b. Ethibond c. Nylon d. Polyesters

3. Muscle a. PDS b. Vicryl c. Prolene

4. Fascia a. Prolene b. PDS

SUTURE SELECTION 5. Subcutaneous Fat

a. Vicryl 6. Subcuticular

a. Monocryl b. Vicryl

7. Capsule a. Vicryl

8. Skin a. Nylon b. Silk

Deep Tissue taper needle; 3-0 suture Subcutaneous Tissue -> taper needle; 4-0 suture Dermal Layer precision needle; 5-0 suture Capsule 2-0 or 30 suture Subcutaneous 4-0 suture Subcuticular 5-0 clear suture Skin 4-0 clear suture

SUTURE TECHNIQUES 1. Simple Interrupted

Good for infected wounds Individual know for each throw

2. Horizontal Mattress Everts skin edges well

3. Vertical Mattress Everts tissue edges well

4. Continuous Running Good to save time Good for large wound areas

5. Subcuticular (Running Intradermal) Leaves the best scar

!

IT

STEWART CLASSIFICATION OF 5™ M E T FRACTURES

Type I Supra-articular @ metaphyseal-diaphyseal junction True Jones!

Type II Intra-articular avulsion, 1 or 2 fracture lines Type III Extra-articular avulsion, PB tears small fragment from the

styloid process Type IV Intra-articular, comminuted fracture, assoc. with crush injury Type V Extra-articular avulsion @ of physis in children (SH Type I)

SALTER-HARRIS CLASSIFICATION OF EPIPHYSEAL INJURIES

Type I Epiphysis is completely separated from metaphysis

Type II Epiphysis, and the growth plate, is partially separated from the metaphysis, which is cracked

Type III Fracture runs through the epiphysis, across the growth plate from the metaphysis

Type IV Fracture runs through the epiphysis, across the growth plate, and into the metaphysis

Type V The end of the bone is crushed and the growth plate is compressed

Type VI (Rang's Addition) Avulsion of peri-chondral ring

Type VII (Ogden's Addition) Avulsion fracture of the epiphysis without involvement of the physis

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GUSTILLO & ANDERSON O P E N FRACTURE CLASSIFICATION SYSTEM

Type I Fracture with open wound < lcm in length Clean, minimal soft tissue necrosis Usually traverse or short oblong

Type II Fracture with open wound >lcm in length Clean, minimal soft tissue necrosis Usually traverse or short oblon

Type III Fracture with open wound >5cm in length Contamination and/or necrosis of skin, muscle, NV, & ST Comminuted > Type Ilia

• Adequate bone coverage > Type Illb

• Extensive soft tissue loss with periosteal stripping and bone exposure

> Type IIIc " Arterial injury needing repair

NAVICULAR FRACTURE - W A T S O N JONES Type 1 Navicular tuberosity fracture Type II Avulsion fracture of dorsal lip Type III A: Transverse body fracture - Nondisplaced

B: Transverse body fracture - Displaced Type IV Stress fracture

FREIBERG CLASSIFICATION - A V N OF 2N D M E T Type I No DJD Articular cartilage intact Type II Peri-articular spurs Articular cartilage intact Type III Severe DJD Loss of Articular Cartilage Type IV Epiphyseal dysplasia; multiple head involvement

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B E R N D T - H A R D Y CLASSIFICATION OF TALAR D O M E LESIONS

Stage I Compression lesion or non-visible lesion

Stage II Fragment attached

Stage III Non-displaced fragment without attachment

Stage IV Displaced fragment

TALAR N E C K FRACTURE CLASSIFICATION - H A W K I N ' S

Type I • Non-displaced talar neck • Disrupts blood vessels entering dorsal talar neck and intra-osseous

vessels • 20% chance AVN

Type II • Displaced talar neck fracture with subluxed or dislocated STJ • Disrupts dorsal neck arterial branches and branches entering from

inferiorly from sinus tarsi & tarsal canal • 40% chance AVN

Type III • Displaced talar neck fracture with dislocated STJ & ankle joint • Disrupts all 3 major blood supplies • 100% chance AVN

Type IV • Displaced talar neck fracture with complete dislocation of STJ • Ankle joint + subluxation or dislocation of the talonavicular joint • Disrupts all 3 major blood supplies • 100% chance AVN

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SNEPPEX CLASSIFICATION OF T A L A R BODY LESIONS

Group I Transchondral / Compression fracture of the talar dome Group II Coronal/Sagital/Horizontal shearing fracture of the entire body

Type I Coronal or Sagital A: Non-displaced B: Displacement of trochlear articular surface C: Displacement of trochlear articular surface with

associated STJ dislocation D: Total dislocation of the talar body

Type II Horizontal A: Non-displaced B: Displacement

Group III Fracture of posterior tubercle of talus Group IV Fracture of lateral process of talus Group V Crush fracture of the talar body

W A T S O N & DOBAS CLASSIFICATION - POSTERIOR LATERAL TUBERCLE OF TALUS (SHEPARD'S FRACTURE)

Stage I Normal Lateral talar process with no clinical significance Stage II Enlarged posterior lateral tubercle of the talus (Steida's Proccss) Stage III Accessory bone / Os Trigonum that may be irritated by trauma Stage IV Os Trigonum + cartilaginous/synchrondrotic union with talus

K U W A D A CLASSIFICATION OF ACHILLES RUPTURE

Type I Partial rupture Type II Complete rupture <3 cm gap Type III Complete rupture 3-6cm gap Type IV Complete rupture >6cm gap

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R O W E CLASSIFICATION OF CALCANEAL FRACTURES

Type I A Medial Tuberosity fracture B Sustentaculum Tali fracture C Anterior Process fracture

Type II A Posterior break fracture withow? Achilles involved B Posterior break fracture with Achilles involvement

Type III Extra-articular body fracture

Type IV Intra-articular body fracture with out depression

Type V A Comminuted, Intra-articular fracture with depression B Comminuted fracture with severe joint depression

SANDER'S C T CLASSIFICATION OF CALCANEAL FRACTURES

* Fractures are classified according to the number of intra-articular fragments and location of fracture lines # of Fractures Type I Any non-displaced intra-articular fracture Type II 1 fracture through posterior facet creating 2 fragments Type III 2 fractures through the posterior facet creating 3 fragments Type IV 3~ intra-articular fracture lines

Location of Fracture Lines:

16

LISFRANC'S FRACTURE CLASSIFICATION - HARDCASTLE

Type A: Total or Homolateral - Disruption of the entire Lisfranc joint - Transverse or Sagital plane - Most common type

Type B: Partial B1 - Medial incongruity with the first met forced medially

- Involves 1st met OR mets 2,3,4 but NOT 5 B2 - Lateral incongruity with lesser mets forced laterally

Type C: Divergent CI - Partial divergence with the Is' met medial and 2nd met laterally

displaced C2 - Total divergence with the 1st met displaced medially and lesser

mets displaced laterally

DIAS CLASSIFICATION OF LATERAL A N K L E LIGAMENT INJURY

Grade I •=> Partial rupture of CFL Grade II •=> Complete rupture of ATFL Grade III <=> Complete rapture of ATFL, CFL, &/or PTFL Grade IV <=> Complete rapture of all 3: ATFL, CFL, & PTFL

+ Partial rupture of the Deltoid Lig

D A N I S - W E B E R CLASSIFICATION OF FIBULAR FRACTURES INVOLVED IN A N K L E FRACTURES

Type A Transverse avulsion fibular fracture BELOW... (SAD) )

Type B Spiral fracture AT... (SERorPAB) ( the level of

TypeC Fibular Fracture ABOVE... t h e syndesmosis

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LAUGE-HANSEN CLASSIFICATION OF A N K L E FRACTURES

SUPINATION ADDUCTION (SAD) a Stage I Transverse avulsion of fibula @/below AJ level

Rupture of the Lateral Collateral Ligament n Stage II Oblique to Vertical fracture of the Medial Malleolus

PRONATION ABDUCTION (PAB) n Stage I Transverse avulsion fracture of Medial Malleolus

- or - Rupture of Deltoid Lig n Stage II Rupture of AITFL & PITFL

- or - Tillaux-Chaput / Wagstaffe fracture n Stage III Short oblique fracture of the fibula @ lvl of syndesmosis

SUPINATION EXTERNAL ROTATION (SER) *** Most Common! n Stage I Rupture of AITFL

- or - Tillaux-Chaput / Wagstaffe fracture n Stage II Spiral/Oblique fracture of fibula @ lvl of syndesmosis n Stage III Rupture of PITFL

- or - Avulsion fracture of Posterior Malleolus (Volkmann's Fracture)

n Stage IV Transverse fracture of Medial Malleolus - or - Rupture of Deltoid Lig

PRONATION EXTERNAL ROTATION (PER) *** Longest healing time! a Stage I Transverse fracture of Medial Malleolus

- or - Rupture of Deltoid Lig n Stage II Rupture of AITFL & Interosseous membrane

- or - Tillaux-Chaput / Wagstaffe fracture n Stage III High Spiral Oblique fracture (Maisonneuve Fracture) n Stage IV Rupture of PITFL

- or - Avulsion fracture of Posterior Malleolus

18

M R I

Tl-Weighted -> good for showing anatomical detail + Short TE + TR + Tissue with short T1 are brighter + Fat

T2-Weighted good for highlighting areas of pathology + Long TE + TR + Tissue with long T2 are brighter + Water, Edema

STIR -> Short Tau Inversion Recovery + Fat suppression + Heavily water-weighted image + Very Sensitive for bone marrow abnormalities

Gadolinium (best for infection) + Contrast-enhanced chemical agent + Shortens T1 relaxation times -> Increases signal intensity on T1

weighted images + Usually used in conjunction with fat suppression + Good for identifying ST masses, inflammation processes, & for

staging bone and ST infection

TE = Time to Echo dec TE + dec TR = Tl-Weighted TR = Time of Repetition inc TE + inc TR = T2-Weighted

