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Surgery
Podiatric Medicine
Peri-operative
Complications
Surgery 2
100
Which bone do you make 1st cut in valenti arthroplasty?
Valenti arthroplasty is joint destructive procedure used for hallux limitus correction. 1st cut from dorsal proximal to plantar distal on the 1st metatarsal head just below the articular cartilage. 2nd cut from dorsal distal to plantar proximal removing 50% to 66% of the dorsal aspect of the base of the proximal phalanx.
100
This organism is a gram-positive, rod-shaped, anaerobic species. Its appearance on a gram stain resembles tennis racket-shaped or drumsticks. What organism and can cause what condition?

Clostridium tetani is a rod-shaped, anaerobic species of pathogenic bacteria, of the genus Clostridium. Like other Clostridium genus species, it is Gram-positive, and its appearance on a gram stain resembles tennis rackets or drumsticks. C. tetani is found as spores in soil or in the gastrointestinal tract of animals. C. tetani produces a potent biological toxin, tetanospasmin, and is the causative agent of tetanus, a disease characterized by painful muscular spasms that can lead to respiratory failure and, in up to 10% of cases, death.

100
What potential complication will occur during the surgery if the patient with a history of hypothyroidism didn't achieve adequate euthyroid level pre-operatively?
Patient with a history of hypothyroidism needs to take levothyroxine for weeks to months until euthyroid pre-operatively and can be safely stopped peri-operatively. Myxedema coma can occur during the surgery. Patient fails to awaken from anesthesia due to carbon monoxide retention
100
A 40 year old male with a history of diabetes mellulitis, hypertension, hyperlipidemia, and asthma. His current meds: hydrochlorothiazide, metformin, simivastatin, albuterol. His pre-op labs as shown: glucose 180 mg/dl, K+ 3.2, BUN 18, Cr 1.1, Hemoglobin 14, Hematocrit 47. What complication can the patient develops during the surgery based on the current findings?

K+ levels should be monitored pre-op in pts who are

taking diuretics to prevent cardiac arrhythmias. Replace if K + <3.5 mEq/L

100
How many incisions are preferred when performing open fasciotomies for compartment syndrome in the foot and what are their locations? (Be specific with the location)
Mcglamry author prefers a 3 incisions approach when performing open fasciotomies. This allows for access to all compartments of the foot. 2 incisions are made dorsally, over the 2nd and 4th metatarsals respectively and a single incision is made along the medial aspect of the patient's foot from the distal aspect of calcaneus, about 4 cm from the posterior heel, extending distally parallel to the plantar aspect for about 6 cm to the midshaft of the 1st met.
200
Autogenous bone graft contains what property of biological mechanism? Allograft?
Autogenous bone graft - osteoconduction, osteoinduction, and osteogenesis


Allograft - osteoconduction

200
Protamine sulfate is originally made from what?
originally from sperm of salmon.
200
Name 3 anti-platelet agents and 3 anticoagulants
Anti-platelet agents: Aspirin, Plavix (CLopidrel), Ticlopine (Ticlid), Prasugrel (Effient)

Anticoagulant agent: Warfarin, Lovenox, Heparin, Apixaban (Eliquis), Dabigatran (pradaxa), Rivaroxaban (Xarelto)

200
What should not be done prior to inserting the catheter in the foot for obtaining compartment pressures?
Never inject a local anesthetic prior to inserting the catheter. The anesthetic fluid will increase the interstitial pressure and give the clinician a falsely elevated compartment pressure reading. A regional nerve block may also give a falsely elevated reading through its vasodilatory effect, thereby increasing the interstitial fluid. If pain control is needed, then IV narcotics or conscious sedation should be provided.
200
What is the name of the opening wedge osteotomy of medial cuneiform to correct pes planus? Metatarsus adductus?
Fowler procedure- medial opening wedge of medial cuneiform to correct metatarsus adductus

Cotton procedure - dorsal opening wedge of medial cuneiform to correct pes planus

300
What 3 tendons are involved in Bridle procedure?
Tibialis anterior, tibialis posterior and peroneus longus tendon transfers. All tendons are transfer together and place into lateral cuneiform to increase dorsiflexion power. Indicated for drop foot, peroneal nerve palsy, Steppage gait, traumatic brain injury, CP, Equinus, Equinovarus
300
What is Matles resting tension position test?

Matles resting tension position: patient lies prone on the examination table with the knee flexed at 90 degrees. Normally, flexing the knee causes the gastrocnemius muscle to shorten, leading to plantarflexion of the foot. With an AT rupture, the affected foot often lies in slight dorsiflexion compared to the uninjured side. 

300
Latex allergy prophylaxis protocol? (there are 3 answers, 1 answer needed only to get credit, medication only)
Dexamethasone 8 mg - steroid

Diphenhydramine (Benadryl) 50 mg IV

Ranitidine (Zantac) - H2 blocker

300
Name 3 treatments for post-operative blue toe
Post-operative blue toe is caused by venous congestion secondary to multiple re-pinning attempts. The digit is warm, mottled-looking and bluish. 

