Christie Anne K.

Lorenzo

20. Full Thickness Skin Grafting (FTSG)

Definition and Usage:

Full Thickness Skin grafting is a type of medical grafting or transplantation of skin

which involves pitching and cutting skin (epidermis and all the dermis) away from
the donor section. The donor site is either sutured directly or split-thickness skin
grafted. The transplanted tissue is called a skin graft.

Skin grafting is often used to treat:

• Extensive wounding or trauma

• Burns
• Areas of extensive skin loss due to infection such as necrotizing
fasciitis or purpura fulminans
• Specific surgeries that may require skin grafts for healing to occur

Procedure:

In order to remove the thin and well preserved skin slices and stripes from the
donor, surgeons use a special surgical instrument called a dermatome. This usually
produces a split-thickness skin graft, which contains the epidermis with only a
portion of the dermis. The dermis left behind at the donor site contains hair
follicles and sebaceous glands, both of which contain epidermal cells which
gradually proliferate out to form a new layer of epidermis. The donor site may be
extremely painful and vulnerable to infection.
The graft is carefully spread on the bare area to be covered. It is held in place by a
few small stitches or surgical staples. The graft is initially nourished by a process
called plasmatic imbibitions in which the graft "drinks plasma". New blood vessels
begin growing from the recipient area into the transplanted skin within 36 hours in a
process called capillary inosculation. To prevent the accumulation of fluid under the
graft which can prevent its attachment and revascularization, the graft is
frequently meshed by making lengthwise rows of short, interrupted cuts, each a few
millimeters long, with each row offset by half a cut length like bricks in a wall. In
addition to allowing for drainage, this allows the graft to both stretch and cover a
larger area as well as to more closely approximate the contours of the recipient
area. However, it results in a rather pebbled appearance upon healing that may
ultimately look less aesthetically pleasing

21. Harrington Rod Instrumentation (HRI)

Definition and Usage:

Harrington Rod Instrumentation is a method of keeping the spine rigid after spinal
fusion surgery by surgically attaching hooks, rods, and wire to the spine in a way
that redistributes the stresses on the bones and keeps them in proper alignment
while the bones of the spine fuse.

It is using of a stainless steel surgical device implanted along the spinal column to
treat conditions such as:

• lateral or coronal-plane curvature of the spine

• scoliosis.

Procedure:

Spinal instrumentation is performed by a neuro and/or orthopedic surgical team with

special experience in spinal operations. The surgery is done in a hospital under
general anesthesia. It is done at the same time as spinal fusion.

The surgeon strips the muscles away from the area to be fused. The surface of the
bone is peeled away. A piece of bone is removed from the hip and placed alongside
the area to be fused. The stripping of the bone helps the bone graft to fuse.

After the fusion site is prepared, the rods, hooks, and wires are inserted. There is
some variation in how this is done based on the spinal instrumentation chosen. In
general, Harrington rods are the simplest instrumentation to install, and Cotrel-
Dubousset instrumentation is the most complex and risky. Once the rods are in
place, the incision is closed.

22. Intra Medullary Nailing (IMN)

Definition and Usage:

Intramedullary (IM) rods are used to align and stabilize fractures. IM rods are
inserted into the bone marrow canal in the center of the long bones of the
extremities, commonly used in:

• Femur fracture

• Tibia fracture

Procedure:

A 4-cm longitudinal incision is made in the skin above the tibial tuberosity. A
standard medial parapatellar approach is used for insertion of the nail. After a guide
wire is inserted and advanced to the proximal fracture site, percutaneous fixation of
2 Schanz screws on the anteromedial surface of the central fragment and 1 Schanz
screw on the anteromedial surface of the distal fragment is then performed under
fluoroscopic guidance Schanz screws are fixated to the far cortex of the tibia. During
this procedure, it is important that the proximal Schanz screw of the central
fragment and that of the distal fragment are situated approximately 2 to 3 cm distal
to the fracture site for later reduction of rotational malaligment of a central
fragment. Longitudinal traction and appropriately directed forces are applied to the
limb manually or skeletal traction is applied to the calcaneus to obtain provisional
alignment during fixation of the Schanz screws, passage of a guide wire, or
intramedullary nailing. The Schanz screws are attached to a T-handle for easy
manipulation of the fragments during the procedure.
Anterior and posterior alignments of the proximal fracture site are reduced using 2
Schanz screws on the central fragment under fluoroscopic guidance, and a guide
wire is advanced to the central fragment. The anterior and posterior alignments of
the distal fracture site are also reduced using 2 Schanz screws on the central
fragment and 1 on the distal fragment, and a guide wire is advanced to the distal
fragment. An unreamed tibial nail of appropriate length and diameter is inserted into
the proximal fragment to the proximal fracture site. A tibial nail is advanced to the
proximal Schanz screw on the central fragment. The rotational alignment of the
central fragment on the proximal fragment is reduced by rotation of the 2 Schanz
screws on the central segment. In clinical experience, an inserted Schanz screw can
be used to rotate the central fragment 40°~50°, within the limits of the overlying
skin, while avoiding further skin damage. A tibial nail is then advanced to the central
fragment while the Schanz screws are extruded to the near cortex ahead of the
advancing tibial nail to avoid impeding passage of the intramedullary nail. Rotational
alignment of the central fragment is reduced using Schanz screws on the central
and distal fragments as same manner. A tibial nail is inserted into the distal
fragment while the Schanz screws are extruded to the near cortex ahead of the
advancing tibial nail. After the nail is inserted and interlocked, the Schanz screws
are removed.
This technique is indicated in non-comminuted, singled segment diaphyseal
segmental fracture. The central segment must be at least 5 cm long, to allow the
insertion of 2 screws to avoid additional fracture or comminution of the central
fragment during the insertion of Schanz screws or manipulation of the central
fragment.