Let's share some tricks

[u/lombardoz]

Ok ortho folks, I'm looking to hear some OR tricks/tips. Impetus for this was a recent soul sucking case where the screw driver broke off in the head of a peripheral glenoid screw on an infected revision shoulder(I'm looking at you, Arthrex....). Baseplate was rock solid and wouldn't move despite the infection. Tried the dermabond trick to no avail. Screw removal set was pointless. Midas Rex didn't help and the baseplate was still locked in place. Eventually, I was able to just muscle the whole baseplate out of the vault with some bone loss. Tears were shed and select words said.

So, let's hear some tricks. From positioning to managing intra op disasters.

[u/anon_NZ_Doc]

What’s the dermabond trick?

[u/lombardoz → u/anon_NZ_Doc]

If a screw is stuck, you can drop some dermabond on the screwdriver tip, push it on the screw then wait for it to dry and try to withdraw it (obviously wound needs to be dry for this to work). It’s not a great technique but worth a try when you’re struggling.

[u/_irish_potato]

If your small pointed reduction clamp is holding something we but is too wide/open to engage the locking mechanism use a second large pointed and place it through the loops of the handle to hold it engaged and lock it in place

[u/M902D]

I tie a vicryl around my screw head for the A-P screw on a retro nail any time I have a big thigh. Saves you from losing it in the sauce.

[u/Jazzlike-Can7519 → u/M902D]

The Synthes retrograde nail has the screw driver that threads onto the screw, negating need to do this (I used to do what you describe for long time before also)

[u/M902D → u/Jazzlike-Can7519]

Yeah so does the Stryker nail I use now. We had Zimmer natural nail where I trained, that set didn’t have a capture.

[u/Zestyclose-Truth1634 → u/M902D]

Where I trained they used to tie a silk suture on the screw head, the idea was silk would break with enouch force, allowing the suture to be removed with a tug after the screw was inserted. They stopped doing that after one of the residents tore the screw clean out of osteoporotic bone.

[u/orthopod]

Always make bigger incisions than the original for hardware removal

[u/REParola]

Fold the suction tubing and put it in the eyes of the clamp you’re using for the bovie box/cord management for less noise

What’s the dermabond trick?

[u/lombardoz → u/REParola]

I just responded above, but basically putting dermabond in the screw head and connecting the screwdriver to it to withdraw a screw

[u/D15c0untMD]

Give the back of the screwdriver a little bonk with a hammer when removing metal. Seats the tip in the screws head better and supposedly breaks the tiny trabeculae inbetween the screws turns, reducing the friction you need to overcome. Not a hard hit, just a little tap. I have no evidence to back this up.

[u/Jazzlike-Can7519 → u/D15c0untMD]

This is absolutely the right way to do this. I have to take out a lot of hardware as a trauma guy and I keep doing little subtle taps as I slowly turn the screwdriver counterclockwise to make sure the screwdriver remains completely seated. Your first one to two turns is where you're most likely to strip the head so this is where people screw themselves.

[u/Excellent_Wheel_8203]

For stripped screw heads I prefer the shukla removal tool. It’s a hard metal that cuts into the screw well. Sometimes if the screw is cold welded and it can’t be removed, I use a carbide drill bit to destroy the screw to the level of the bone below which will facilitate plate removal. The remainder of the screw can then be removed with a trephine removal tool.

[u/12baller12]

Bone wax on the screw driver head when putting a screw in down a deep wound e.g. pelvis

[u/carlos_6m → u/12baller12]

To keep it stuck? Nice... Sounds like a good trick if your screwdriver doesn't lock onto the screw

[u/lombardoz → u/carlos_6m]

Ya. This is super helpful mostly for cortex screws.

[u/Kalpagony]

If you have trouble positioning pointed reduction clamps and it keeps slipping off: lightly drill the surface with a 2mm K wire where you want the end to grab onto, just don't drill all the way through the cortex. If fascia sutures on a thick patient are hard to do (especially on the thigh) you can stick the handle of you forceps under the fascia and slide the needle along it to make sure your exactly in the right layer.

[u/satanicodrcadillac]

Spine related but if you approach using the suction, grab a small piece of ioban to cover the little hole so you don’t have to be putting excessive pressure on your thumb. Extra points if you use the bovie with a pedal. 

[u/bonedoc87]

For percutaneous fixation of metacarpal or
proximal phalanx fractures, the reduction can usually be achieved and held during k-wire or IM screw guidewire placement by just holding the patient’s hand in a fist.

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[u/CwTano]

Always know the docs favorite playlist to lighten the mood when a hex driver breaks off in a perif screw. If you’re unsure put any song remixed by the chipmunks on.

Sterile ky jellies all over the soft tissue when metal and sparks are flying from the Midas to protect them.