Objectives
- Indications for post-op dressings
- Basic technical components to forefoot post-op dressings
- Possible complications associated with post-op dressings
Introduction
- There is not a lot of information out there about the type of dressing you should do in each situation
- If you use these techniques, don’t be surprised if someone else does it differently
- You need to find what makes sense and seems to work for you
- Watch the video on D2L and take notes
- If you’re going to get equipment, get something that is designated as a bandage scissors
- If you don’t place something with the dressing appropriately, you can do all the work of fixing a deformity then ruin it with bad dressings
Materials
- Non-adherent mesh (sterile) - Adaptic = brand name, lay this right over the wound – use it as an interface
- Sterile gauze
- Gauze roll
- Paper tape - Make sure there are no allergies to adhesives, paper tape is pretty benign, so this is less irritating than nylon
- Ace/elastic bandage
- Bandage scissors
- NOTE: Make sure you have all the materials necessary for the dressing change
Purpose of a dressing
- Infection control
- Maintain correction
- Compression
- Hemostasis
Infection prevention notes
- Keep area clean – protect from bacteria that could cause a post-op infection
- “Stitches out on Monday” = three days later because epithelialization occurs within 3 days
- We are working with areas of the body that has more tension on the skin, so we don’t take out this early
- It takes 30% tensile strength in order to prevent the skin from breaking open
- We are going to leave a non-absorbable suture in for 10-14 days
- It actually takes up to 17 days, but no one leaves them in that long because you get rail road shaped scars
- After taking stitches out – epidermal sutures – “Steri strips”
- One of the purposes is to protect from bacteria – if it isn’t infected in the first 3 days, it probably isn’t going to become infected
Maintain the correction notes
- With hammertoes, you end the procedure with a straight toe
- You want to maintain this alignment – so you need to prevent drifting while healing
- It isn’t going to do any additional correction, but you can maintain what you have
- You aren’t going to make it go from good to better, but it keeps what you have
Compression
- The toes are going to swell, so we want a fairly snug dressing to reduce swelling
Hemostasis
- It is going to bleed when you take off the tourniquet, so you need something to absorb the blood
General notes on video
o The dressing will not correct the deformity for you
o The purpose of the dressing is to maintain the correction you have already corrected
o It can cause some degree of un-doing of correction (i.e. hallux varus or back to hallux valgus)
o Remember that for hammertoe procedures, there are dorsal incisions that will tend to contract, and can elevate the toes after corrective surgery – toe will be straight but with have lack of toe purchase and patient will be unhappy
o Need to be very careful while doing a dressing
Incisions
o REMEMBER: incisions should go PARALLEL to relaxed skin tension lines
o This means for a distal bunion or hammertoe procedure, we would do a transverse incision, but we wouldn’t get enough exposure, so this will not work
o Instead, we compromise by doing a “S” shaped incision somewhat so it is not just a straight linear incision which has high risk of wound dehiscence
o It will not be completely perpendicular to the relax skin tension lines
o The curve of the “S” should be right at the joint
o When you get into surgery, there are sterile pens, you can plan out your incision and can also make small lines across the incision to make sure you line it back up correctly
Bunion dressing
o Prior to doing the dressing, you will lay down a layer of non-adherent mesh (sterile) dressing (Adaptic©) in order to have a non-sticky interface
o If you try to just use gauze and the wound bleeds, you will have it stuck in their wound and it will be painful to remove
o Use a larger 4x4 gauze is used
o Cut it at the 2/3 junction and lay overtop of the toe, with the 1/3 cut portion distal and able to be wrapped between the first and second toes in order to cover the wound
o Take a couple additional gauze pads and lay them over the wound site
o Then take a gauze roll and always roll like a snail (the roll should be on top, the extended portion should be coming out the bottom of the roll) – because you use control – this is for EVERYTHING you roll
o ALWAYS ROLL MEDIAL TO LATERAL with your gauze roll
Bunion dressing continued
o Can be fairly snug on the wound while rolling the gauze
o Hold the gauze roll in place and go around a couple times – use both hands and need to be tight enough for it to easily stay on the foot
o After a couple rolls, angle it so that it starts going towards the toes then cut it with the scissors (NEVER set the scissors down – keep them around your 4th finger)