19

ANESTHETICS

Esters • Higher incidence of allergies • Metabolized in Blood (Cholinesterase in plasma) • Types

~ Cocaine ~ Procaine ~ Chloroprocaine ~ Tetracaine

Amides • Metabolized by CYP450 system in Liver • Types

~ Lidociane / Xylocaine (0.5, 1, 1.5, or 2% solutions) ~ Bupivicaine / Marcaine (0.25, 0.5, or 0.75% solutions) "* C/I<l2y/0

~ Mepivicaine / Carbocaine (1, 1.5, 2, or 3% solutions)

0.5% solution = 5 mg/cc drug 1% solution = 10 mg/cc drug

Ex: 5cc of 1% Xylocaine (lidocaine) = 50mg of Xylocaine given Ex: 3cc of 0.5% Marcaine (bupivicaine) = 15mg of Marcaine given

Dosing: 0.25% solution = 2.5 mg/cc drug lcc = lmL

Toxic Doses: Lidocaine Plain = 300mg

w/ Epi = 500mg

Onset & Duration: Onset: 5min Duration: l-2h

Marcaine Plain = 175mg Onset: 10-15min w/ Epi = 225mg Duration: 6-8h

20

6 Ways to Increase Comfort of the Injection: 1. Quick Stick 2. Slow Injection 3. Small Gauge Needle (large # = small gauge) 4. Small Syringe (less pressure) 5. Cold Spray 6. Warm the Solution (to body temp)

Draw up with 18G Inject with 25 or 27G

Ankle Ring Block: Superficial = Saphenous N., Sural N., Superficial Peroneal N. (IDCN.MDCN)

Deep = Posterior Tibial N., Deer Peroneal N.

** Fact: If you mix Lidocaine and Marcaine, you will only have partial anesthesia deep into surgery. Only mix to avoid toxic doses.

D e e p

F i b u l a r N.

S a p h e n o u s N.

S u p e r f i c i a l F i b u l a r N

Ta la r Troch lea

** Fact: If you need to inject more volume, use a small percent of drug solution.

— P o s t . T ib i a l S u r a l N.

N .

Ex: 30cc of 1% gives more anesthesia than 15cc of 2%

Saphenous N Posterior Tibial N Sural N Deep Peroneal N Superficial N

.5-lcc l-3cc .5-lcc .5-lcc .5-lcc

give the most here since this N is the largest

between 2 Long Extensor Tendons plantarflex & invert

Hemostasis = Tourniquet Pressures: Ankle: +100 over systolic ~250mmHg Thigh: +200 over systolic ~ 350mmHg

21

CORTICOSTEROID INJECTIONS Corticosteroid injections are used to control local inflammatory reactions

Phosphates: short-acting (clear) Acetates: long-acting (cloudy)

All corticosteroids are collagenilytic and therefore should not be injected into the same area of soft tissue more than 3-4 times per year.

Side Effects: ~ Soft tissue atrophy ~ Tendon rupture ~ Skin discoloration (lightening)

Cocktails Commonly used in Podiatry: Always draw up the Lido/Marc 1" 1. Plantar Fasciitis j followed by Dex or Kenalogl

a. lcc Kenalog-10 (lOmg/mL) b. 0.75cc 1% Lidocaine c. 0.75cc 0.5% Marcaine

2. Joint Injections a. 0.2cc Dexamethasone Phosphate b. 0.5cc 1% Lidocaine

3. Intermetatarsal Neuromas a. 0.3cc Dexamethasone Phosphate b. 0.5cc 1% Lidocaine

22

RADIOGRAPHIC D A T A

Angle: Normal: Hallux Abductus Angle 0-15° Proximal Articular Set Angle (PASA) 0-8° Distal Articular Set Angle (DASA) 0-7° Intermetatarsal Angle

1 - 2 0 - 8 ° 2-5 16° ±4° 4-5 8° + 2°

Hallux Interphalangeal Angle (HIA) 0-10°+ 2° Metatarsal Length + 2mm Metatarsus Adductus 0-8° Tibial Sesamoid Position Positions 1-3

1 = Medial to midline of hallux 2 = Touching midline medially 3 = 2/3 medial + 1/3 lateral to midline 4 = 1 / 2 medial + 1/2 lateral to midline 5 = 1/3 medial + 2/3 lateral to midline 6 = touching midline laterally 7 = lateral to midline of hallux

Calcaneal Inclination Angle 18-22° Talar Declination Angle 210

TaloCalcaneal Angle (Kite) 17-21° Bohler's Angle 25-40° Angle of Gissane 125-140°

| Calcaneal Fracture resulting in ! Joint Depression => Bohler's Angle J.

Angle of Gissane :

23

CLASSIFICATION OF J O I N T D E F O R M I T I E S

Positional De+formities: PASA + DASA < HAA PASA and DASA within normal range (0-8°) Joint is Subluxed

Structural Deformities: PASA + DASA = HAA PASA and DASA abnormal Joint is Congruous

Combined Deformities: PASA + DASA < HAA PASA and DASA abnormal Joint is Dislocated

fr.

(A) Congruous: (B) deviated: (C) surtaxed.

24

PROXIMAL OSTEOTOMIES IM between 15-22°, normal PAS A NOT for a short metatarsal

I. Closing Base Wedge • 1-1.5cm from met-cuneiform joint • 4-6weeks NWB

Indications: • Structural Lg IMA • Splayfoot • Juvenile/Recurrent HAV • Met Primus Elevatus • HAV + MetAdductus • C/I in Elderly

£

II. Juvara - Types A,B,C A: Oblique, distal lateral to proximal medial with an intact medial cortical hinge B: same as A but the medial hinge is sectioned after wedge resection C: Oblique, without wedge resection

25

PROXIMAL OSTEOTOMIES CONTINUED.

III. Opening Base Wedge (Trethowan) • Good for a short metatarsal • Use medial eminence for the graft

IV. Crescentic • 1.5cm from met-cuneiform joint • Easy traverse plane correction • Good for short metatarsal

26

PROXIMAL OSTEOTOMIES CONTINUED.

V. Double Osteotomy • IM and PASA correction

VI. Proximal V • Good screw fixation • Unlikely to get elevates

VII. Lapidus • IM> 18° • Fusion of the base of 1st met to the medial

cuneiform • Indications:

• Pain with motion at met-cuneiform joint • Hypermobility of 1st met-cuneiform j oint

27

( C C ( ( C < ( 1 C C C ( C C C ( ( ( C C (

MIDSHAFT OSTEOTOMIES ** Troughing is unique to midshaft osteotomies

t. Ludloff Osteotomies • IM 1-2 angle: 13-20° • Abnormal HAA J • Normal to short Is ' metatarsal / • Elevatus is a risk

II. Mau • IM 1-2 angle: 13-20° • Abnormal HAA • Normal to short 1st metatarsal • Due to cut, decreases elevates

potential

/

29

MIDSHAFT OSTEOTOMIES CONTINUED.

III. Sca r f - "Z" • Dorsal to Plantar - 50:50 or 66:33 cut • Very Stable, technically difficult • 2 screw fixation

IV. Off-Set "V" • Modification of the Austin • Cut angled <55°

MO

30

DISTAL OSTEOTOMIES HAV angle - 35° IM angle — 16 0

Some PASA correction

I. Reverdin • Some PF possible

II. Hohmann • Very unstable; Rigid Fixation necessary • Shortening occurs with fragment removal

/

31

DISTAL OSTEOTOMIES CONTINUED.

III. Mitchell - "Step-down Osteotomy" • Used for long 1st metatarsal • Good visualization of possible change

IV. Wilson • Dramatic shortening possible

32

DISTAL OSTEOTOMIES CONTINUED.

V. Austin / Chevron / Distal "V" • Transpositional - PASA, IM, DF/PF possible • Joint preserving • Possible of Juvenile HAV • Displace capital fragment 'A to 'A bone width

VI. Reverdin Green / Distal "L" • Cut 2/3 way through bone, then plantar cut

33

INTERNAL FIXATION

4 Main Principles of Internal Fixation: 1. Anatomical Reduction 2. Rigid Internal Fixation 3. Atraumatic Technique 4. Early active RoM

Rules of 2's: • Fracture / Osteotomy site should be • 2 points of fixation is better than 1 • 2 threads should purchase the distal • 2 finger tightness

Kirschner Wires (K-wires): • Steel wires used as permanent or temporary fixation • Dependent on diameter • Available in both smooth and threaded • Threaded wires provide more stable purchase • BUT are weaker & harder to remove • Both are measured by outer diameter • ONLY maintain compression • Sizes: 0.028, 0.035, 0.045, 0.062 inches

Steinmann Pins: • Very similar to K-wires • Larger diameter than K-wires • Provide Inc Stability • Measured in 64ths • Sizes: 8/64 (1/8), 7/64, 6/64...

2x's the diameter of the bone

cortex

34

INTERNAL FIXATION CONTINUED

Monofilament Wire: • Malleable Steel • Provide interfragmentary compression » Measured in Gauges (small gauge = large diameter) • Techniques:

> Cerclage fashion • circling around a bone

> Interfrag fashion • placed in between 2 fragments • always pull on the proximal fragment • most stable

35

INTERNAL FIXATION CONTINUED.

Monofilament Wire Continued... > Box Wire fashion

• 2 boxes at 90° to each other • One wire is placed medial to lateral • Other is placed dorsal to plantar

Tension Band Wiring: • Combines K-wire with MF wire • Requires that there is a soft tissue structural component • Two K-wire's placed the parallel fashion across fracture site with the

MF wire in a figure 8 pattern around the K-wire on the site opposite to the tendon's anatomical pull.

