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All pictures came from class notes / handouts.
Most of the pictures were referenced from Dr. Hetheringtons book.

3

1ubc oj Coricri-.

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, Sanders 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

4

1ubc oj Coricri- (Coriirucd).
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 2s 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





5

1ubc oj Coricri- (Coriirucd).

Topic Page #
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
5
th
Digit Arthroplasty 57
Rearfoot Surgery
Plantar Fasciotomy 58
Haglunds 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


6

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

PRE-OP NOTE
Surgeon
Pre-Op Dx
Planned Procedure
Medications
Allergies
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
ORDERS:
VANDIMAX
Date/Time/Signature
Vitals
Activities
Nursing
Diet
Ins/Outs
Meds
Ancillary
X-ray
ADMISSION ORDERS &
NOTE:
ADC VAANDILMAX
Date/Time/Signature
Admit to
Dx
Condition
-






Vitals
Activities
Allergies
Nursing
Diet
Ins/Outs
Labs
Meds
Ancillary
X-ray

7

POST-OP NOTE: SAPPA HEMI FC
2
P
2

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



Findings
Pathology
Prophylaxis
Complications
Condition

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



POST-OP VISIT: SOAP
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

8

LAYER OF THE FOOT

1
st
Layer
1. Abductor Hallucis M.
2. Abductor Digiti Minimi M.
3. Flexor Digitorum Brevis M.
2
nd
Layer
1. Quadratus Plantae M.
2. Lumbricales M.
3
rd
Layer
1. Flexor Hallucis Brevis M.
2. Flexor Digiti Minimi M.
3. Adductor Hallucis M.
4
th
Layer
1. Dorsal Interossei M. (4)
2. Plantar Interossei M. (3)

KEY LAB VALUES
Chem 7
Na Cl BUN
K CO Cr

CBC
HgB
HCT

Glucose
Platelets
WBC
(23-29mmol/L)
(5-20mg/dL)
(M: <1.2 W: <1.1mg/dL)
(97-107mEq/L)
(3.5-5mEq/L)
(136-145mEq/L)
(<110mh/dL)
(4500 -
11,000/L)
(M: 14.4-16.6g/dL)
(W: 12.2-14.7g/dL)
(M: 43-49%)
(W: 37-43%)
(150,000-450,000L)

9

INDICATIONS FOR HOSPITALIZATION POST-OP

1. Fever >101.6
o

2. Ascending Cellulitis / Suspect Osteomyelitis
3. Lymphangitis / Lymphademopathy
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

POST-OP 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 1
st
week
b. Virchows Triad
i. Hypercoagulation
ii. Venous Stasis
iii. Endothelial Damage

5. Wonder drugs / fever / benign / medicines

10

SUTURES

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

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



11

SUTURE SELECTION
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
5. Subcutaneous Fat
a. Vicryl
6. Subcuticular
a. Monocryl
b. Vicryl
7. Capsule
a. Vicryl
8. Skin
a. Nylon
b. Silk














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
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

12

STEWART CLASSIFICATION OF 5
TH
MET 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 metaphysic
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 metaphysic
Type IV
Fracture runs through the epiphysis, across the growth plate, and
into the metaphysic
Type V
The end of the bone is crushed and the growth plate is compressed
Type VI
(Rangs Addition) Avulsion of peri-chondral ring
Type VII
(Ogdens Addition) Avulsion fracture of the epiphysis without
involvement of the physis


13

GUSTILLO & ANDERSON OPEN FRACTURE CLASSIFICATION SYSTEM
Type I
Fracture with open wound <1cm in length
Clean, minimal soft tissue necrosis
Usually traverse or short oblong
Type II
Fracture with open wound >1cm 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 IIIa
Adequate bone coverage
Type IIIb
Extensive soft tissue loss with periosteal stripping and bone
exposure
Type IIIc
Arterial injury needing repair

NAVICULAR FRACTURE WATSON JONES
Type I 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 AVN OF 2
ND
MET
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

14

BERNDT-HARDY CLASSIFICATION OF TALAR DOME 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 NECK FRACTURE CLASSIFICATION HAWKINS

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


15

SNEPPEN CLASSIFICATION OF TALAR 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

WATSON & DOBAS CLASSIFICATION POSTERIOR LATERAL
TUBERCLE OF TALUS (SHEPARDS FRACTURE)

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

KUWADA CLASSIFICATION OF ACHILLES RUPTURE

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






16

ROWE CLASSIFICATION OF CALCANEAL FRACTURES

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

Type II A Posterior break fracture without Achilles involved
B Posterior break fracture with Achilles involvement

Type III Extra-articular body fracture

Type IV Intra-articular body fracture without depression

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


SANDERS CT 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:






17

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

Type C: Divergent
C1 Partial divergence with the 1
st
met medial and 2
nd
met laterally
displaced
C2 Total divergence with the 1
st
met displaced medially and lesser
mets displaced laterally

DIAS CLASSIFICATION OF LATERAL ANKLE LIGAMENT INJURY

Grade I B Partial rupture of CFL
Grade II B Complete rupture of ATFL
Grade III B Complete rupture of ATFL, CFL, &/or PTFL
Grade IV B Complete rupture of all 3: ATFL, CFL, & PTFL
+ Partial rupture of the Deltoid Lig

DANIS-WEBER CLASSIFICATION OF FIBULAR FRACTURES
INVOLVED IN ANKLE FRACTURES

Type A Transverse avulsion fibular fracture BELOW
(SAD)
Type B Spiral fracture AT
(SER or PAB)
Type C Fibular Fracture ABOVE
(PER)
the level of
the syndesmosis

18

LAUGE-HANSEN CLASSIFICATION OF ANKLE FRACTURES

SUPINATION ADDUCTION (SAD)
Stage I Transverse avulsion of fibula @/below AJ level
Rupture of the Lateral Collateral Ligament
Stage II Oblique to Vertical fracture of the Medial Malleolus

PRONATION ABDUCTION (PAB)
Stage I Transverse avulsion fracture of Medial Malleolus
or Rupture of Deltoid Lig
Stage II Rupture of AITFL & PITFL
or Tillaux-Chaput / Wagstaffe fracture
Stage III Short oblique fracture of the fibula @ lvl of syndesmosis

SUPINATION EXTERNAL ROTATION (SER) *** Most Common!
Stage I Rupture of AITFL
or Tillaux-Chaput / Wagstaffe fracture
Stage II Spiral/Oblique fracture of fibula @ lvl of syndesmosis
Stage III Rupture of PITFL
or Avulsion fracture of Posterior Malleolus
(Volkmanns Fracture)
Stage IV Transverse fracture of Medial Malleolus
or Rupture of Deltoid Lig

