Bere 5/2025 #15. I had a number of surgeries today. But the one that I enjoyed the most was also the most stressful. It was the last one of the day and I started about 4:30. He had a wound on his leg about 3 months ago, and his family put scalding water on it and burnt his leg. This created a chronic wound and a significant knee contracture. I enjoy releasing contractors as it changes someone life significantly. It is stressful because anatomical structures can be pulled into the scar tissue and arteries and nerves can be in the wrong place and be injured. I have friends that have worked in burn centers and Im sure are much better at dealing with this than I am. But this patient has me. I’ve done some before in Cameroon and here, but I still have angst until it’s released and I haven’t injured anything and they have function after.
His knee is bent almost 90 deg. And can’t straighten. We prep the leg all over and also prepare his thigh for taking a skin graft. I use cautery to cut into the scar going across it so that it opens up longer. It is really thick. I cut about ¾ inch deep and still in scar tissue. Im starting to worry about popliteal vessels and nerve when I hit some bleeding. I suture the small vessel. I go to a different areal and continue. I get in a good plane and head towards the area where I got bleeding. I find his pedal pulse and then compress this vessel. It isn’t the popliteal as his pulse remains strong. So I cut across it and realize Im still a far bit away. I get to an area where my cautery is making his leg twitch. So there is a nerve near by. I slowly dissect and find a small cutaneous nerve. I have gotten about 30 degrees of extension with this cut. So I move higher an make another. And also do one lower. As I take these deeper I get more and more extension. After I get full extension Im able to relax a little. Now I realize if I put skin graft on it like it is. He will have thick and thin areas giving the back of his leg a very bizarre appearance. So I cut off a lot of scar tissue and this evens it out some. Using the dermatome I shave off a half layer of thigh skin in two swaths. Then Caleb (med student) and I start the long process of sewing these to the site we just opened. It has to stay put because if the skin graft shifts on the wound bed, it then dies. So it has to stay in one place. After suturing about an hour, we put xeroform dressing and build a plaster splint to help hold his leg straight and then attach everything before the plaster dries. I hold the leg straight about 15 min, till the plaster is very hard.
Another I had that day was an older man who was about 60 and had been in a Moto accident about 3 months ago. He had a patellar fracture and the two halves of his patella were separated by about 1.5 inches. I walked with a cane and could flex his leg about 30 degrees. I had seen him in clinic and told him that I could repair the patella but he would require a splint or a cast afterwards and would likely not be able to flex his leg in the future without much physical therapy (which is now available at the hospital). I’m skeptical that fixing his patella will give him any more mobility at this point and may make his leg straight forever. After discussion all this with him, he still wants it fixed. So in the OR I cut down to his knee. The scar tissue is thick and hard to remove. I remove it from the ends of the bones too and rongour the edges to get fresh bone exposed. I free up to get mobility of the upper segment so that it can move back down to where it belongs, as the muscles have pulled it up and away from the bottom half. I don’t have screws to put the halves back together so I use what I have- suture. I suture the halves back together. I fount a huge 5 suture with a sharp needle so this one I go through the bone with too and after about 6 different sutures I get the halves about ¼ in. apart. I then cut down on his side over the pelvic bone. I expose the rim of the pelvis and nibble away pieces of this to place in the gap that will be new bone to encourage new growth. After filling the gap with these pieces, I suture the skin back together in layers.
It’s been a long day and Im tired. One more day to go. I shower and go to bed wet, with a fan blowing on me. I hope to sleep before I finish evaporating. I’m just falling asleep when I get a call. A man can’t pee and he’s moving in pain. At least that’s what I think I hear. So I go in.
To be continued…
