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whereas one out of 50 control specimens sent directly to the microbiology lab was positive.  Probably an appropriate step is to place your graft in an antibiotic solution and some have recommended placing it in a closed cup of antibiotic solution, shaking vigorously, and transferring to another cup of antibiotic solution several times to accomplish a dilutional cleaning as well as an antibiotic bactericidal effect.  

Wound closure: Many surgeons are surprised to find that the tensile strength of Vicryl and Dexon is higher than corresponding sizes of nonabsorbable suture (excepting stainless steel suture).  Vicryl and Dexon lose 50% of their strength in three weeks, but by then the wound should have healed significantly, thus there are not many situations in which nonabsorbable suture is really needed.  Obviously, if you do develop a wound infection, it is desirable to have an absorbable suture that will not serve as a chronic foreign body.  Each suture strangulates some tissue - - you need enough to put the tissue in contact so it will heal - - more suture is not necessarily better.  

Hemovacs:  Several studies have randomly compared wounds treated with hemovacs and wounds treated without.  Surprisingly, the complication rates are the same or higher in wounds treated with suction drains.  This does not mean that in a bloody wound a hemovac may not be a good idea, but routine use of suction drains is apparently not advisable.   

X-rays:  If you are going to get an x-ray to evaluate your surgical procedure, get it in the operating room while you can still fix it if there is a problem.  In general, they shouldn’t be obtained in the recovery room.  There is a tremendous charge for the portable film, the quality is poor, and it is too late to “fix it.”  If you are not going to get it in the operating room, get it a few days later when the patient can go down to x-ray for a better quality film at a lower cost.  In the operating room consider using fluoroscopy, rather than x-ray, so that you can quickly reposition and shoot a better aligned exposure if your position or technique are bad (this prevents accepting an inadequate film because of your frustration over the long period of time it will take to shoot another one).  

Dressings:  Put on a neat one.  The patient doesn’t know whether you did a neat or a sloppy job inside of him, but the patient may well assume that a sloppy dressing represents the quality of work you did internally.  

Elastic bandages:  It is very easy with Ace wraps and Coban to apply them too tightly.  This occurs most commonly when you are bandaging a small area, and rather than cutting off the excess bandage, you go back and forth over the same area several times, adding successive layers of compression.  It is easy to produce painful ischemia in this fashion.  Thus, wrap your ace wrap loosely and without multiple layers.  When you are called about excessive postoperative pain, consider loosening the bandage.

Intramedullary Nailing:


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