PRONATION EXTERNAL ROTATION (PER) *** Longest healing time!
Stage I Transverse fracture of Medial Malleolus
or Rupture of Deltoid Lig
Stage II Rupture of AITFL & Interosseous membrane
or Tillaux-Chaput / Wagstaffe fracture
Stage III High Spiral Oblique fracture (Maisonneuve Fracture)
Stage IV Rupture of PITFL
or Avulsion fracture of Posterior Malleolus


19

MRI

T1-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 waterweighted image
+ Very Sensitive for Bone Marrow abnormalities

Gadolinium (best for infection)
+ Contrastenhanced 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 = T1-Weighted
TR = Time of Repetition inc TE + inc TR = T2-Weighted






20

ANESTHETICS

Esters
Higher incidence of allergies
Metabolized in Blood (Cholinesterase in plasma)
Types
~ Cocaine
~ Procaine
~ Cholorprocaine
~ 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 <12y/o

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

Dosing:
0.25% solution = 2.5 mg/cc drug 1cc = 1mL
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

Toxic Doses: Onset & Duration:
Lidocaine Plain = 300mg Onset: 5min
w/ Epi = 500mg Duration: 1-2h

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


21

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)

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.

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

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

Saphenous N .5-1cc
Posterior Tibial N 1-3cc give the most here since this N is the largest
Sural N .5-1cc
Deep Peroneal N .5-1cc between 2 Long Extensor Tendons
Superficial N .5-1cc plantarflex & invert

Hemostasis = Tourniquet Pressures:
Ankle: +100 over systolic ~250mmHg
Thigh: +200 over systolic ~ 350mmHg
ueep
llbular n.
Superflclal
llbular n.
Sural n.
osL. 1lblal
n.
Saphenous
n.
1alar
1rochlea
M
M
L
M
Achllles 1endon
Draw up with 18G
Inject with 25 or 27G

22

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:
1. Plantar Fasciitis
a. 1cc Kenalog-10 (10mg/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





Always draw up the Lido/Marc 1
st

followed by Dex or Kenalog!

23

RADIOGRAPHIC DATA

Angle: Normal:
Hallux Abductus Angle 0-15
o

Proximal Articular Set Angle (PASA) 0-8
o

Distal Articular Set Angle (DASA) 0-7
o

Intermetatarsal Angle
1-2 0-8
o

2-5 16
o
+ 4
o

4-5 8
o
+ 2
o

Hallux Interphalangeal Angle (HIA) 0-10
o
+ 2
o

Metatarsal Length + 2mm
Metatarsus Adductus 0-8
o

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
o

Talar Declination Angle 21
o

TaloCalcaneal Angle (Kite) 17-21
o

Bhlers Angle 25-40
o

Angle of Gissane 125-140
o



Calcaneal Fracture resulting in
Joint Depression B Bhlers Angle
Angle of Gissane

24

CLASSIFICATION OF JOINT DEFORMITIES

Positional Deformities:
PASA + DASA < HAA
PASA and DASA within normal range (0-8
o
)
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





25

PROXIMAL OSTEOTOMIES
IM between 15-22
o
, normal PASA
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


26

PROXIMAL OSTEOTOMIES CONTINUED

III. Opening Base Wedge
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





27

PROXIMAL OSTEOTOMIES CONTINUED

V. Double Osteotomy
IM and PASA correction








VI. Proximal V
Good screw fixation
Unlikely to get elevates







VII. Lapidus
IM > 18
o

Fusion of the base of 1
st
met to the medial
cuneiform
Indications:
Pain with motion at met-cuneiform joint
Hypermobility of 1
st
met-cuneiform joint




28



29

MIDSHAFT OSTEOTOMIES
** Troughing is unique to midshaft osteotomies

I. Ludloff Osteotomies
IM 1-2 angle: 13-20
o

Abnormal HAA
Normal to short 1
st
metatarsal
Elevatus is a risk









II. Mau
IM 1-2 angle: 13-20
o

Abnormal HAA
Normal to short 1
st
metatarsal
Due to cut, decreases elevates
potential








30

MIDSHAFT OSTEOTOMIES CONTINUED

III. Scarf 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
o






31

DISTAL OSTEOTOMIES
HAV angle 35
o
IM angle -- 16
o

Some PASA correction

I. Reverdin
Some PF possible



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




32

DISTAL OSTEOTOMIES CONTINUED

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











IV. Wilson
Dramatic shortening possible




33

DISTAL OSTEOTOMIES CONTINUED

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







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





34

INTERNAL FIXATION

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

Rules of 2s:
Fracture / Osteotomy site should be 2xs the diameter of the bone
2 points of fixation is better than 1
2 threads should purchase the distal cortex
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


35

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













36

INTERNAL FIXATION CONTINUED

Monofilament Wire Continued
Box Wire fashion
2 boxes at 90
o
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-wires 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 tendons anatomical pull.
Size of wire measured in gauges -- Lower gauge; thicker wire
26 & 28 are common in Podiatry


37

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 = 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




38

INTERNAL FIXATION CONTINUED

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

Head 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
o
)

Rake Angle Thread to axis angle

Tip Angle Tip to axis angle

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

39

INTERNAL FIXATION CONTINUED

Screw Diagram:










40

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


41

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




42

INTERNAL FIXATION CONTINUED

General Screw Fixation Technique:
~ Place one screw perpendicular to the fracture / osteotomy line for
maximal compression. Place the 2
nd
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




43

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 2xs the width of the
bone or has a fracture angle that is less than 40
o
.

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

44

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



45

INTERNAL FIXATION CONTINUED

Soft Tissue Anchors:
9 Used for reattachment of tendons or ligaments
9 2 basic types: Expandable / Screw type
9 Complications: Improper Placement / Failure of Suture / Pullout

Plates:
9 Various size and shape allow alignment of the bones and stability
across the fracture / osteotomy site
9 Stability allows for early passive RoM
9 Adequate screw fixation is important for the plate to function properly
9 Plate designs include semitubular, 1/3 tubular, 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.


