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Irrigation and Debridement (I and D) Tibia Operative Sample


Infection, left tibia.

Infection, left tibia.

Irrigation and debridement, left tibia.

SURGEON:  John Doe, MD


SPECIMENS:  Multiple cultures and cell count.



TOURNIQUET TIME:  28 minutes.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and placed supine on the operating room table.  He received general anesthesia by the anesthesia team.  A tourniquet was placed on the left upper thigh.  The left leg was then prepped and draped in normal sterile fashion.  The leg was then held elevated for approximately 5 minutes.  The tourniquet was inflated to 250 mmHg.  The proximal incision was then opened in elliptical fashion, excising the granulating wound proximally to healthy tissue.  Dissection was carried down.  The metal plate was directly underneath the wound and appeared intact.  There was no significant gross purulent material that was seen; however, there was some cloudy material which was expressed.  A rongeur was then used to debride any nonvitalized tissue.  Good bleeding was seen from the wound edges.  The middle incision appeared to be fully healed; however, the point of rupture was a few centimeters medial to this incision with poor skin seen.  This was the area of the previous fracture blister, which has regressed.  An elliptical excision was then performed of this tract and excised.  Dissection was carried down once again to the metal hardware.  There was communication between the middle and proximal incision, distal incision appeared to be fully healed.  It appeared that there was no tract distally.  Once again, a rongeur was used to debride any nonvitalized tissue.  Then, 9 liters of irrigation solution with vancomycin antibiotic was used to irrigate the two incisions.  The irrigation was used along the track of the hardware.  It was used in the proximal incision, both medial, lateral, proximal and distal, through the middle incision; once again medial, lateral, proximal and also distal as much as possible.  All fluid was expressed from the leg.  The ankle was arranged to allow irrigation fluid to track into the muscle and onto the bone.  The plate was irrigated with pulsatile lavage as well.  After, 9 liters of irrigation, 3-0 Monocryl was used to close the subcutaneous tissues followed by 2-0 nylon in retention suture configuration for both incisions.  There was no skin compromise or blanching after the wound closure.  The tourniquet was deflated prior to wound closure.  Hemostasis was achieved mainly with pressure.  There were good bleeding edges at the wounds, both proximal and middle.  After wound closure, sterile dressing was applied.  The left lower extremity was placed in an AO splint.  The patient tolerated the procedure well and was taken to the recovery room in stable disposition.  Multiple cultures and cell counts were sent from both proximal and middle incisions for analysis.  In the recovery room, 1 g of vancomycin was then given intravenously.