• Size of wire measured in gauges — Lower gauge; thicker wire • 26 & 28 are common in Podiatry

36

INTERNAL FIXATION CONTINUED. . .

Staples: • Primarily used for fractures, osteotomies & fusions • Inserted manually or with pneumatic gun • Provide compression, distraction or maintain compression • Be careful about thickness of bone - DO NOT use if cortical bone is

greater than 2-3mm, may cause cortical fractures or not seat in bone properly

Pre-Drills:

Neutralization-^

Compression 4 : Divergent Lines

Distraction = Convergent Lines

Richards Staple: GOLD STANDARD for major fusion Os Staple: Heat activated Uniclip: Has an aperture

Requires a tool to compress the legs after insertion

37

INTERNAL FIXATION CONTINUED. . .

Screws: These features can differ depending on the function of the screw.

Flead Has various configurations; hexagonal, cruciate, slotted...

Land The curve-contoured underside of the screw head Increases the surface contact between the screw and the bone Reduces the chance from stress-risers

Shaft/Shank Area of the screw that is void of the thread pattern

Thread The means by which the screw purchases the bone

Thread Diameter The diameter across the thread width

Measurement is the value used to describe the screw size

Core Diameter Diameter between the thread patterns

Pitch Distance between the adjacent threads Run-Out Junction where the shaft meets the thread

Weakest point on the screw

Avoid placing the run-out near the fracture / osteotomy site

Lead Distance that the screw advances with each turn (360°)

Rake Angle Thread to axis angle

Tip Angle Tip to axis angle

Tip Either rounded (needs pre-tapping) or fluted (self-tapping) 38

INTERNAL FIXATION C O N T I N U E D

Screw Diagram:

L A N D Undersurface of the head of the

screw which comes in contact with bone

R U N O U T weakest point in screw

P I T C H Distance between threads,

cortical screws have a smaller pitch than cancellous screws

T H R E A D D I A M E T E R f This value is used to describe the t

screw sizeO.e. a 2.7mm screw has a 2.7 millimeter thread diameter)

< F r

<

H E A D Hexagonal allows for the most efficient translation of torque and reduce CAM-OUTfiifting out of the screw driver from the screw head)

S H A N K Only present in cancellous screws

R A K E A N G L E Thread to axis angle

C O R E D I A M E T E R Diameter of the screw between the threads

T I P A N G L E Tip to axis angle

39

INTERNAL FIXATION CONTINUED . . .

Types of Screws:

1. Cortical Screws • Threaded the entire length of the screw • Have smaller pitch for greater number of contacts between the

screw and the dense cortical bone

2. Cancellous Screws • Partially threaded • Larger pitch to provide greater distance of contact between the

screw and the less dense, porous cancellous bone

3. Cannulated Screws • Hollow center down the length of the screw to be used over a guide

wire • Offers easier placement and less complications • May have decreased pullout strength

4. Herbert Screws • Ho head and two set of threads proximally not distally • Proximal threads have greater pitch than the distal threads • Indicated for intra-articular fractures • Compressive strength of Herbert screw are less than conventional

screws

5. Interference Screws • Fully threaded, headless screw • Does not provide interfragmentary compression but resists axial

displacement of one fragment on another • Indicated for stabilization of tendon grafts to bone and tendon

reattachment

40

INTERNAL FIXATION CONTINUED. . .

Types of Screws Continued:

6. Absorbable Screws • Available in natural / synthetic polymers • Most common absorbable polymers used are based on alpha-

hydroxy acids such as L-lactic acid, glycolic acid, & para-dioxanone • Need to be able to last 6-8 weeks

Basic Properties for the Ideal Absorbable Implant: ~ Posses and initial strength to meet biomechanical demands ~ Degrades in a predictable manner over time ~ Undergoes complete absorption without harm to surrounding tissues

41

INTERNAL FIXATION CONTINUED. ..

General Screw Fixation Technique: ~ Place one screw perpendicular to the fracture / osteotomy line for maximal compression. Place the 2nd screw perpendicular to the longitudinal axis of the bone this provides greatest resistance to the axial loading forces on the bone.

~ If only a single screw placement is allowed - place the screw in an angle that is halfway between the angle that is perpendicular to the fracture line and perpendicular to the long axis of the bone

Diagram: A. 2 Screw Technique B. 1 Screw Technique

b.

42

INTERNAL FIXATION CONTINUED

General Screw Fixation Technique Continued: Load Screw Technique • This technique is commonly used in plate fixation. • Involves placement of 2 screws in the plate that is closest to the

fracture line to be drilled offset away from the fracture line. • As the screws are advanced the bone segments between the two screws

are further compressed.

Lag Screw Technique • Placement of the screw so that ONLY the thread engages the distal

cortex of the bone. • Thus further advancement of the screw results in approximation and

subsequent interfragmentary compression. • Most effective in fracture / osteotomy that is 2x's the width of the

bone or has a fracture angle that is less than 40°.

Partially Threaded Screw Insertion Technique 1. Thread / Pilot Hole 2. Countersink (increases surface contact between screw head and the bone) 3. Depth gauge (measures distance between the proximal and distal cortex) 4. Tap 5. Insert Screw

Fully Threaded Screw Insertion Technique 1. Thread / Pilot Hole 2. Countersink 3. Glide Hole 4. Depth gauge 5. Tap 6. Insert Screw

43

INTERNAL FIXATION CONTINUED . . .

Screw Selection Chart:

Thread Diameter Thread Hole Gliding Hole Tap Diameter Mini-Fragment 1.5 1.1 1.5 1.5 2.0 1.5 2.0 2.0 2.7 2.0 2.7 2.7 Small-Fragment 3.5 2.5 3.5 3.5 4.0 (partial/cancel) 2.5 NA 3.5 4.0 (full/cancel) 2.5 NA 3.5 Large-Fragment 4.5 3.2 4.5 4.5 4.5 (mall) 3.2 NA 4.5 6.5 (partial/cancel) 3.2 NA 6.5 6.5 (full/cancel) 3.2 NA 6.5

44

INTERNAL FIXATION CONTINUED. ..

Soft Tissue Anchors: S Used for reattachment of tendons or ligaments •S 2 basic types: Expandable / Screw type S Complications: Improper Placement / Failure of Suture / Pullout

Plates: S Various size and shape - allow alignment of the bones and stability

across the fracture / osteotomy site •S Stability allows for early passive RoM •S Adequate screw fixation is important for the plate to function properly •S Plate designs include semitubular, 1/3 tubular, Vi tubular, T - plate, L

- plate, calcaneal plate...

Types of Plates: 1. Neutralization Plate

a. Prevents torsional / bending forces from acting on the lag screws

b. The ridge extension of the plate on the bone proximal & distal to the fracture / osteotomy site helps neutralize any extra forces along the bone segment

2. Compression Plate a. Generate compressive forces along the fracture / osteotomy site

by either placing the plate on the tension side of the bone, off-set drilling (AKA load screw technique) or pre-bending the plate.

45

INTERNAL FIXATION CONTINUED. . .

Plates Continued...

3. Dynamic Compression Plate (DCP) a. Employs the concepts of offset drilling with unique plate

designs to optimize the compressive forces of the plate b. Disadvantage is it increases periosteal damage and decrease

intramedullary blood supply to the area, decreasing the overall strength of the bone segment

4. Limited Contact Dynamic Compression Plate a. Has a series of recessed undercuts on the undersurface of the

plate which allows limited contact between the bone and the plate

b. Generates less disruption to the vascular supply

5. Buttress Plate a. Anchored to the main stable fragment b. Supports the load-bearing bone c. Indicated in impacted fracture that results in comminution (e.g.

tibial plateau and the tibial pilon fractures)

6. Bridge Plate a. Useful in unstable comminuted fractures by spanning the

length of the comminution b. Frequently used with bone grafts to fill the voids in the bone

46

EXTERNAL FIXATION External fixation implements the use of wires, pins, and rods to keep bone segments in alignment or compression. Furthermore they allow distraction of bone segments by the principle of tension-stress effect.

Advantages: > Use in open fractures, acute, fractures, infected fractures and non-

unions > Requires minimal tissue dissection > Allows compression, neutralization, or fixed distraction of bone

segments > Length can be maintained in a comminuted fracture > Allows access to the wound site for care, monitoring and dressing

changes

> Full weight bearing is allowed immediately post-operatively

Disadvantages: > Requires skin and pin tract care > Difficult frame construction > Bulky frame > Fracture through the bone is possible > Refracture possible after frame removal > Expensive Basic Principles of External Fixation: 1. Frame should avoid and respect all vital structures in the area 2. Allow access to the wound site 3. Frame must meet the mechanical demand of the patient and injury

47

EXTERNAL FIXATION CONTINUED. . .

Complications: S Pin irritation - avoid pin placement in muscle •S Pin tract infection - most common complication (30%) •S Neurovasculature Impalement - Anterior Tibial A. & Deep Fibular N.

and they are most commonly involved •S Delayed Union / Non-Union - due to faulty frame construction •S Compartment Syndrome - due to increase in the intracompartmental

pressures (mmHg) •f Refracture - once the frame has been removed due to tension

shielding, a rare complication

Types of External Fixators:

1. Unilateral Fixators S Produces compressive or distraction forces S Used to fixate fractures, fuse joints, and lengthen •S Available in small or large, it is attached to the bone by multiple

half-pins screwed into the bone and attached to the fixator with the clamp

•S Main disadvantage - not create any sagital plane stability & therefore should not weight bear immediately post-op

48

EXTERNAL FIXATION CONTINUED

Types of External Fixators Continued...