46

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



47

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






48

EXTERNAL FIXATION CONTINUED

Complications:
9 Pin irritation avoid pin placement in muscle
9 Pin tract infection most common complication (30%)
9 Neurovasculature Impalement Anterior Tibial A. & Deep Fibular N.
and they are most commonly involved
9 Delayed Union / Non-Union due to faulty frame construction
9 Compartment Syndrome due to increase in the intracompartmental
pressures (mmHg)
9 Refracture once the frame has been removed due to tension
shielding, a rare complication

Types of External Fixators:

1. Unilateral Fixators
9 Produces compressive or distraction forces
9 Used to fixate fractures, fuse joints, and lengthen
9 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
9 Main disadvantage not create any sagital plane stability &
therefore should not weight bear immediately post-op


49

EXTERNAL FIXATION CONTINUED

Types of External Fixators Continued

2. Circulator Fixators
9 Produces compressive and distraction forces
9 Used to fixate fractures, treat non-unions, limb-lengthening , soft
tissue lengthening, and correction of congenital deformities.
9 Utilizes trans-osseous wires with half-pins to position the wires in
different plane stability
9 Limited by the circular frames ability to fit the extremity and
patients comfort of wearing the apparatus

3. Hybrid Fixators
9 Combination of unilateral and the circular fixator
9 Used to treat tibial plafond fractures and pilon fractures
9 Utilizes trans-osseous wires and half-pins and footplate to allow
early weight bearing

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






50

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.



51

COMMON FOREFOOT PATHOLOGIES AND SURGERIES

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

Radiographic Appearance
AP
Focal joint space narrowing
Joint mice
Spurring
Asymmetry
Squaring of metatarsal head
Lateral
Dorsal Flag Sign
Spurring
Sclerosis
Metatarsus Primus Elevatus

Etiologies = TIN-MAC
Trauma
Infection
Neoplasm of bone or soft tissue
-
Metabolic
Anatomic
Structural = short/long 1
st
ray, Met Primus Elevatus
1. Mearys Angle deviation (b/s talus should b/s 1
st
met)
2. Parallelism between 1
st
& 2
nd
metatarsals
3. Metatarsal parabola / protrusion deviation
Biomechanical = pronation, hypermobile 1
st
ray
Congenital



52

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)
1
st
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
nd
,
proximal migration of sesamoids
2. Implant = Hemi or Total must cover cortical surfaces
3. McKeever = 1
st
MPJ arthrodesis positioned dorsiflexed and
abducted with no rotation
DF = 10-15
o
off weight bearing one finger under toe
5-10
o
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



53

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 / DIPJ
FDL / FDB = actively plantarflex MPJ, PIPJ, DIPJ
Interossei = prevent buckling
Lumbricales = hold digits rectus (plantarflex MPJ, dorsiflex PIPJ /
DIPJ)

Types of Deformities:



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 4
th
and 5
th

Late stance phase biomechanical abnormality
Tx = Derotational Arthroplasty

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

54

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
9 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
Hibbs Tenosuspension if Flexible


55

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED

Hammertoes Surgical Procedures:
SOFT TISSUE
1. Tenotomy = stab incision medial or lateral to tendon deformities only
9 PF digit with blade in place flexible deformities only
9 Older population only lose strength & stability
2. Capsulotomy
3. Tendon Transfer
4. Girdlestone
9 Transfer FDL & FDB to dorsal head of proximal phalanx to restore
intrinsic function
5. Hibbs
9 Transfer EDL to base of proximal phalanx or met head
6. Kuwada & Dockery
9 Modification of Girdlestone drill hole in base of proximal phalanx
and bring tendons up through it
7. Lengthening
8. Z-Plasty at level of MPJ
9. Percutaneous stab incision and splint
**Complications: Muscle spasm caused by overcorrection, tenosynovitis,
scarring, adhesion, weakness, bowstringing, and nerve entrapment

OSSEOUS
1. Arthroplasty
9 Post resection of base of proximal phalanx
9 Gotch & Kreuz resect base of proximal phalanx and syndactylize
digits
2. Arthrodesis
9 Lambrinudi fusion of PIPJs and DIPJs
9 Young-Thompson Peg-in-Hole Fusion (Peg from Prox.Phalanx)
9 High amount of shortening
3. Taylor PIPJ fusion using K-Wire

56

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED

Hammertoes
Sequential Reduction:
1. Z-Plasty
2. Arthroplasty
3. Extensor Hood Release
4. MPJ 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 1
st
med head
~ Insert tendon through drill hole and suture back on itself





57

5
TH
DIGIT ARTHROPLASTY
1. Lazy S Incision
9 Lateral condylectomy of distal and middle phalanges with resection
of head of proximal phalanx

2. Derotational Arthroplasty
9 Distal Medial Proximal Lateral Incision

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



58

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







59

REARFOOT SURGERY CONTINUED

Haglunds Deformity:
Angles:
Philip-Fowler Angle = normal 44-69
o
, >75
o
pathological
Total angle of Ruck = Philip-Fowler + Calcaneal Inclination Angle
Normal up to 90
o
, pathological if > 110
o

Parallel Pitch Lines most objective method of determining a
Haglunds deformity

Procedures:
Longitudinal incision lateral to TA
Dissection down to posterosuperior Calcaneus
Aggressive removal of pathologic bone, but dont 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 Haglunds 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



60

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
9 Resect at insertion, pass under the joint capsule and reattach at
medial aspect of the capsule
9 Indicated in HAV to realign the sesamoid apparatus
2. Abductor Hallucis
9 Transected at insertion, rerouted inner 1
st
met head and fixated at
lateral base of proximal hallux
9 Indicated in Hallux Varus with an osteotomy
3. Extensor Hallux Longus
9 Transected at origin, rerouted under DTIL, fixated to lateral base
of proximal hallux
9 IPJ needs fused
9 Indicated when have sagital component with Hallux Varus
4. Jones Suspension
9 EHL excised from insertion, drill a hole transversely through 1
st

met head, rerouted through hole and sutured on itself
9 Indicated with cock-up deformity, flexible cavus, lesser
metatarsalgia, chronic ulcers, weak TA, flexible plantarflexion of
1
st
met
5. Hibb's Tenosuspension
9 EDL detached from insertion, bundled together and placed
through midfoot at the base of the 3
rd
met or lateral cuneiform
9 Indicated to release retrograde buckling at MPJs, met equines,
flexible cavus, claw toes

