DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Osteomyelitis to the distal aspect of right second metatarsal and base of right second proximal phalanx.
POSTOPERATIVE DIAGNOSIS: Osteomyelitis to the distal aspect of right second metatarsal and base of right second proximal phalanx.
OPERATION PERFORMED: Resection of head of right second metatarsal and base of right second proximal phalanx.
SURGEON: John Doe, MD
ANESTHESIA: MAC with local consisting of 12 mL of 1:1 mixture of 2% lidocaine plain and 0.5% Marcaine plain injected in an ankle block fashion.
PATHOLOGY: Bone from right second metatarsal head was sent for both culture and pathological analysis. Bone from right second proximal phalanx was sent for both culture and pathological analysis. Deep wound cultures were also obtained.
HEMOSTASIS: Right pneumatic ankle tourniquet set at 250 mmHg.
ESTIMATED BLOOD LOSS: Less than 5 mL.
MATERIALS: None.
INJECTABLES: None.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic male who is presenting today for resection of infected bone. The patient was previously hospitalized for infected ulcer to the right hallux, which was infected with MRSA. The patient underwent a right hallux amputation several months ago and had healed that amputation fine. However, upon subsequent visits, the patient had developed pain and swelling about the right second metatarsophalangeal joint. X-rays showed changes consistent with osteomyelitis of the head of the right second metatarsal and base of the right second proximal phalanx. The patient elected for surgical debridement of this infected bone and soft tissue. At this time, the patient is aware of the risks, benefits, and alternatives of the surgical correction offered. The patient has been n.p.o. for approximately 18 hours prior to surgery. The patient was medically cleared for surgery and has signed the consent.
DESCRIPTION OF OPERATION: Under mild IV sedation, the patient was wheeled back into the operating room and placed on the operating table in supine position. A well-padded right pneumatic ankle tourniquet was placed about the patient’s right ankle. The above-mentioned cocktail was injected in the above-mentioned fashion to achieve local anesthesia. The foot was then scrubbed, prepped, and draped in the usual aseptic manner. The right foot was elevated in Esmarch for exsanguination.
Attention was then directed to the dorsal aspect of the patient’s right foot where the patient had a contracture of the right second digit with hyperextension at the right second metatarsophalangeal joint and hyperflexion of the right second proximal interphalangeal joint. The incision was made overlying the right second metatarsophalangeal joint extending distally to the right second proximal interphalangeal joint, and extending approximately one third proximal to the right second metatarsal head. The incision was deepened down in a layered fashion using combination of sharp and blunt dissection. Care was taken to carefully retract all vital neurovascular structures. All bleeders were cauterized or ligated as necessary.
An incision was then made utilizing the #15 blade overlying the periosteum of the distal one third of the right second metatarsal, the right second metatarsophalangeal joint capsule, and the proximal aspect of the right second proximal phalanx. Utilizing the #15 blade, the periosteum was reflected off those bony structures. It was immediately noticeable that the right second metatarsal head was fragmented into many small pieces, was yellowish in consistency along with the cartilaginous cap being yellowish and loosely adhered to the subchondral bone. All of these changes were consistent with the osteomyelitis diagnosis as seen on x-ray.
Once the bones were freed up from their soft tissue attachments, and with the second extensor tendon carefully retracted laterally, a sagittal saw was utilized to make a bone cut from dorsal to plantar through the base of the proximal phalanx of the second metatarsal and at a 45 degree angle from dorsal distal to proximal plantar through the distal one third of the right second metatarsal head. When marking out the osteotomy site, care was taken to carefully note that the bone was deemed hard and showed no intraoperative signs of infection at the levels of the osteotomy sites.
Once the osteotomies were made, a #15 blade was used to free up the bone from its plantar soft tissue attachments and the head of the second metatarsal and base of the second proximal phalanx were then removed from the operative field and set aside to be halved and sent for both culture and pathological analysis. At this point, deep cultures were then obtained from the space remaining from the resected bone. Utilizing a hand rasp, all the prominent bony edges were smoothed down. The remaining bone was once again inspected for intraoperative signs of bone infection, of which none were seen. The space was then copiously flushed with normal sterile saline.
Next, biodegradable OsteoSet implantable beads were mixed utilizing vancomycin as the antibiotic and these small beads were packed filling the empty space left from the resected bone. Care was also taken to pack the beads into the medullary canal of the proximal phalanx of the right second digit. Once the beads were packed in place, the periosteum and capsule of the former joint was closed utilizing 3-0 Vicryl. The extensor tendon was then plicated proximally to regain tension and subsequently counteract the shortening and loss of tension caused by resection of the bone. This was done utilizing horizontal sutures both medially and laterally along the extensor tendon to the underlying periosteum while tensioning the extensor tendon proximally and distally.
Next, subcutaneous closure was obtained utilizing 4-0 Vicryl in a simple interrupted suture fashion. Skin was then closed utilizing 4-0 nylon in a simple interrupted suture fashion. The incision was then dressed with Betadine-soaked Adaptic, 4 x 4s, Kling, and an Ace bandage. The tourniquet was deflated and a prompt hyperemia response was noted to the right foot as mentioned earlier. The patient was then transferred to recovery and will be discharged home with postoperative instructions.