2. Circulator Fixators •S Produces compressive and distraction forces •S Used to fixate fractures, treat non-unions, limb-lengthening , soft

tissue lengthening, and correction of congenital deformities. •S Utilizes trans-osseous wires with half-pins to position the wires in

different plane stability S Limited by the circular frame's ability to fit the extremity and

patient's comfort of wearing the apparatus

3. Hybrid Fixators S Combination of unilateral and the circular fixator S Used to treat tibial plafond fractures and pi Ion fractures S Utilizes trans-osseous wires and half-pins and footplate to allow

early weight bearing

4. Taylor Spatial Frame Fixators •S Newest external fixation device •S Allows for reduction and stabilization of fracture S Its unique feature allows for reduction of complex triplane

deformities

49

EXTERNAL FIXATION CONTINUED. . .

Dynamization: After removal of the plate, the bone may be prone to re-fracture during weight-bearing because of weakening of the bone from disuse osteopenia. To prevent this complication it is important to gradually release tension in the trans-osseous wires and loosen the pins to allow the bone to gradually strengthen as it bears weight.

Fixator Care & Management: Pin sites need to be kept clean with sterile solution and applied antibiotic cream in order to prevent infection and seal the opening around the pins. Avoid applying Betadine around the pins in order to avoid corrosion.

50

COMMON FOREFOOT PATHOLOGIES AND SURGERIES

Hallux Limitus / Rigidus Decreased or absent RoM at the 1st MPJ Normal RoM = 90° (20-25° PF + 60-65° DF)

Radiographic Appearance AP

> Focal joint space narrowing > Joint mice > Spurring > Asymmetry

Lateral > Dorsal Flag Sign > Spurring P- Sclerosis > Metatarsus Primus Elevatus

> Squaring of metatarsal head

Etiologies = T I N - M A C Trauma Infection Neoplasm of bone or soft tissue

Metabolic Anatomic

Structural = short/long 1st ray, Met Primus Elevatus 1. Meary's Angle deviation (b/s talus should b/s 1st met) 2. Parallelism between 1st & 2nd metatarsals 3. Metatarsal parabola / protrusion deviation Biomechanical = pronation, hypermobile 1st ray

Congenital

51

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED. . .

Hallux Limitus / Rigidus Continued... Joint Procedures: Joint Preserving

1. Cheilectomy = Valenti (V-cheliectomy) 2. Osteotomies

> Proximal Phalanx = Bonny-Kessel (proximal DFWO) > 1st Metatarsal

• Waterman = Distal DFWO • Mitchell = step-down shortening procedure • Youngswick = chevron double dorsal cut elevates • Sagital Z = corrects for elevates • Lambernudi = diaphyseal PFWO, for elevatus

Joint Destructive 1. Keller = Proximal Phalanx arthroplasty / for elderly / less

functional > Complications - transfer metatarsalgia, stress fracture of 2" ,

proximal migration of sesamoids 2. Implant = Hemi or Total - must cover cortical surfaces 3. McKeever = 1st MP J arthrodesis - positioned dorsiflexed and

abducted with no rotation > DF = 10-15° off weight bearing - one finger under toe > 5-10° of abduction > Toe will no longer bend so patient cannot squat down

Joint Distraction with External Fixator: 1. Cheilectomy, mini rail 2. 7mm distraction intra-operatively, 2 weeks rest, then 1mm

distraction qd for 7d = Total 14mm Distraction

52

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED. ..

Hammertoes Function of Lesser Digits: > Decelerate the foot ^ Stabilize the forefoot > Aid in propulsion > Provide kinesthetic sensation

Function of Musculature: > EDL / EDB = dorsiflex MPJ - passive flexion at PIPJ / D1PJ > FDL / FDB = actively plantarflex MPJ, PIPJ, DIPJ > Interossei = prevent buckling > Lumbricales = hold digits rectus (plantarflex MPJ, dorsiflex PIPJ /

DIPJ)

Types of Deformities:

MPJ PIPJ DIPJ Hammertoe Extension Flexion Extension Claw Toe Extension Flexion Flexion Mallet Toe Rectus Rectus Flexion

Etiologies for Contracted Digits: 1. Flexor Stabilization (Most Common)

> Weakness of intrinsic Interossei Ms > Adv. of Quadratus Plantae > Pronated foot type - flexors fire longer and harder > Causes AdductoVarus deformity on 4th and 5th

> Late stance phase biomeehanical abnormality > Tx = Derotational Arthroplasty

53

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED. . .

Hammertoes Etiologies Continued:

2. Flexor Substitution (Least Common) > Weakness of Triceps Surae - Flexors gain mechanical advantage

over extensors > Supinated foot type - late stance phase abnormality > Tx = suture FDL to Achilles tendon to strengthen muscles

•S Must perform Arthrodesis

3. Extensor Substitution > Weak Tibialis Anterior - extensor gains mechanical advantage

over Lumbricales > Begins flexible and becomes rigid -> reduce early w/ weight

bearing > Pes Cavus / Ankle Equinus / TA weakness / EDL spasticity and

pain are frequent symptoms > Swing phase biomechanical abnormality > Tx = Arthrodesis if Rigid

Hibb's Tenosuspension if Flexible

54

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED.

Hammertoes Surgical Procedures: SOFT TISSUE 1. Tenotomy = stab incision medial or lateral to tendon deformities only

S PF digit with blade in place - flexible deformities only •S Older population only - lose strength & stability

2. Capsulotomy 3. Tendon Transfer 4. Girdlestone

•S Transfer FDL & FDB to dorsal head of proximal phalanx to restore intrinsic function

5. Hibbs •S Transfer EDL to base of proximal phalanx or met head

6. Kuwada & Dockery •S Modification of Girdlestone - drill hole in base of proximal phalanx

and bring tendons up through it 7. Lengthening 8. Z-Plasty at level of MP J 9. Percutaneous stab incision and splint """Complications: Muscle spasm caused by overcorrection, tenosynovitis, scarring, adhesion, weakness, bowstringing, and nerve entrapment

OSSEOUS 1. Arthroplasty

•S Post - resection of base of proximal phalanx •S Gotch & Kreuz - resect base of proximal phalanx and syndactylize

digits 2. Arthrodesis

S Lambrinudi - fusion of PIPJs and DIPJs •S Young-Thompson - Peg-in-Hole Fusion (Peg from Prox.Phalanx) •S High amount of shortening

3. Taylor - PIP J fusion using K-Wire

55

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED. . .

Hammertoes Sequential Reduction:

1. Z-Plasty 2. Arthroplasty 3. Extensor Hood Release 4. MP J Capsulotomy 5. Volar Plate Release 6. Tendon Transfer (Girdlestone, Kuwanda & Dockery, Hibbs)

** Kelikian Push-Up Test: Performed between each step to determine if sufficient correction has been established. If you get dorsiflexion when placing GFR on the met head then do the next step.

Hallux Hammertoe: Etiology: > Muscle imbalance > Iatrogenic after sesamoid removal or detachment of FHB > IPJ sesamoid binding FHL tendon

Treatment: Flexible - IPJ fusion with EHL lengthening Rigid - IPJ fusion with Jones Tendon Transfer

~ Cut EHL distally from insertion ~ Drill hole transversely through 1st med head ~ Insert tendon through drill hole and suture back on itself

56

5™ DIGIT ARTHROPLASTY 1. Lazy "S" Incision

•S Lateral condylectomy of distal and middle phalanges with resection of head of proximal phalanx

2. Derotational Arthroplasty •S Distal Medial Proximal Lateral Incision

3. Complications •S Floppy Digit •S Edema (sausage digit) •S Floating Toe with Metatarsalgia •S Regeneration of Proximal Phalanx •/ Infection ^ Decreased sensation •S Blue toe

57

REARFOOT SURGERY Spurs are incidental findings only and are rarely the cause of pain.

1. May be painful if directed plantarly 2. Must be present to be approved for orthotics

Conservative therapies should be used for the first 3-9 months

Plantar Fasciotomy: 1. Plantar L shaped incision at the medial midfoot 2. Release of the medial band of the plantar fascia 3. NWB for 3 weeks 4. Sutures out after 3 weeks

Endoscopic Plantar Fasciotomy: 1. Small incision in the medial rearfoot 3 fingers from the posterior

heel and 2 fingers up from the plantar foot 2. Blunt dissection to the fascia 3. Insert spatula across plantar aspect of foot, dissecting fascia from

plantar fat pad - remove spatula 4. Insert trochar into slotted tube and insert through dissected incision

- remove trochar 5. Insert scope into tube laterally and blunt probe medially - separate

medial and central bands of plantar fascia 6. Insert cutting tool into medial tube and cut medial band of plantar

fascia while pulling instrument out of the tube 7. Visually observe abductor hallucis muscle belly before removing

tube and irrigating incision site

58

REARFOOT SURGERY CONTINUED. . .