61

TENDON TRANSFERS CONTINUED

Types Continued...
6. Tibialis Anterior Transfer
9 3 incisions at (1) proximal dorsal leg, (2) TA insertion at medial
plantar cuneiform / tubercle 1
st
met, and (3) the new area of
insertion in the midfoot
9 Release from insertion, reroute out the proximal incision, with
tendon, with tendon passer brought to new insertion (usually 3
rd

cuneiform)
9 Indicated for recurrent clubfoot, flexible forefoot equines,
dropfoot, tarsometatarsal amputation, Charcot Marie Tooth
deformity

7. Split Tibialis Anterior Tendon Transfer (STATT)
9 3 incisions at (1) base of 1
st
met, (2) anterior leg over TA just
lateral to medial malleolus and (3) over peroneus tertius at base of
5
th
met
9 Split tendon through proximal insertion, lateral slip passed
through peroneus tertius sheath and sutured to tendon fixated to
cuboid
9 Indicated for spastic RF equines, spastic equinovarus, fixed
equinovarus, FF equines, flexible cavovarus deformity, DF
weakness, excessive supination in gait

8. Cobb Procedure
9 STATT but reroute to TA to PA tendon
9 Indicated for PT dysfunction



62

TENDON TRANSFERS CONTINUED

Types Continued...
9. Tibialis Posterior Tendon Transfer
9 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
9 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 3
rd

cuneiform)
9 Indicated for weak anterior muscles, equinovarus, spastic
equinovarus, recurrent clubfoot, dropfoot, complications from
Charcot Marie Tooth, peroneal nerve plaste, leprosy, Duchennes
MS
9 Muscle goes from a stance to a swing muscle during gait

10. Peroneus Longus Tendon Transfer
9 3 incisions (1) lateral, lower leg, (2) lateral cuboid and (3) base of
3
rd
met/lateral cuneiform
9 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 3
rd

cuneiform
9 Indicated for anterior muscle weakness, dropfoot



63

BUNION PROCEDURES TO KNOW BASED ON ANGLES

IM Angle

Normal: 0-8
o

12-16
o

Distal
Osteotomy
Austin
Hohman (Neck) -- Trapaziodal
Mitchell (Neck)
Wilson (Neck)
Reverdin Laird (Distal L)
Short Z
Waterman
Youngswick
>16
o
Proximal
Osteotomy
Base Wedge
Lapidus (Met-Cuneiform Fusion)
Hypermobile

Cresentic
Juavara
Proximal V of Kotzengerb
Comments: with a thin Met shaft may need to use a proximal procedure
Mitchell shortens the length of met shaft used in Long Met Length
( >2mm longer than 2
nd
met)
Taylors Bunion = Symptomatic when IM
4-5
>9
o
Splayfoot = IM
1-2
+ IM
4-5
>20
o


DASA

Normal: 0-8
o

>8
o

Proximal
Osteotomy
Proximal Akin
-- cylindrical akin w/ long prox phalanx
-- oblique
-- transverse
-- Bonnel-Kessel DF wedge
Comments:


PASA

Normal: 0-8
o

>8
o

Distal
Osteotomy
Reverdin
Reverdin Green PASA
Comments:

64

Abnormal
PASA
+
IM Angle


IM:12-16
o
+ Abn P

Distal
Osteotomy
Biplane Austin
Reverdin Laird (Distal L) PASA + IM
Reverdin Green
Biplane Mitchell Roux
Hohmann
Shaft
Osteotomy
Mau
Ludloff
Scarf / Z
Klotzenberg
Juvara
IM: >16
o
+ Abn P
Proximal
Osteotomy
Lapidus w/ Reverdin
V Osteotomy
Logroscino (Base Wedge Reverdin)
Cresentic
Juavara
Proximal V of Kotzengerb
Comments:


HAA

Normal: 0-16
o

> 16
o
Silver
McBride
Adductor Hallucis Tenotomy
Lateral Capulotomy
Comments: ST or Osseous Abnormality
HAA + IM
1-2
13-20
o
= Lodloff + Mau
(+ PASA) = Scarf Z

HIA

Normal: 0-10
o

> 10
o
Distal Akin
Comments:




65


Tibial Sesamoid Position

Normal: 0-3
4-7 Fibular Sesamoidectomy
Fibular Sesamoid Release
Comments:


Lateral
Deviation
Angle
Normal: 2.5
o
+
IM
4-5

Normal: 0-8
o


IM: 8-12
o

Normal 2
Slight
Increase

LDA: Inc
Distal Osteotomy
exostectomy
dist.
metaphyseal
osteotomy
Reverse Austin
Reverse Mitchell
Reverse Hohmann
Reverse Wilson
Reverse Mercado
IM: > 15/16
o

Marked Inc

LDA:
Severe Lat
Bowing
Proximal
Osteotomy
Base Wedge
Comments:





66



67



Cici npoiiuri 1ir-
io row joi
id
cui
Joiuiior- o Cxicir-ip-

Dr. Bodmans Drugs p. 68
Dr. Caldwells Drugs p. 74
Dr. Caldwells Wound Care p. 84
Ankle Scopes p. 90


68






























69





70







71



72



73




74



75

LACTAMASES
SENSITIvE PENICILLINS
Penicillin v (P0)
Penicillin u, Aqueous (Iv)
Penicillin u, Piocaine (IN)
Ampicillin
Amoxicillin

RESISTANT PENICILLINS (S
RB
uENERATI0NS) Resist H0N0oys!
H
Nethacillin (Iv)
0
0xacillin (Bactocil)(P0)
N
Nafcillin (0nipen)(P0)
0
Bicloxacillin (P0)
EXTENBEB SPECTR0N PENICILLINS (4
TB
uENERATI0NS)
Caiboxypenicillins Caibenicillin
Ticaiicillin
0ieiuopenicillins Nezlocillin
Pipeiazine Penicillin Pipeiacillin
u
+
: Stiep
u

: Eikenella coiiouens

Buman Bites

Nisseiia gonoiihea

STB Septic }oint

Anaeiobes: Clostiiuium peifiingens
** Tx: Clostiiuium Tetani if
alleigic to Tetanus Toxoiu
Tx: Stiep Thioat & 0titis Neuia
u
+
: Stiep
u

: Eikenella coiiouens
Nisseiia gonoiihea
BELPS
2
Anaeiobes::
** 0seu in kius insteau
of Augmentin!
HELPS
2
:
Haemophilus
E. coli
Listeiia
Pioteus miiabellus
Shigella
Salmonella
** Tx: Tieponema Paliuum
(Syphilis)
Lactamase Resistant Staph Auieus
** Toxic, not useJ!
If iesistant to this = NRSA!
Bioau Spectium

BoN0TcoveiLactamase
u
+
: uoou Coveiage
u

: Coveiage


Anaeiobes: Coveiage
** Tx: PseuJomonos oeruqinoso
hiqb No
-
looJs
ovoiJ pts w, hTN
Bewore of hypokolemio!
BR0u INTERACTI0NS: Waifaiin, 0ial Contiaceptives, Piobeneciu, Aminoglycosiues
CI with pts on Nethotiexate
Rbeumotioloqist 0ocs tell pts tbey ore C,l!