o Cut the gauze roll, only on the proximal end, then wrap the distal (intact) end of the gauze roll around the hallux
o Can continue to go around the ankle, but he tends not to – just cut the gauze and tape it with either nylon tape or paper tape
o If the dressing is too loose, use paper tape and tape it half on the dressing, half on the skin to anchor it
o Finish by taking a stockinette that you use for casts and rolling it up the leg
o Put an ace wrap on top of this
o Then roll up the bottom of the stockinette so you can see the tips of the toes for cap fill time (CFT)
o When your patient comes in for their post-op appointment and you need to take the dressing off, cut it on the bottom of the foot and peel it up and off the top of the foot
Tailor’s bunion dressing
o VERY similar to the bunion dressing, but much smaller region to dress
o Use the 3x3 instead of the 4x4
o A lot of times with a Tailor’s bunion repair there will also be a hammertoe repair, so we will extend the dressing all the way to the tip of the toe
o You can add an extra gauze pad to the top of the incision for extra absorbency
o With the gauze wrap, we want to go LATERAL TO MEDIAL
o Hold it in place while wrapping, wrap around a couple times, angle and cut half of the wrap
o Fold it through the toe then continue to wrap a couple times before cutting and taping it down
o This holds the toe in a nice rectus position
Hammertoe dressing
o A little more complicated
o Can use a 3 inch or 4 inch and unfold it then fold it in half the long skinny way
o Loop around the toes and can cross it and rotate/derotate as much as you want to hold the correction
o Can do for as many toes as needed
o Remember, incision will extend beyond the toes, so place gauze pads over incision on dorsum of foot and wrap around with gauze pad
o Continue with the gauze pad around the toes by cutting the roll in half, going around the medial aspect of the 2nd toe, coming around the front, cut again, then go around the medial aspect of the 3rd toe
o Now we are out of balance – we have the toes in an adducted position
o Now you just hold the gauze roll down and reverse it in order to balance it – this time when you go around each of the toes you do it by going around the lateral aspect
o Hold gauze wrap in place with tape
o At this point we have gone around either side of the toe to hold things in place
o If you do toes 2, 3 and 4, you don’t have enough gauze to go around each of the toes twice, so since these toes all function together, they can be wrapped together – “bundled toes”
Nail procedure dressing
o This is the simplest, but one that a lot of people make a mistake with this one
o Put Silvadene and dressing on the toe then use a 2 inch or 3 inch gauze pad
o You want to KEEP THE WOUND OPEN, so apply gauze MEDIAL TO LATERAL***
o This will pull the nail fold away from the nail, keep the wound open and allow it to heal
o If they have a lot of pain, it is a lot of times from the opposite wound dressing
o The phenol and drainage can’t escape and the patient ends up getting a mild cellulitis and pain
o If you do a total nail, it doesn’t matter what way you go
o You can go around with the gauze wrap as many times as you want to
o Take Coban dressing, go around it once or twice
o Lay the device over the toe, lay the stocking over the toe, twist twice, fold it down
o Wrap it with Coban again
o Make it look nice so you give the patient a good impression of your skill level
Notes on bunion dressing
- At the level of the MPJ, I ADDUCTED the toe – this is to reinforce the correction I just did
- The skin over time has adapted to the bunion, so you need to adduct the toe so it doesn’t go back into the abducted position
- Hallux varus deformity or recurrence can occur from dressing the wound improperly
- First post-op visit is 3-4 days (a little earlier than others) in order to apply another dressing and is more comfortable
- See them again in 1 week, take out stitches and put steri-strips on
Complications
- Completely longitudinal incision
- Vascular compromise - with tight dressing – can result in wound dehiscence and wound gaping open, can get gangrene if the dressing is too tight
- Cause alignment problems - Have everything as perfectly as possible in rectus position
- Wound dehiscence - this is one of the differences in plastic surgeons, we are working on a body part that hangs in a dependent position - use dressing to reduce tension on the skin and prevent dehiscence
- Increased inflammatory response - longer healing period will result
-
65 - Arthrodesis Procedures of the Forefoot70
-
66 - Planning for Deformity Correction36
-
67 and 68 - Flatfoot Surgery I and II45
-
69 - Posterior Calcaneal Heel33
-
70 - Metatarsus Adductus40
-
71 - Pediatric Flatfoot52
-
72 - Arthrodesis of Rearfoot and Ankle27
-
73 - Ankle Arthroscopy19
-
74 - Heel Pain20
-
75 - Tarsal Coalition35
-
76 - Post-op Dressing17
-
77 and 78 - Pediatric Hip, Knee and Leg96