Haglund's Deformity: Angles: • Philip-Fowler Angle = normal 44-69°, >75° pathological • Total angle of Ruck = Philip-Fowler + Calcaneal Inclination Angle -

Normal up to 90°, pathological i f> 110° • Parallel Pitch Lines - most objective method of determining a

Haglund's deformity

Procedures: • Longitudinal incision lateral to TA • Dissection down to posterosuperior calcaneus • Aggressive removal of pathologic bone, but don't chase the bump • If you need to reflect the TA, reattach with a soft tissue anchor and

remain NWB for 3 weeks

Keck & Kelly Osteotomy: • Indicated for increased CIA angle with no Haglund's deformity • Dorsal wedge osteotomy of the posterior calcaneus • Rotate posterior aspect of Calcaneus dorsally after wedge removal -

MAINTAIN PLANTAR HINGE • Secure with cancellous screws • NWB for 6 weeks

59

TENDON TRANSFERS

Tendon Transfer - detachment of the tendon from insertion then relocate to new position

Tendon Transplantation / Translocation - rerouting the tendon without detachment from its insertion

Types: 1. Adductor Hallucis

•S Resect at insertion, pass under the joint capsule and reattach at medial aspect of the capsule

S Indicated in HAV to realign the sesamoid apparatus 2. Abductor Hallucis

S Transected at insertion, rerouted inner 1st met head and fixated at lateral base of proximal hallux

•S Indicated in Hallux Varus with an osteotomy 3. Extensor Hallux Longus

•S Transected at origin, rerouted under DTIL, fixated to lateral base of proximal hallux

•S IPJ needs fused S Indicated when have sagital component with Hallux Varus

4. Jones Suspension S EHL excised from insertion, drill a hole transversely through 1st

met head, rerouted through hole and sutured on itself •S Indicated with cock-up deformity, flexible cavus, lesser

metatarsalgia, chronic ulcers, weak TA, flexible plantarflexion of 1st met

5. Hibb's Tenosuspension •S EDL detached from insertion, bundled together and placed

through midfoot at the base of the 3rd met or lateral cuneiform •S Indicated to release retrograde buckling at MPJs, met equines,

flexible cavus, claw toes

TENDON TRANSFERS CONTINUED. ..

Types Continued... 6. Tibialis Anterior Transfer

•S 3 incisions at (1) proximal dorsal leg, (2) TA insertion at medial plantar cuneiform / tubercle 1st met, and (3) the new area of insertion in the midfoot

•S Release from insertion, reroute out the proximal incision, with tendon, with tendon passer brought to new insertion (usually 3rd

cuneiform) •S Indicated for recurrent clubfoot, flexible forefoot equines,

dropfoot, tarsometatarsal amputation, Charcot Marie Tooth deformity

7. Split Tibialis Anterior Tendon Transfer (STATT) •S 3 incisions at (1) base of 1st met, (2) anterior leg over TA just

lateral to medial malleolus and (3) over peroneus tertius at base of 5th met

•S Split tendon through proximal insertion, lateral slip passed through peroneus tertius sheath and sutured to tendon fixated to cuboid

•S Indicated for spastic RF equines, spastic equinovarus, fixed equinovarus, FF equines, flexible cavovarus deformity, DF weakness, excessive supination in gait

8. Cobb Procedure •S ST ATT but reroute to TA to PA tendon •S Indicated for PT dysfunction

61

TENDON TRANSFERS CONTINUED. . .

Types Continued... 9. Tibialis Posterior Tendon Transfer

•S 3 incision (1) insertion of the PT at navicular tuberosity, (2) anterior leg, middle 1/3 just lateral to tibial crest and (3) one at new insertion at dorsal midfoot

•/ Tendon released from navicular Tuberosity, dissected free at the medial leg insertion to expose the IM and the PT pulled through this opening then brought to new insertion level (usually 3rd

cuneiform) •S Indicated for weak anterior muscles, equinovarus, spastic

equinovarus, recurrent clubfoot, dropfoot, complications from Charcot Marie Tooth, peroneal nerve plaste, leprosy, Duchenne's

•S Muscle goes from a stance to a swing muscle during gait

10. Peroneus Longus Tendon Transfer •S 3 incisions (1) lateral, lower leg, (2) lateral cuboid and (3) base of

3rd met/lateral cuneiform •S Suture the Peroneus Longus to the Brevis , cut the longus at the

level of the cuboid and the tendon is brought through the proximal incision and back through the medical incision to the 3rd

cuneiform •S Indicated for anterior muscle weakness, dropfoot

MS

62

BLINION P R O C E D U R E S T D K N O W B A S E D ON ANT.I KS

1M Angle

Normal: 0-8°

f .

8-16° Distal Osteotomy

Austin Hohman (Neck) — Trapaziodal Mitchell (Neck) Wilson (Neck) Revcrdin Laird (Distal L) Short Z Waterman Youngswick

>16° Proximal Base Wedge Osteotomy Lapidus (Met-Cuneiform Fusion)"^""0 4 ' '2

Cresentic Juavara Proximal V of Kotzengerb

1 Comments: with a thin Met shaft 4 may need to use a proximal procedure Mitchell - shortens the length of met shaft -> used in Long Met Length

(>2mm longer than 2nd met) Taylor's Bunion = Symptomatic when IM4.S >9°

' Splayfoot = IM|.2 + IM4.5 >20°

1 DASA >8° Proximal Proximal Akin Osteotomy — cylindrical akin w/ long prox phalanx

Normal: 0-8" — oblique — transverse

4̂ — Bonnel-Kessel ->DF wedge 1 Comments:

PASA >8° Distal Reverdin

1 Osteotomy Reverdin Green PASA Normal: 0-8°

1 Comments:

1

63

Abnormal IM: 12-16° Distal Biplane Austin PASA

+ + Abn P Osteotomy Reverdin Laird (Distal L) PASA + IM

Reverdin Green h -IM Angle Biplane Mitchell ->Roux

Hohmann K

Shaft Mau u Osteotomy Ludloff

Scarf / "Z" Klotzcnbcrg Juvara

K

k IM: >16° Proximal Lapidus w/ Reverdin + Abn P Osteotomy V Osteotomy

Logroscino (Base Wedge Reverdin) Cresentic Juavara Proximal V of Kotzengcrb

J -

K

K Comments:

K

HAA > 16° Silver McBride

Normal: 0-16° Adductor Hallucis Tenotomy Lateral Capulotomy

Comments: ST or Osseous Abnormality t HAA + IM,.2 13-20° = Lodloff + Mau

(+ t PASA) = Scarf Z

H I A

Normal: 0-10°

> 10° Distal Akin

K

Comments: |

64

1 Tibial Sesamoid Position 4-7 Fibular Sesamoidectomy 1 Tibial Sesamoid Position Fibular Sesamoid Release

^ N o r m a l : 0-3 Comments:

1 Lateral IM: 8-12" Distal Osteotomy Reverse Austin Deviation Normal 2 exostectomy Reverse Mitchell

1 Angle Slight clist. Reverse Hohmann Normal: 2.5° Increase metaphyseal Reverse Wilson

I + osteotomy Reverse Mercado IM4.5 LDA: Inc

1 Normal: 0-8° IM:> 15/16° Proximal Base Wedge Marked Inc Osteotomy

LDA: T J, Severe Lat

Bowing 1 Comments:

( C < ( < ( ( . ( I ( ( ( ( ( ( ( ( ( C ( ( (

Othgr Important Things to Know for 3rd y^ar

"Rotations & Cxtszrnships

Dr. Bodman's Drugs p. 68

Dr. Caldwell's Drugs p. 74

Dr. Caldwell's Wound Care p. 84

Ankle Scopes p. 90

67

GROUP CLASS GENERIC BRAND % VEHICLES SIZE SIC INDICATION

*

'2 -S 3 aa Ti B <

Macrolide erythromycin topical

Benzamydn 3 gel 46.6 gm jar or 60 packets

BID Acne Vulgaris

*

'2 -S 3 aa Ti B <

Macrolide

erythromycin Erygel 2 gel 30.60 gm tubes

qdor BID

Acne Vulgaris

*

'2 -S 3 aa Ti B <

Protein Synthesis Inhibitor

mupirocin Bactroban 2 cream or ointment

1 gmto 30 gm tubes

TID 7-14 davs

Impetigo or infections (bacterial)

*

'2 -S 3 aa Ti B <

Broad bacitracin Bacitracin 500 u/g

ointment 30 gm tube

BID or TID 7 davs

Superficial Infections

*

'2 -S 3 aa Ti B <

Broad

silver sulfadiazine Silvadene 1 cream 50 gm tube

qd-BID

2Bd/3fd degree bums

*

'2 -S 3 aa Ti B <

Broad

polymycinB sulfate

Betadine 10.000 U/g

ointment lAoz tubes or 1/32 oz packets

Qd Superficial Infections

) ) ) ) ) ) ) ) ) ) } 3 i ) > ) . ) )

) " ) ) ) ) ) ) ) 3 ) ) ) ) ) ) ) ) ) )

GROUP CLASS GENERIC BRAND % VEHICLES SIZE SIC INDICATION AHylamine terbinafine Lamisil 1 cream 30 gm Qd Onychomycosis

or Tinea butenafine Mentax 1 cream 15-30

gmtube BID Tinea pedis

Lotrimin Ultra

1 cream 15-30 gmtube

BID 7 days

Tinea pedis

Azoles econazole Spectazole 1 cream 15,30, 85 gm tubes

Qd Tinea

miconazole Monistat 2 cream 1530 BID Tinea

1 '•2

Deim gmtube 1 '•2

Fungoid 2 solution 29.57 ml sol

BID Tinea pedis

i clotrimazole Lotrimin 1 cream, lotion, solution

15,30. 45 gm tubes or 10-30 ml sol

BID Tinea

Olamines ciclopiroxolamine Penlac 8 solution 3.3 ml qhsx 48 wks

Mild Onychomycosis

ciclopirox Loprox 0.77 cream, gel, lot, susp

lOOgm gel

BID Tinea

TOPICAL STEROIDS I. Most

Potent diflorasone diacetate Psorcon 0.05 cream,

ointment 15,30,60 gm

qdto TIB

LSG

II. desoximetasone Topicort 0.05 and 0.25

cream, gel, ointment

15,60gm BIB Psoriasis

III. fluticasone Cutivate 0.05 cmi and 0.00 5 oint

cream, ointment

15,30,60 gm

BID Eczema

IV. Mid Potent

hydrocortisone valerate Westcort 02 ointment cream

15,45,60 mi

qdto QID

Eczema

V. triamcinolone Kenalog 0.1,0.5 cm and 0.025,0.1 lot and 0.1 oint and 63 g aerosol

cream, lotion, ointment aerosol

60 ml lotion, 15, 60 gm ointment 15,20,60, 80 gm cream

BIB to QIB

Eczema.