Pt must toke oll 10J of meJs or else qet post-strep qlomerulonepbritis

76

LACTAMASES
C0NBINATI0N BR0uS
Pipeiacillin Tazobactam (Zosyn)(Iv)
Amoxicillin Clavulanic Aciu (Augmentin)(P0)
Ticaicillin Clavulanic Aciu (Timentin)(Iv)
Ampicillin Sulbactam (0nasyn)(Iv)


Bioau Spectium
u
+
: Stiep, Staph auieus
u

:Neisseiiagonoiihea
Anaeiobes: ;
**0nrelioble oqoinst 6

infections!
**Stopb oureus is susceptible to
AuqmentinSS%JuetoHRSA
Tx: PseuJomonos oeruqinoso & Proteus mirobilis
NeeJs 4.Sq q6b for pseuJomonos
B0SAuE B0X:
Zosyn = S.S7Sg q6h
Augmentin = 87Smg q12h
Timentin = S.1g q6h
0nasyn = S.ug q6h

77

CEPHALUSPURINS
1
ST
uENERATI0N
Cephalexin (Keflex)(P0)
Cephauioxil (Buiicef)(P0)
Cefazolin (Ancef)(Paienteial)
2
NB
uENERATI0N
Cefuioxime (Ceftin)(P0)
(Zinacef)(Paienteial)
Cefoxitin (Nefoxin)(Paienteial)
S
RB
uENERATI0N
Cefixime (Supiax)(P0)
Cefpouime (vantix) (P0)
Ceftiiaxone (Rocephin)(Paienteial)
Ceftaziuime (Foitaz)(Paienteial)
Cefuinii (0mnicef)
4
TB
uENERATI0N
Cefipime (Naxipime)
EXTENBEB uENERATI0N
Ceftobipiole

u
+
: Noie active against Staph auieus than S
iu
u
u

: uoou Coveiage
(+ Pseuuomonas)
An: 7
u
+
: uoou Staph auieus
Staph epiueimiuis
Stiep
u

: Some PEcK
An: Some not B.froqilis
< 80% susceptibility to Ancef
u
+
: Almost as goou as 1
st
u
u

: Extenueu BEN PEcKS

An: 7
HEN PEcKS:
Haemophilus influenza
Enteiobactei aeiogens
Neisseiia species
Pioteus miiabilis
E. coli
Klebsiella pneumonia
Seiiatia
u
+
: Significantly
u

: Supeiioi Coveiage
(Foitaz Pseuuomonas)
(Rocephin Neisseiia)
An: 7
*Coveis Staph & Stiep bettei than 1
st
u. NIC levels aie supeiioi to Cephalexin
4xsbetteifoiStaph7xsbetteifoiStiep
B0SAuE B0X:
0mnicef = Suumg q12h
*Not qooJ for Stopb
u
+
: ; Active against NRSA
u

: ;
An: 7
BR0u INTERACTI0NS: Avoiu Cephalospoiins if pt alleigic to Penicillin!
Cefuinii(2
nu
u) & Cefuioxime(S
iu
u) aie alloweu foi Penicillin alleigy!
0ue to Jifferent structure.

78

CARBAPENAMS

ImipenamCilastin (Piimaxin)
Neiopenam (Neiiem)
Eitapenam (Invanz)(IvIN)
Boiipenam


Bioau Spectium
u
+
: ; Nost
u

: ; Nost (pseuuomonas iesistant)

(mycoplasma iesistant)
An: ; Excellent
*IB specialists 0NLY!
u
+
: Staph & Stiep only (Infeiioi to Imipenam)
u

: ; (Supeiioi to Imipenam)
An: :
*Nostly IB specialists
Seizuie Risk!
u
+
: ;
u

: Limiteu
An: ;
Bioau Spectium
u
+
: ;
u

: ; (pseuuomonas)
An: ;

BR0u INTERACTI0NS:
CI in pts with Penicillin alleigy
CI in pts with Seizuie Bistoiy
Eitapenam inteiacts with Piobeniciu.
B0SAuE B0X:
Invanz = 1g qu
CiCl < Sumlmin = Suumg 6h pie-uialysis

79

MUNUBACTAM

Aztieonam (Azactam)(IvIN)
AMINUCLYCUSIDES

uentamycin
Tobiamycin
Amikacin
CLYCUPEPTIDES
1
ST
uENERATI0N
vancomycin (P0Iv)
2
NB
uENERATI0N
Balbavancin(P0Iv)
S
RB
uENERATI0N
Telavancin
u
+
: ; -- NRSA, vRSA, Stiep, C.uifficile
u

: 1
An: 1
u
+
: :
u

: ; (1pseuuomonas)
An: :
*0K for Penicillin Allerqy
No mojor renol toxicities; only
Jose oJjust for renol insufficiency
or Jiolysis
u
+
: ; NRSA
u

: ; Pioteus miiabilis
Pseuuomonas
Klebsiella
E. coli
Salmonella
Shigella
An: :
ABvERSE BR0u REACTI0NS:
0totoxicity {lrreversible)
Nephiotoxicity {Reversible)
BypoK
+
uentamycin
BypoNg
+
Amikacin
* N0T use on 0iobetics or Hy6rovis

Peok {S0min post Jose) & Trouqb
{S0min before next Jose) levels ore
recommenJeJ
u
+
: ;
Iv

NRSA
u

: ;
P0

Clostiiuium uifficile
An: ;
ABvERSE BR0u REACTI0NS:
0totoxicity {Reversible)
Nephiotoxicity {Reversible)
Reu Nan Synuiome
vestibulai Imbalance
Thiombophlebitis
u
+
: ; -- NRSA, vRSA, Stiep
u

: 1
An: 1
Tx: FnJocorJitis Propbyloxis
forptsollerqicto-loctoms
- Keep for reserve coses! B0SAuE AB}0STNENT B0X:
Sukg: 7Sumg
Su-74kg: 1uuumg
7S-9ukg: 12Sumg
>9ukg: 1Suumg
Noimal Tiough = S-1umguL
If tiough iange >1SmguL
uouble the uose time inteival
B0SAuE B0X:
vancomycin = 1g slow push Iv
{over 60min)