Treatment: sequence is not important. Elevate extremity, remove ice, compression dressing, and time and patience

300

What is the name of the procedure to counterbalance an anatomic defect characterized by congenital absence of the medial cuneiform bone in a child with metatarsus adductus?

Bankart -total excision of cuboid
400
What is Pierrot Murphy procedure?
Pierrot Murphy procedure is indicated for spastic gastrocsoleus equinus. It is used to decrease the lever arm of the Achilles tendon. It is used to reroute Achilles tendon anterior to FHL tendon and casted in 15 degrees plantarflexion
400
Pt has hx of chronic gout. Pt had tried all gout medications and could not tolerated them much. What is the last medication to prescribe for gout? 

Krystexxa - pegloticase. Its recombinant purine-like uricase. Used for severe, treatment-refractory, chronic gout. It is a third line treatment in those in whom other treatments are not tolerated. The drug is administered by infusion intravenously. 

400
What is the perioperative protocol for managing a rheumatoid patient is currently taking prednisone for 2 years who is scheduled to have pan-metatarsal head resection (moderate surgical stress)?
Major surgical stress (pantalar fusion, triple arthrodesis): 100 mg hydrocortisone prior to sx, then 100 mg q6h for 1st 72 hours.

Moderate surgical stress (pan-metatarsal head resection): 100 mg hydrocortisone prior to sx, then 50 mg q6h for day 1 and 25 mg q6h for day 2.

Minor surgical stress (hammertoe): 100 mg hydrocortisone at the time of sx

400
40 year old male was transported to the recovery room following the right 2nd toe surgery with k-wire fixation. 30 minutes later, the nurse noted his right 2nd toe skin was white and poor capillary refill time was noted. The nurse called you to evaluate his post-operative ischemic toe. Name all treatments in sequential orders (Be specific)

Treatment for post-operative ischemic toe: (sequence is very important!!!) 

1) Remove ice

2)Place foot in dependent position 

3) Loosen bandages

4) Slide digit proximally along K-wire 

5) Local PT block 

6) Remove K-wires

7) Remove sutures

8) Nitroglycerine patch in femoral area 

9)Consult vascular surgeon

400
What is triplane fracture? What is the treatment according to McGlamry?
Triplane fracture is best regarded as type 4 salter harris. On AP projection view, it appears as salter harris type 3. On lateral projection view, it appears as salter harris type 2. Occurs in younger kids from 12 to 15 prior to physis closure with lateral physis last to close. Occurs mostly in Distal tibia. First, try closed reduction. If fails to attempt closed reduction and the gap is greater than 2 mm, then percutaneous pinning or cortical screws.
500
When should the incisions be closed after the original open fasciotomies for foot compartment syndrome?
According to Mcglamry, the incisions are closed 5 to 7 days after the original surgery. When possible, delayed primary skin closures is performed with simple interrupted nylon sutures. But edema and skin retraction usually results in a great amount of tension that prevents skin closure. Split thickness skin grafting is often needed to close these incisions.
500

An ulcer that refers to an aggressive ulcerating squamous cell carcinoma presenting in an area of previously traumatized, chronically inflamed, or scarred skin and they are commonly present in the context of chronic wounds including burn injuries, varicose veins, venous ulcers, ulcers from osteomyelitis, and post radiotherapy scars. What ulcer?

Marjolin's ulcer
500
What is the bridging therapy/peri-operative management for the patient who is on warfarin who is scheduled for right foot bunion and hammertoes surgery? (be specific for every step)
1) Stop Warfarin 5 days before the sx (if INR 2 to 3)

2) Stop Warfarin 6 days before the sx (if INR 3 to 4.5)

3) Start Heparin 36 hours after the last dose of warfarin

4) On the day of the surgery, make sure to check INR < 1.5 (maybe 1.2)

5) Restart Heparin 24 hours post-operatively

500
What is pin tract infection classification?

Pin tract infections: Dahl’s Classification 

Grade 0 – clear fluid – NaCl cleansing with topical abx

Grade 1 – slightly red fluid - NaCl cleansing with topical abx

Grade 2 – red/tender yellow drainage – PO abx with TD pin care

Grade 3 – red/painful/purulent – definitive PO abx

Grade 4 – radiolucency with purulence – removal of pin/possible IV abx

Grade 5 – sequestrum – removal of pin/debridement of pin tract and IV abx

500

What is the recommendation for fixating Maisonneuve fracture? (be specific with everything, type of screw, type of plate, placement of screw, etc)

With a Maisonneuve fracture, the fracture is fixated with a one-third tubular plate and distally, two 3.5 mm cortical screws fully threaded are placed 3 to 5 cm proximal to the syndesmosis level. The screws should be directed from posterolateral to anteromedial at an angle of 25-30 degrees from the sagittal plane of the leg. The transfixation screw must purchase both cortices of the fibula and the lateral cortex of the tibia (3 total cortices). In Maisonneuve fractures - *** don't open reduce due to complication with peroneal nerve ***