vi. hv dro cortisone/lido caine Lidamanfle 0.5 and 3 cream, lotion

85 gm BIB to TIB

Itching

vn. Least Potent

hydrocortisone Hytone 1-2.5 cream, lotion, ointment

28.4,60 gm cream and 30 gm ointment and60 ml lotion

BIB to QIB

"Winter itch

) ) ) ) ) ) ) ) ) ) ) ) ) ) } ) ) ) ) ]

) ) ) ) 3 > ) ) ) ) ) ) ) ) ) ) ) 3 ) )

GROUP INDICATION GENERIC BRAND % VEHICLE SIZE SIC CONDITION Scabicide Scabies pemiethiin Elimite 5 cream 60 gm 8-14

h Infestation

Emollients Xerosis ammoiium lactate

La c-Hy drin 12 cream, lotion

140.385 gm cream and225, 400 gm bottle lotion

BID Xerosis

lactic acid Lactinol 10 lotion 354.84 ml bottle

BID Xerosis

pramoxine HCL Amlactin 1 cream 140 gm tubes

BID Xerosis

Keratolytics hyperkeratosis urea

Cannol 40 cream, lotion

28.35,85 gmtube

BID Hyper-keratosis

Carmol 40 Gel 15ml bottle

BID Onvchauxsis

urea. Ve, lactate

Kerala c 50 gel, 35 lotio n

gel. lotion 18ml gel and325 ml lotion

BID Keratodemia

Urea Vanamide 40 Cream 85 gm BID Kerato derma Antiviral acyclovir Zovirax 5 ointment 15gm

tube 6x/d x 7d

Herpes

Antiperspirant hyperhidrosis Alum. Chloride

Drysol 20 Solution 35,37.5, 60 ml

qhs Macerated Webspaces

GROUP INDICATION | GENERIC BRAND % VEHICLE SIZE SIG CONDITION Antipsoriatks betamethasone

dipropionate Diprolene 0.05 ointment,

gel, lotion 15.50 gmtube ointme ntand 30,60 ml lotion

qdto BID

Psoriasis

calcipotriene Dovonex .005 cream, ointment, solution

60,120 gmtube cream and 60 ml solution and60, 120gm tube ointment

BID psonasis

tazarotene Tazorac 0.05. 0.1

gel 30,100 gm tubes

qhs psonasxs, acne vulgaris

Deodorant chlorophvlline copper/papain /urea

Panafil 0.5, 10

ointment 30 gm tube

qdto BID

ulcer

Depigmenting hydro quinolone Melanex 3 solution BID

) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) } ) )

) ) ) ) > ) ) ) ) ) 3 ) ) ) ) ) 3 } )

GROUP INDICATION GENERIC BRAND % VEHICLE SIZE SIC CONDITION Waittx's vemicae Imiquimod Aldara 5 cream 12

packets 3x/w eek

recalcitrant Waittx's

vemicae sabcycBc acid

Compound W

17 geL liquid. pads

0.31 floz or 7 gm tube

qd or BID

pt applied

Waittx's

hyperhidrosis Formalde-hyde

Formalyde-10

10 spray 60ml qd pt applied

Anti-Par asitics Ivermectin Stromectol PO 3mg qd scabies Miscellaneous Gent amy cin Garamycin 0.1 cream,

ointment 15 gm tube

TID or QID

Skin Infections

) ) ) ) ) } ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )

S E N S I T I V E P E N I C I L L I N ' S

Penicillin V (po)

B - L A C T A M A S E ' * ;

Penicillin G, Aqueous (iv) ** Tx: Clostridium Tetani if

allergic to Tetanus Toxoid

Penicillin G, Procaine (IM) --** Tx: Treponema Palidum

(Syphilis) Tx: Strep Throat & Otitis Media G+: Strep G-: Eikenella corrodens

Nisseria gonorrhea HELPS2

Anaerobes:®

G+: Strep G-: Eikenella corrodens">HumanBites

Nisseria gonorrhea^STDSEPtici°lnt

Anaerobes: Clostridium perfringens

Ampicillin

Amoxicillin _ ** Used in kids instead

of Augmentin!

HELPS2: Haemophilus E. coli Listeria Proteus mirabellus Shigella Salmonella

R E S I S T A N T P E N I C I L L I N ' S ( 3 R D G E N E R A T I O N S ) RESISTMONDAY'SI MMethacillin (iv)

** Toxic, not used!

0 Oxacillin (Bactocil)[po)

V i p-Lactamase Resistant Staph Aureus N Nafcillin (Unipen)(po)

D Dicloxacillin (po) If resistant to this = MRSA!

E X T E N D E D S P E C T R U M P E N I C I L L I N ' S ( 4 ™ G E N E R A T I O N S )

Carboxypenicillins ^— Carbenicillin A High Na+ loads \ avoid pts w/ HTN \ Beware of Hypokalemia! \ T i c a r i c i l l i n

Ureidopenicillins- - Mezlocillin

Broad Spectrum"*00 N0Tcover P-Lactamasc

G+: Good Coverage G~: | Coverage Anaerobes: | Coverage

** Tx: Pseudomonas aeruginosa Piperazine Penicillin — Piperacillin

DRUG INTERACTIONS: Warfarin, Oral Contraceptives, Probenecid, Aminoglycosides C/I w i t h p t s on M e t h o t r e x a t e Mw'rmVoiogtaDocs ten pts theyanc/n

R - I.ACTAMASK'S

COMBINATION DRUGS

Piperacillin / Tazobactam (Zosynjfiv) Tx: Pseudomonas aeruginosa & Proteus mirabilis

» Needs 4.5g q6h for pseudomonas

Amoxicillin / Clavulanic Acid (Augmentin) (po) **Staph aureus is susceptible to Augmentin < 35% due to MRSA

Ticarcillin / Clavulanic Acid (Timentin)(iv)

Ampicillin / Sulbactam (Unasyn}pv) **Unreliable against G~ infections!

Broad Spectrum G+: Strep, Staph aureus G-: Neisseria gonorrhea.. Anaerobes: 0

DOSAGE BOX:

Zosyn = 3.375g q6h Augmentin = 875mg q l2h Timentin = 3.1g q6h Unasyn = 3.0g q6h

76

1 S T G E N E R A T I O N

Cephalexin (KefIex)(poj

Cephadroxil (Duricef}(po) >

Cefazolin (Ancef) (Parenteral) J < 80% susceptibility to Ancef

G+: Good Staph aureus Staph epidermidis /

;

Strep G-: Some PEcK An: Some not B.fragilis

2 N ° G E N E R A T I O N

Cefuroxime (Ceftin)(Po) 1 I G*: Almost as good as 1 s t GN

(ZinaceQ(paranterai) vj G~: Extended HEN - PEcKS

Cefoxitin (Mefoxin)(parcnterai) J ; , A n : ®

HEN - PEcKS: Haemophilus influenza Enterobacter aerogens Neisseria species Proteus mirabilis E. coli Klebsiella pneumonia Serratia

3 R D G E N E R A T I O N

Cefixime (Suprax)(po)

Cefpodime (Vantix) (po)

C e f t r i a x o n e ( R o c e p h i n ) ( p a r e n t e r a i ) V *Not good for Staph [

Ceftazidime (Foitaz)(Parenteral)

G+: Significantly J.J4 G-: Superior Coverage

(Fortaz Pseudomonas) (Rocephin Neisseria)

An: 13 Cefdinir (Omnicef) J " '

*Covers Staph & Strep better than 1 s t G. MIC levels are superior to Cephalexin 4x's better for Staph / / 7x's better for Strep

D O S A G E B O X :

4T" G E N E R A T I O N Omnicef = 300mg q l 2 h Cefipime (Maxipime)

! G+: More active against Staph aureus than 3 rd G i | G~: Good Coverage

(+ Pseudomonas) i An: S j

E X T E N D E D G E N E R A T I O N

Ceftobiprole G*: 0 - Active against MRSA G-: 0 Mn:

D R U G I N T E R A C T I O N S : Avoid Cephalosporins i f p t allergic to Penicillin! Cefdinir(2ndG) & Cefuroxime(3rdG) are allowed for Penicillin allergy!

• Due to differen t structure.

C A R B A P K N A M ' S

Imipenam-Cilastin (Primaxin) *ID specialists ONLY! Broad Spectrum

G+: 0 - Most G-: 0 - Most [pseudomonas - resistant)

(mycoplasma - resistant) An: 0 - Excellent

I ^ ~ \

Meropenam (Merrem)

*Mostly ID specialists

I Seizure Risk!

G+: Staph & Strep only [Inferior to Imipenam) G": 0 (Superior to Imipenam) An: SI

Ertapenam (Invanz)(iv/iM)

G*: 0 G~: Limited An: 0

DOSAGE B o x :

Invanz = lg qd CrCl < 30ml/min = 500mg 6h pre-diaiysis

Doripenam Broad Spectrum G+: 0 G-: 0 (pseudomonas) An: 0

D R U G I N T E R A C T I O N S :

C/I in pts with Penicillin allergy C/I in pts with Seizure History Ertapenam interacts with Probenicid.

78

Aztreonam (Azactam](iv/iM) *OK for Penicillin Allergy No major renal toxicities; only dose adjust for renal insufficiency or dialysis

MONOBAfTAM

G+: 13 G-: 0 (?pseudomonas) An: 13

Gentamycin Tobramycin Amikacin

G*:0 G-: 0

* NOT use on Diabetics or My Gravis

Peak (30min post dose) & Trough (30min before next dose) levels are recommended

\ An: 13

MRSA Proteus mirabilis Pseudomonas Klebsiella E. coli Salmonella Shigella

; A D V E R S E D R U G R E A C T I O N S :

I Ototoxicity (Irreversible) I Nephrotoxicity (Reversible) j HypoK* Gentamycin • HypoMg+ — Amikacin

1 S T G E N E R A T I O N

Vancomycin (po/iv) Tx: Endocarditis Prophylaxis for pts allergic to (i-lactams - Keep for reserve cases!