80

TETRACYCLINES

Boxycycline
Ninocyline
Nethacycline
Tetiacycline BCL


MACRULIDES

Eiythiomycin


Azithiomycin
(Zithiomax)
* Some Anti-lnflommotory
properties seen on 0A

u
+
: ; Staph auieus
NRSA
u

: ; E. coli
Klebsiella
Enteiobactei
vibiio vulnificans

Salt Watei
Rickettsia
Chlamyuia
An: :
ABvERSE BR0u REACTI0NS:
NonSpecific uI Issues ~0ontqive0oxycylcinebeforebeJ erosive esopboqitis
Photosensitivity
Photo-0nycholysis (Boxycycline)
1Acute Pancieatitis
C0NTAINBICATI0NS:
No Piegnant Kius ~ tootb Jiscolorotion in kiJs unJer 8y
CI foi pts on Bigoxin -- Toxicity
CI foi pts on Accutane

Acne
-- ICP, Pseuuomotoi Ceiebii Risk
Absoiption is limiteu by:
~ Foou ~ Nilk
~ Antacius ~ Iion
u
+
: ; Staph Stiep Coiynebacteiium minitussimum*
u

: :
An: :
u
+
: ; Staph Stiep
u

: :
An: :
ABvERSE BR0u REACTI0NS:
uI 0pset
Piolongeu Beait Bepolaiization ~ Toisaues ue Pointes
BR0u INTERACTI0NS: Potent Inhibitois of CYP SA4
Cyclospiine Siiolimus Taciomilus
CI foi pts on Caibazepine & Theophyline
0ial Bose = 2x Risk of Suuuen Beath
Combineu with Ca2+ Chanel Blockeis
= 5x Risk of Suuuen Beath
{verpomil, 0iltiozom)
* Eiythiasma Coial Reu Woous Lamp
0etox in liver
FxcreteJ in Bile
B0SAuE B0X:
Zithiomax = Suumg 1
st
Bay
(z-pack) 2Sumg qu next 4 uays
ABvERSE BR0u REACTI0NS:
uI 0pset
Piolongeu Beait
BR0u INTERACTI0NS:Potent Inhibitois of CYP SA4
Bigoxin Coumauin
BNucoA Reuuctase
Rorely useJ -- poor
ST penetrotion

81

LINCUSAMIDES

Clinuamycin (Cleocin)




CHLURAMPHENICUL


SULFUNAMIDES

TiimethopiimSulfamethoxazole (Bactiim Septia)
* 6ooJ Bone Penetrotion
* Poor CNS Penetrotion
u
+
: ; Fulminate uioup A Stiep

Neciotizing Fasciitis
uioup B Stiep
~ moy sbow resistonce

NRSA
~ moy sbow resistonce
Staph Auieus**
u

: :
An: ; B. fiagilis
ABvERSE BR0u REACTI0NS:
Biaiihea
Pseuuomembianous Colitis
BR0u-BR0u INTERACTI0N:
Respiiatoiy Paialysis with m. ielaxants (Baclofen Biazepam)
*Staph Auieus iesistant to
eiythiomycin on C&S can
uevelop inuucible iesistance to
Clinuamycin
*C&S of oiganism is sensitive
to Clinuamycin but iesistant to
eiythiomycin B uo N0T give
Clinuamycin because it will
uevelop iesistance
B0SAuE B0X:
Cleocin = 6uumg 1hi pie-op
6iven os propbyloxis for
bocteriol enJocorJitis
u
+
: :
u

: :
An: ; Seiious Infections
. Last iesoit foi vRE
ABvERSE BR0u REACTI0NS:
uiay Baby Synuiome
Seveie Bone Naiiow Toxicity
Aplastic Anemia
* Bewore in pts over S0 yeor olJ
u
+
: ; Staph & Stiep
NRSA
u

: ;
An: :
ABvERSE BR0u REACTI0NS:
Acute pancieatitis
BR0u-BR0u INTERACTI0N:
TS + Methotrexate = Bone Marrow Suppression
TS + Coumadin/Digoxin = Toxicity of C/D
TS + Oral Sulfonylureas = Hypoglycemia

82

5-NITRUIMIDAZULE

Netioniuazole (Flagyl)

FLUURINATED 4-QUINULUNES

Cipiofloxacin (Cipio)
Levofloxacin (Levaquin)
Noxifloxacin (Avelox)
* Tx PseuJomembronous Colitis
ABvERSE BR0u REACTI0NS:
Peiipheial Neuiopathies
Nv with Alcohol Consumption
Baik Biown 0iine
BR0u-BR0u INTERACTI0N:
Anti-Coagulation effects of Warfarin
u
+
: :
u

: :
An: ; B. fiagilis
B0SAuE B0X:
Flagyl = 1Smgkg loauing uose
7.Smgkg q6h Iv -oi- Suumg tiu
u
+
: :
u

: ; most active
against P. aeiuginosa
infection of bones & joints

An: :
B0SAuE B0X:
Cipio = 7Sumg biu
BR0u-BR0u INTERACTI0N:
Not give within 2hr of: Multivitamins, Antacids, Sulcralfate
MANY interactions! Theophyline, Caffeine, Warfarin, NSAIDs, ddI (HIV)
May see Torsades de Pointes & Ventricular Fibrillation

**May produce a false (+) on viral assay for opiates
B0SAuE B0X:
Levo = Suumg qu (poIv)
u
+
: ; Stiep
u

: ; N. gonoiihea
An: :
ABvERSE BR0u REACTI0NS:
uI Beauache Phlebitis
oll ore rore!

