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off before the end of the case, thus liberating the bacteria which have “sweated out of the pores.”  Therefore, if they are to be used, it is well worth the surgeons’ while to expend time trying to be sure that they stick down well and do not peel loose.  

Tourniquets:  Prep solutions which run under tourniquets have been thought to cause full thickness skin loss (“burns”), so it is important that any padding underneath the tourniquet be kept dry.  Skin which gets pinched in a fold under a tourniquet will suffer a full thickness loss—make sure this didn’t happen by running a finger under the tourniquet after application.

Measure twice, cut once: There is nothing more dismaying (and litiginous) than to find that you are operating on the wrong extremity!  Check before you prep - - Ask the patient before he goes to sleep if possible and mark the operative site with “yes” or the other leg with “no”, don’t use an “X” because it can mean X “marks the spot” or mean “no.”  The AAOS advocates “signing” the operative site. This error usually occurs when the operative extremity appears normal, as in arthroscopy.  Also, anytime you are about to make an irrevocable cut (as in an osteotomy) check it twice before you cut and find that you went the wrong direction. In the spine, always mark your level and obtain an x-ray, never trust a count from a landmark you have found in the wound.

Skin incisions: Studies have shown lower infection rates with a single incision that goes all the way through the skin into the subcutaneous tissue.  When the skin is cut with multiple “delicate” passes of the knife, little islands of necrotic tissue are left between adjacent passes (that do not go through the vertex of the depth of the incision), and these necrotic islands are presumably the reason for the increased infection rate.  This is not to say that you should not use great care in areas with immediately subjacent neurovascular structures (i.e., the hand), but in areas where there are no important subdermal structures (lateral hip incisions), a bold stroke all the way through the skin into the subcutaneous tissue is desirable.  

Cautery: Cautery smoke is full of carcinogens—suck it up if you can. Using “coag” generates much more heat and tissue necrosis than using “cut”, thus making your wound more infection prone.

Obese patients: Have high infection rates! There is evidence that this is increased by using cautery to cut, thus producing a heat necrosed, poorly vascularized, bacterial growth paradise. Use the knife.

“Blunt” vs. “sharp” dissection: Both have their advantages and drawbacks.  Sharp dissection causes less tissue trauma and is desirable in dissecting in regions where you are certain there are no important neurovascular structures that might be transected sharply.  Blunt dissection produces more tissue injury and in the long-run more scar, but because spreading tends to disrupt tissue along its natural planes, it can prevent injury to important structures.  


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