GlYCOPEPTIDES

G+: 0 G-: 0 An: 0

DOSAGE B o x :

Vancomycin = lg slow push IV Cover 60min)

IV^MRSA •^Clostridium difficile

DOSAGE A D I U S T M E N T B o x :

50kg: 750mg r n -7/11 , n n A Normal Trough = 5-10mg/dL 5 0 - 7 4 k g : lOOOmg [ if trough range >15mg/dL-> 7 5 - 9 0 k g : 1 2 5 0 m g j cloubln the dose time interval >90kg : 1 5 0 0 m g J

2 N D G E N E R A T I O N

Dalbavancin(po/iv) G+: 0 -- MRSA, VRSA, Strep, C.difficile G-:? An:?

3 " " G E N E R A T I O N , i Telavancin | G*: 0

G : ? An:?

- MRSA, VRSA, Strep

ADVERSE DRUG REACTIONS:

Ototoxicity (Reversible) Nephrotoxicity (Reversible) Red Man Syndrome Vestibular Imbalance Thrombophlebitis

Absorption is limited by: TETRACYCI.INF'S ~ Food ~ Milk

~ Antacids ~ Iron

Doxycycline * Some Anti-Inflammatory properties seen on OA

Minocyline

Methacycline

Tetracycline HCL

G+: 0

G-: 0

An: H

Staph aureus MRSA E. coli Klebsiella Enterobacter Vibrio vulnificans">SaltWater

Rickettsia Chlamydia

A D V E R S E D R U G REACTIONS:

N o n s p e c i f i c GI I s s u e s ~ Don't give Doxycylcine before bed erosive esophagitis Photosensitivity Photo-Onycholysis [Doxycycline) ?Acute Pancreatitis CONTALNDICATIONS:

No P r e g n a n t / Kids ~ tooth discoloration in kids under 8y C/I for pts on Digoxin -- f Toxicity C/I for pts on Accutane4Acne - | ICP, Pseudomotor Cerebri Risk

MACROLIDE'S * Erythrasma Coral Red Woods L

Erythromycin Rarely used — poor ST penetration

An: 0

Oral Dose = 2x Risk of Sudden Death 4

Combined with Ca2+ Chanel Blockers = 5x Risk of Sudden Death (Verpamil, Diltiazam)

Azithromycin [Zithromax)

G+: 0 Staph / Strep / Corynebacterium minitussimum* ! G-:E / '

ANVPRSK D R U G REACTIONS:

GI Upset Prolonged Heart Depolarization ~ Torsades de Pointer D R U G INTERACTIONS : Potent Inhibitors of CYP 3A4 Cyclosprine / Sirolimus / Tacromilus C/I for pts on Carbazepine & Theophyline

Detox in Liver Excreted in Bile

G+: 0 Staph / Strep G-: IS An: HI

DOSAGE BOX: Zithromax= 500mg 1 s t Day (z-pack) 250mg qd next 4 days

A D V E R S E D R U G REACTIONS:

GI Upset Prolonged Heart D R U G LNTERACTIONS:Potent Inhibitors of CYP 3/. fDigoxin / / ^Coumadin HMGcoA Reductase f

Clindamycin (Cleocin) * Good Bone Penetration * Poor CNS Penetration

G+: 0

DOSAGE BOX: Cleocin = 600mg l h r pre-op

Given as prophylaxis for G~: E bacterial endocarditis ^n: [yj

A D V E R S E P R U G REACTIONS:

Diarrhea Pseudomembranous Colitis D R U G - D R U G INTERACTION:

^Respiratory Paralysis with m.

Fulminate Group A Strep^NecrotlzlnsFasditis

Group B Strep -may Show resistance M R S A ~ may show resistance

Staph Aureus

B. fragilis

*Staph Aureus resistant to erythromycin on C&S can develop inducible resistance to Clindamycin *C&S of organism is sensitive to Clindamycin but resistant to erythromycin ^ do NOT give Clindamycin because it will develop resistance

relaxants (Baclofen / Diazepam]

C H L O R A M P H E N I C O L

A D V E R S E DRUG REACTIONS:

Gray Baby Syndrome Severe Bone Marrow Toxicity Aplastic Anemia

' G*: 0 G": 0 An: 0 Serious Infections

Last resort for VRE

S U L F O N A M I D E S

Trimethoprim-Sulfamethoxazole (Bactrim / Septra)* Beware in pts over so year old

G+: 0 Staph & Strep MRSA

G-: 0 An: HI

ADVERSE DRUG REACTIONS:

Acute pancreatitis D R U G - D R U G i N T E R a r n n N :

T-S + Methotrexate ~ f Bone Marrow Suppression T-S + Coumadin/Digoxin = T Toxicity of C/D T-S + Oral Sulfonylureas = Hypoglycemia

81

Metronidazole (Flagyl) * Tx Pseudomembranous Colitis

DOSAGE BOX:

Flagyl = 15mg/kg loading dose 7.5mg/kg q6h IV -or- 500mg tid

G-: S An: 0 fragilis

A D V E R S E D R U G R E A C T I O N S :

Peripheral Neuropathies N/V with Alcohol Consumption Dark Brown Urine D R U G - D R U G I N T E R A C T I O N :

f Anti-Coagulation effects of Warfarin

FI.IIORINATRD 4-OUINOLONES

Ciprofloxacin (Cipro) DOSAGE B o x :

Cipro = 750mg bid

* Post antibiotic effects (G+)

Moxifloxacin (Avelox) * Good in ST * Good for diabetic foot infections with inoperable atherosclerosis * May work against TB

G+: IS G~: 0 most active against P, aeruginosa infection of bones & joints

An: IS

Levofloxacin (Levaquin),' {' Vl : DOSAGE BOX: : ;

Levo = 500mg qd [po/IV) ; |

G+: 0 Strep G": 0 N. gonorrhea An: IS

C O N T R A I N D I C A T I O N S :

Under age 18 Pregnant / Nursing

* Attacks joints *Can cause Tendonitis / Rupture

A D V E R S E D R U G R E A C T I O N S :

GI / Headache / Phlebitis a"are rare! !

Broad Spectrum G+: 0 staph^some resistallce

Strep4enhanced

G": 0 An: 0 B. fragilis

! DRiir.-DRiir. I N T R R A C T I O N :

I Not give within 2hr of: Multivitamins, Antacids, Sulcralfate MANY interactions! - Theophyline, Caffeine, Warfarin, NSAIDs, ddl (HIV)

! May see... Torsades de Pointes & Ventricular Fibrillation

\ **Mav produce a false (+) on viral assav for opiates

82

Rifampin * Turns fluids Orange *CYP450 system * Tx Leprosy * Tx Vanco Resistant MRS A

RIFAMYCIN

Broad Spectrum G*: 0 Staph aureus

Strep epidermidis MRSA

G~: 0 N. gonorrhea Mycobacterium

An: S

D O S A G E BOX:

Not given alone Give with Cipro / Bactrim i

STREPTOr.RAMINS

Dalfopristin/Quinopristin (Synercid)___ * Reserve this drug!!!

G+: 0 VRE MRSA MRSE

G-: (H An: 0

A D V E R S E D R U G R E A C T I O N S :

Arthralgia / Myalgia Nausea Thrombophlebitis t LFT's Injection Site Reaction

Linezolid (Zyvox) * Good bone penetration * Check weekly CBC's

OXAZOLIDINONES

G+: 0 VRE MRSA VRSA

G-: HI An: 13

A D V E R S E D R U G R E A C T I O N S :

Mylosuppresion N / V * ' a c t ' c acidosis

Optic Neuropathy* Tx>imo

Daptomycin (Cubicin) * Check weekly CPK's

DOSAGE BOX:

: 4mg/kg qd

CYCLIC-I,IPOPFPTIDE

0 MRSA VRSA

An: IS

D R I I C I N T E R A C T I O N S :

Tobramycin Statins * My°pau>y

Gl.YCVI.rYn.IMFS Tigecycline (Tygacil)

* Check weekly CPK's

! DQSAQK BOX: .j IV: lOOmg Loading Dose ,

50mgbid

Broad Spectrum G+: 0 MRSA

VRSA G~: 0 An: 0

A P V R R S R DRIir, R F A C T I O N S :

N/V Tooth Discoloration

Itraconazole (Sporanox) Onychomycosis Tinea pedis(°ff'aber>

ORAI. ANTIBIOTICS

Dermatophytes Candida Molds

DOSAGE BOX:

Pulse Dosing = 2x lOOmg tabs in AM & PM with food Take for 1 week of the mo. for months ;

Terbinafine (Lamisil) i Dermatophytes Onychomycosis v Tinea pedisC°ff^abe^

; DOSAGE B o x :

; Pulse Dosing = 250mg qd 1 week/mo over 2mo : Normal = 250mg qd 3mo

A I W E R S R D R U G R E A C T I O N S :

GI upset / Rash / Headache Hepatotoxicity -> LFT's A L T S A S T

D R U G I N T E R A C T I O N S :

Statins Ca2+ Channel Blockers Tikosyn Erythromycin C O N T R A I N D I C A T I O N S :

Patient with CHF!

