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Adult bone infections: Usually one of three conditions are present if the patient cannot resolve the infection with the help of a little PO antibiotic: 1) There is still dead bone or foreign body (“foreign body” including internal fixation devices although infection can often be controlled in the presence of “stable” fixation) in the wound. 2) There is instability, i.e. nonunion or loose internal fixation. 3) The patient is immunocompromised (malnutrition, diabetes, HIV).

Debriding dead bone: This is a very difficult task in that dead bone is hard to tell from live bone. If you take out too much you have a difficult reconstruction problem. If you don’t take out enough, it’s pus party time! Helpful hints: a) soft tissue won’t be well attached to dead bone, so dissect gently to recognize this phenomenon. b) live bone will have granulation tissue on it in a chronic wound. c) the interface between live and dead bone will be weakened by resorption – if you grasp the dead bone in a rongeur and twist it, it will often break at this weakened interface. d) when it breaks properly at the interface the remaining bone will look spongy [and bleed]. e) if you give tetracycline for 4-12 months prior to debriding someone with a chronic infection, the live bone will fluoresce under a Wood’s lamp (blacklight).

Bone saws: Three hints: 1) A new, sharp blade and constant irrigation will keep the heat (bone necrosis) down so that your osteotomy will heal. 2) Sometimes heat is good if you don’t want what you are removing to grow back (revision of amputation, Mumford distal clavicle resection) 3) If the pitch of the saw changes from that high annoying whine to a lower hum, it is because the blade is stuck (instead of the small blade moving, the handpiece is moving, and it has a lower harmonic frequency) so pull it back to free it up.

Speed:  Surgical speed must be balanced against the risk of surgical errors.  Both the infection rate and the anesthetic complication rate increase in a linear fashion with the length of a procedure. Therefore, it is desirable to operate as quickly as possible if this does not result in the commission of errors.  Recognize that you are more likely to be able to operate quickly when doing a commonly performed procedure in an area which does not have numerous easily damaged neurovascular structures, i.e., a hip fracture.  When operating in unfamiliar territory or in the proximity of structures of major importance or when carrying out an unusual procedure, it is wise to slow down and take great care.  Recognizing the difference between these situations can keep you out of serious trouble.  

Fast Surgeons: Surgeons who have consistently short operative times generally do not make quick movements (at least the good ones) rather they do not make wasted movements. If you observe them carefully you will see that they have a plan, they make the steps in the plan in order, they don’t stand waiting (if the nurses don’t have the instrument they need for a particular step of the operation, they either go on to another step or they find a substitute instrument and make do with it until the nurse finds the proper instrument), and they don’t go back to look at some part of the operation they have already completed.

Slow surgeons are indecisive and they dither. They tend to stand around thinking (because they haven’t thought ahead), they wait for nurses to get stuff while plaintively

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