* Post ontibiotic effects {6
-
)
Bioau Spectium
u
+
: ; Staph

some iesistance

Stiep

enhanceu

u

: ;
An: ; B. fiagilis
* uoou in ST
* uoou foi uiabetic foot
infections with inopeiable
atheioscleiosis
* Nay woik against TB
C0NTRAINBICATI0NS:
0nuei age 18
Piegnant Nuising
* Attocks joints
*Con couse TenJonitis , Rupture

83

RIFAMYCIN
Rifampin

STREPTUCRAMINS
BalfopiistinQuinopiistin (Cipio)
UXAZULIDINUNES
Linezoliu (Zyvox)
CYCLIC LIPUPEPTIDE
Baptomycin (Cubicin)
CLYCYLCYCLINES
Tigecycline (Tygacil)
Bioau Spectium
u
+
: ; Staph auieus
Stiep epiueimiuis
NRSA
u

: ; N. gonoiihea
Nycobacteiium
An: :
* Turns fluiJs 0ronqe
* CYP 4S0 system
* Tx leprosy
* Tx vonco Resistont HRSA

B0SAuE B0X:
Not given alone uive with Cipio Bactiim
u
+
: ; vRE
NRSA
NRSE
u

: :
An: :
ABvERSE BR0u REACTI0NS:
Aithialgia Nyalgia
Nausea
Thiombophlebitis
LFTs
Injection Site Reaction
* Reserve tbis Jruq!!!
u
+
: ; vRE
NRSA
vRSA
u

: :
An: :
ABvERSE BR0u REACTI0NS:
Nylosuppiesion
Nv
lactic aciuosis

0ptic Neuiopathy

Tx >1mo

* 6ooJ bone penetrotion
*CbeckweeklyCBCs
u
+
: ; NRSA
vRSA
u

: :
An: :
BR0u INTERACTI0NS:
Tobiamycin
Statins

Nyopathy

*CbeckweeklyCPKs

B0SAuE B0X:
4mgkg qu
Bioau Spectium
u
+
: ; NRSA
vRSA
u

: ; An: ;
ABvERSE BR0u REACTI0NS:
Nv
Tooth Biscoloiation

*CbeckweeklyCPKs

B0SAuE B0X:
Iv: 1uumg Loauing Bose
Sumg biu

84

URAL ANTIBIUTICS
Itiaconazole (Spoianox)
Teibinafine (Lamisil)
Fluconazole (Biflucan)
uiiseofulvin (uiis-PEu)
URAL ANTIPARASITIC
Thiabenuazole (Nintezol)
Iveimectin
Beimatophytes
Canuiua
Nolus
0nycbomycosis
Tineo peJis
{off lobel)

ABvERSE BR0u REACTI0NS:
uI upset Rash Beauache
Bepatotoxicity LFTs
ALT & AST
BR0u INTERACTI0NS:
Statins Ca
2+
Channel Blockeis
Tikosyn Eiythiomycin
C0NTRAINBICATI0NS:
Patient with CBF!
Beimatophytes
0nycbomycosis
Tineo peJis
{off lobel)

ABvERSE BR0u REACTI0NS: Raie
Beauache Abnoimal Taste
uieen vision

BR0u INTERACTI0NS: CYP4Su 2B6
Cimetiuine Cyclospoiine
Rifampin Noitiiptyline
Caffeine
B0SAuE B0X:
Pulse Bosing = 2Sumg qu 1 weekmo ovei 2mo
Noimal = 2Sumg qu Smo
Beimatophytes
Canuiua
Nolus
B0SAuE B0X:
Pulse = Suumgweek
ABvERSE BR0u REACTI0NS:
Seveie Skin Rash
Alopecia
Biug Inteiactions: CYP4Su SA4
Cbronic Tineo peJis
Beimatophytes ABvERSE BR0u REACTI0NS:
Paiesthesia Rash Beauache

BR0u INTERACTI0NS:
0ial Contiaceptives
Waifaiin
Baibituates
B0SAuE B0X:
2Sumg tiu (x4-8 weeks)
B0SAuE B0X:
Pulse Bosing = 2x 1uumg tabs in AN & PN with foou
Take foi 1 week of the mo. foi ___ months
* Cutoneous lorvo Hiqrons

B0SAuE B0X:
Nintezol = 1u% aqueous solution qiu
Iveimectin=2uugkgpox1uosefoi1-2uays

85

WUUND CARE & DRESSINCS

ACTICUAT = Nanociystalline Silvei (antimiciobial effect up to 7uays)
Reuuces Exuuates while maintaining a moist wounu enviionment
Noisten with steiile watei
(N0T SALINE!!! Silvei ieacts with Saline)

Effective against vRE & NRSA
IUDUSURB CEL J IUDUFLEX DRESSINC = Absoibent Iouine Cauexomei
Slowly ieleases small amounts of a u.9% elemental iouine
ALLEVYN FUAM
Noueiate to Bigh Exuuate
Nevei use the auhesive type!
HYPAFIX
Auhesive, non-woven fabiic
Bolu post-op uiessings catheteis uiainage tubes in place
HYDRUCEL SHEETS = Elastouel, Nu-uel, vigilon, Ameiigel
Low Exuuate
Re-Epithelializing wounus
NonAuhesive
uas peimeable
(+) Pioviues Noistuie
qu change foi infecteu wounus
(+) No tiauma upon iemoval
() Potential to maceiate suiiounuing skin
HYDRU-CEL = Buoueim uel, Nu-uel, Restoie, Bypeigel
Low Exuuate
Paitial Full thickness wounus
0se once gianulation tissue is piesent
(+) No tiauma upon iemoval
(+) Pioviues Noistuie
() Potential to maceiate suiiounuing skin

86

TRANSPARENT FILMS = 0psite, Tegeueim, Bioclusive, Epivew
Auhesive, Polyuiethane film
Low Exuuate
Nay be useu ovei absoiptive wounu filtei oi hyuiogels
N0T foi INFECTI0N!
Supeificial Wounus (Blisteis)
(+) 0p to 7u weai time (semi-peimeable)
(+) Allows visual assessment
(+) Pioviues Noistuie
() Potential to maceiate suiiounuing skin with excessive uiainage
() N0T absoiptive
() Auhesive may teai healthy skin
HYDRUCULLUIDS = Buoueim, Buoueim CuF
Contiol uel Foimula
, Tegasoib, Restoie
Auhesive, 0cclusive
Low Exuuate
uianulating & Epithelializing Paitial Thickness Wounus
Nay be useu ovei absoiptive wounu filtei oi hyuiogels
N0T foi INFECTI0N!
Covei least 1inch of suiiounuing skin
(+) 0p to Su weai time
() Nay teai healthy skin
() Potential to maceiate suiiounuing skin with excessive uiainage
Change uiessing befoie it leaks
0uoiBiainage aie Noimal
FUAM = Acticoat Noistuie Contiol, Allevyn, Polymem, Teille
Auhesive Boiuei

Polyuiethane
Auhesive oi NonAuhesive
Noueiate to Bigh Exuuates
vaiying Thickness
Infecteu wounus if changeu uaily
venous Leg 0lceis
(+) 0p to 7u weai time
() Nay teai healthy skin