A D V E R S E D R U G R E A C T I O N S : Rare Headache / Abnormal Taste Green Vision DRUG I N T E R A C T I O N S : CYP450 2D6 Cimetidine Cyclosporine Rifampin Nortriptyline Caffeine

Fluconazole [Diflucan)

DOSAGE BOX:

Pulse = 300mg/week ;

Dermatophytes Candida Molds

A D V E R S E D R U G R E A C T I O N S :

Severe Skin Rash Alopecia Drug Interactions: CYP450 3A4

Griseofulvin (Gris-PEG); D e r m a t o p h y t e s j Chronic Tinea pedis v

I DOSAGE BOX:

• 250mg tid (x4-8 weeks)

A D V E R S E D R U G R E A C T I O N S :

Paresthesia / Rash / Headache D R U G I N T E R A C T I O N S :

Oral Contraceptives Warfarin Barbituates

Thiabendazole (Mintezol) * Cutaneous Larva Migrans

Ivermectin

DOSAGE B o x :

Mintezol = 10% aqueous solution qid Ivermectin = 200fig/kg po xldose for l-2days

84

W O U N D CARE & D R E S S I N G S

\ C T I C O A T = Nanocrystalline Silver (antimicrobial effect up to 7 days) ft Reduces Exudates while maintaining a moist wound environment ft Moisten with Sterile water (NOT SALINE!!! Silver reacts with Saline)

ft Effective against VRE & MRSA

I O D O S O R R G E I . / IODOFLEX DRESSING = Absorbent iodine Cadexomer & Slowly releases small amounts of a 0.9% elemental iodine

ALLEVYN F O A M

•ft Moderate to High Exudate ft Never use the adhesive type!

H Y P A F I X

ft Adhesive, non-woven fabric ft Hold post-op dressings / catheters / drainage tubes in place

HYDROGEI. S H E E T S = ElastoGel, Nu-Gel, Vigilon, Amerigel ft Low Exudate • Re-Epithelializing wounds ft NonAdhesive ft Gas permeable ft (+) Provides Moisture ft qd change for infected wounds ft (+) No trauma upon removal ft (-) Potential to macerate surrounding skin

H Y D R O - G E L = Duoderm Gel, Nu-Gel, Restore, Hypergel ft Low Exudate ft Partial -> Full thickness wounds ft Use once granulation tissue is present ft (+) No trauma upon removal ft (+) Provides Moisture ft (-) Potential to macerate surrounding skin

85

T R A N S P A R E N T FILMS = Opsite, Tegederm, Bioclusive, Epivew A Adhesive, Polyurethane film ft Low Exudate ft May be used over absorptive wound filter or hydrogels A NOT for INFECTION! A Superficial Wounds (Blisters) •ft [+) Up to 7d wear time [semi-permeable) ft (+) Allows visual assessment •ft (+) Provides Moisture ft (-) Potential to macerate surrounding skin with excessive drainage ft (-) NOT absorptive ft (-) Adhesive may tear healthy skin

H Y D R O C O L L O I D S = Duoderm, Duoderm CGF00"'1"0'Gel Formula, Tegasorb, Restore ft Adhesive, Occlusive • Low Exudate •ft Granulating & Epithelializing Partial Thickness Wounds ft May be used over absorptive wound filter or hydrogels A NOT for INFECTION! ft Cover @ least linch of surrounding skin ft (+) Up to 3d wear time ft (-) May tear healthy skin ft (-) Potential to macerate surrounding skin with excessive drainage ft Change dressing before it leaks ft Odor/Drainage are Normal

F O A M = Acticoat Moisture Control, Allevyn, Polymem, TeilIeAdhcsiveBorder

"ft Polyurethane ft Adhesive or NonAdhesive ft Moderate to High Exudates •ft Varying Thickness •ft Infected wounds if changed daily -ft Venous Leg Ulcers ft (+) Up to 7d wear time ft (-) May tear healthy skin

86

ALGINATE = Sorbsan, Dermacea Alginate, Kaltostat, Curasorb A Seaweed Polymer & Gel formed when fibers interact with wound fluid A Pad or Rope Form A Partial/Full Thickness Granulating Wounds A Moderate to High Exudates & (V) Haemostatic effect A (+) Up to 7d wear time A (-) Requires 2° dressing A Infected wounds if changed daily A Tan mucoid appearance upon removal A ALGINATE W I T H COLLAGEN = Fibracol

• 90% Collagen, 10% Alginate A ALGINATE IMPREGNATED W I T H SILVER

A B S O R P T I V E W O U N D FILTERS

A Sheets, Rope, Paste, Granules, Powder made of Starch Polymers A Deep Wounds A Heavy Exudate

COLLAGEN B A S E D P R O D U C T S : Medifil Particles/Pads/Gels, SkinTempNy|onMeshovcr

A Use Collagen Gels for Dry Wounds collagen membrane

A Use Sheets for Low -> Moderate Exudative Wounds A Use Powders, Particles, Pads for Moderate Heavy Exudative Wounds A Actions: Absorbent, Hemostasis, Chemotaxis, Provisional Matrix in wounds

for Granulation tissue formation A P R I S M A colonized or contaminated wounds

• 55% Collagen / / 44% ORC Oxidized Regenerated Cellulose

• 1% Silver A P R O M O G R A N

• 55% Collagen / / 44% ORC • Only matrix proven to bind & reduce MMPs Matrbi

MetaloProtinase

• ORC/Collagen combo binds more MMPs in the dressing the ORC or Collagen alone

A P E G A S U S = Unite Biomatrix • Enzyme resistant collagen scaffold - Fenestrated

87

R E C O M B I N A N T D N A TECHNOLOGY

ft R E G R A N E X = Becaplermin " Recombinant PDGF Platelet-derived growth factor

•/ Attracts monocytes & fibroblasts -- inflammatory phase •/ Stimulates granulation tissue

• Refrigerate • Regranex Gel 0.01%

•/ 15g tube, apply qd, spread evenly and thin (l/16 t h inch) •S Cover in moist saline gauze dressing

ft P R O C U R A N = Thrombin-Induced Platelet Releasate • GF from patients own blood • 50-200cc of blood drawn from patient

^ Spin down, separate, activate the thrombin • 1 blood draw = 3mo of daily application

G R A F T S

ft A P L I G R A F T = Bilayered Skin Equivalent • Epidermis & Dermis Dermls slde down

• Newborn foreskin • FedEx in 24hr in petri dish - use immediately • Place a compressive wrap over it

ft D E R M A G R A F T = Human Dermal Replacement • Newborn foreskin • Cover with Allevyn & Hypofix tape • DO NOT use with any other topical agent

ft O A S I S

• Small Interstine Submucosa Pig/Porcine • SIS scaffold attracts patients cells • Store @ room temp up to 18mo

ftINTERGRA

• Collagen-GlycosAminoGlycan Biodegradable Matrix Cow/Bovine

• Porous Matrix of cross-linked bovine tendon collagen/GAGs • Semi-Permeable Polysilxane (Silicone) layer • Sterile Preperation

V G R A F T JACKET

• Processed Human Dermal Membrane • 3-D Bioactive Frame - supports granulation tissue • Deep Wounds

ft G A M M A G R A F T

• Irradiated human skin allograft • Epidermis & Dermis • Store @ room temp • After 24hr in place — remove secondary covering and allow area to air-

dry for 2-3hr -> once dried in place there is no need to recover it • (+) Patients can do this at home

ropir.AI. F.NZYMES: ft SANTYL = Collagenase

• Digests collagen in necrotic tissue • Collagen in healthy tissue or in newly formed granulation tissue is not

attacked • May be used as an Antibiotic Powder • Stop use when granulation tissue is well established

ft Accuzyme, Gladase • Papain ^Proteolytic enzyme from papaya • Urea Protein denaturing agent • May have a burning sensation in patients "A"13

• Cleanse with normal saline, NOT water ft Panafil

• Papain • Urea • Chlorophyllin Copper Complex Sodium •=> Inhibits hemagglutinating &

inflammatory properties of protein degradation products in the wound ft Elase = FibrinolysinDesoxyribonuclease RARE 2 Flnd

TOPICAL AC.ENTS FOR LOCAL B L O O D FLOW

ft X E N A D E R M O I N T M E N T

• Balsum of Peru O Increased blood flow to wound site • Castor Oil •=> Creates a moist environment • Trypsin >=> Maintains moist wound bed • Aluminum Magnesium Hydroxide Stearate ^ Fluid Repellent

89

ANKLE SCOPES

PORTALS: • Anterior

o AnteroMedial • Medial to Tibialis Anterior • Visualize: medial gutter & medial transchondral margins • Caution: TA, Saphenous V & N

o Accessory AnteroMedial o AnteroLateral

• Lateral to EDL or Peronial Tertius " Visualize: lateral gutter • Caution: EDL, Peronial Tertius, Superficial Peroneal N

o Accessory AnteroLateral o AnteroCentral

• Lateral to EHL • Caution: AntTibial A, Deep Peroneal N, EHL & EDL tendons

o Medial Midline Portal • Posterior

o PostcroMedial • Medial to the Achilles Tendon • Caution: Sural N, Lesser Saphenous V

o Accessory PosteroMedial o Modified PosteroMedial o PosteroLateral

• Lateral to the Achilles Tendon • Visualize: the posterior process of the talus & posterior media talar dome • Caution: T-D-A-N-H

o Accessory PosteroLateral o TransAchilles o Coaxial Portals

2 1 POINT EXAM: • 8 Anterior Points

o Deltoid Lig o AntMed Gutter o Med / Central / Lat - Talar Dome o Ant TibioFibular Articulation o AntLat Gutter o Anterior Gutter

6 Central Points o Med / Central / Lat - TibioTalar Art. o Posterior Inferior TibioFibular Lig o Transverse TibioFibular Lig o Capsular Reflection of the FHL tenr1

7 Posterior Points o PostMed Gutter o Med / Central / Lat - Talar Dome o Post TibioFibular Artie o PostLat Gutter o Posterior Gutter