87

ALCINATE = Soibsan, Beimacea Alginate, Kaltostat, Cuiasoib
Seaweeu Polymei
uel foimeu when fibeis inteiact with wounu fluiu
Pau oi Rope Foim
PaitialFull Thickness uianulating Wounus
Noueiate to Bigh Exuuates
(+) Baemostatic effect
(+) 0p to 7u weai time
() Requiies 2
o
uiessing
Infecteu wounus if changeu uaily
Tan mucoiu appeaiance upon iemoval
ALuINATE WITB C0LLAuEN = Fibiacol
9u% Collagen, 1u% Alginate
ALuINATE INPREuNATEB WITB SILvER
ABSURPTIVE WUUND FILTERS
Sheets, Rope, Paste, uianules, Powuei maue of Staich Polymeis
Beep Wounus
Beavy Exuuate
CULLACEN BASED PRUDUCTS: Neuifil PaiticlesPausuels, SkinTemp
Nylon Nesh ovei

0se Collagen uels foi Biy Wounus
collagen membiane

0se Sheets foi Low Noueiate Exuuative Wounus
0se Powueis, Paiticles, Paus foi Noueiate Beavy Exuuative Wounus
Actions: Absoibent, Bemostasis, Chemotaxis, Piovisional Natiix in wounus
foi uianulation tissue foimation
PRISMA colonizeu oi contaminateu wounus
SS% Collagen 44% 0RC
0xiuizeu Regeneiateu Cellulose

1% Silvei
PRUMUCRAN
SS% Collagen 44% 0RC
0nly matiix pioven to binu & ieuuce NNPs
Natiix NetaloPiotinase

0RCCollagen combo binus moie NNPs in the uiessing the 0RC oi
Collagen alone
PECASUS = 0nite Biomatiix
Enzyme iesistant collagen scaffolu -- Fenestiateu

88

RECUMBINANT DNA TECHNULUCY
RECRANEX = Becapleimin
Recombinant PBuF
platelet-ueiiveu giowth factoi

9 Attiacts monocytes & fibioblasts -- inflammatoiy phase
9 Stimulates gianulation tissue
Refiigeiate
Regianex uel u.u1%
9 1Sg tube, apply qu, spieau evenly anu thin (116
th
inch)
9 Covei in moist saline gauze uiessing
PRUCURAN = ThiombinInuuceu Platelet Releasate
uF fiom patients own bloou
Su-2uucc of bloou uiawn fiom patient
9 Spin uown, sepaiate, activate the thiombin
1 bloou uiaw = Smo of uaily application
CRAFTS
APLICRAFT = Bilayeieu Skin Equivalent
Epiueimis & Beimis
Beimis siue uown

Newboin foieskin
FeuEx in 24hi in petii uish use immeuiately
Place a compiessive wiap ovei it
DERMACRAFT = Buman Beimal Replacement
Newboin foieskin
Covei with Allevyn & Bypofix tape
B0 N0T use with any othei topical agent
UASIS
Small Inteistine Submucosa
PigPoicine

SIS scaffolu attiacts patients cells
Stoie ioom temp up to 18mo
INTERCRA
CollagenulycosAminoulycan Biouegiauable Natiix
CowBovine

Poious Natiix of cioss-linkeu bovine tenuon collagenuAus
Semi-Peimeable Polysilxane (Silicone) layei
Steiile Piepeiation

89

CRAFT )ACKET
Piocesseu Buman Beimal Nembiane
S-B Bioactive Fiame suppoits gianulation tissue
Beep Wounus
CAMMACRAFT
Iiiauiateu human skin allogiaft
Epiueimis & Beimis
Stoie ioom temp
Aftei 24hi in place -- iemove seconuaiy coveiing anu allow aiea to aii-
uiy foi 2-Shi once uiieu in place theie is no neeu to iecovei it
(+) Patients can uo this at home
TUPICAL ENZYMES:
SANTYL = Collagenase
Bigests collagen in neciotic tissue
Collagen in healthy tissue oi in newly foimeu gianulation tissue is not
attackeu
Nay be useu as an Antibiotic Powuei
Stop use when gianulation tissue is well establisheu
Accuzyme, 6loJose
Papain BPioteolytic enzyme fiom papaya
0iea B Piotein uenatuiing agent
Nay have a buining sensation in patients
RARE

Cleanse with noimal saline, N0T watei
Panafil
Papain
0iea
Chloiophyllin Coppei Complex Souium B Inhibits hemagglutinating &
inflammatoiy piopeities of piotein uegiauation piouucts in the wounu
Elase = FibiinolysinBesoxyiibonuclease
RARE 2 Finu

TUPICAL ACENTS FUR LUCAL BLUUD FLUW
XENADERM UINTMENT
Balsum of Peiu B Incieaseu bloou flow to wounu site
Castoi 0il B Cieates a moist enviionment
Tiypsin B Naintains moist wounu beu
Aluminum Nagnesium Byuioxiue Steaiate B Fluiu Repellent

90

ANKLE SCUPES
PORTALS:
Anterior
AnteroMedial
Medial to Tibialis Anterior
Visualize: medial gutter & medial transchondral margins
Caution: TA, Saphenous V & N
Accessory AnteroMedial
AnteroLateral
Lateral to EDL or Peronial Tertius
Visualize: lateral gutter
Caution: EDL, Peronial Tertius, Superficial Peroneal N
Accessory AnteroLateral
AnteroCentral
Lateral to EHL
Caution: AntTibial A, Deep Peroneal N, EHL & EDL tendons
Medial Midline Portal
Posterior
PosteroMedial
Medial to the Achilles Tendon
Caution: Sural N, Lesser Saphenous V
Accessory PosteroMedial
Modified PosteroMedial
PosteroLateral
Lateral to the Achilles Tendon
Visualize: the posterior process of the talus & posterior media talar dome
Caution: T-D-A-N-H
Accessory PosteroLateral
TransAchilles
Coaxial Portals







6 Central Points
Med / Central / Lat TibioTalar Artic
Posterior Inferior TibioFibular Lig
Transverse TibioFibular Lig
Capsular Reflection of the FHL tend
7 Posterior Points
PostMed Gutter
Med / Central / Lat Talar Dome
Post TibioFibular Artic
PostLat Gutter
Posterior Gutter
21 POINT EXAM:
8 Anterior Points
Deltoid Lig
AntMed Gutter
Med / Central / Lat Talar Dome
Ant TibioFibular Articulation
AntLat Gutter
Anterior Gutter