DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Delayed union, anterior process of calcaneus fracture.
POSTOPERATIVE DIAGNOSIS: Delayed union, anterior process of calcaneus fracture, with bone cyst.
PROCEDURES PERFORMED:
1. Removal of delayed union site.
2. Debridement of nonunion.
3. Packing with bone morphogenic protein.
SURGEON: John Doe, MD
ANESTHESIA: Local with monitored anesthesia care.
HEMOSTASIS: Esmarch bandage for approximately 1-1/2 hour.
ESTIMATED BLOOD LOSS: None.
MATERIALS: Were 2-0 and 3-0 Vicryl and 4-0 nylon for closure.
INJECTABLES: Preoperatively 20 mL of 0.5% Marcaine plain, intraoperatively 10 mL of 2% Xylocaine plain, postoperatively 1.5 mL of dexamethasone phosphate plain, and a popliteal block.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in the supine position with IV intact for intravenous sedation. She was given 1 gram of Ancef IV piggyback for prophylactic antibiotic. She was transferred from the cart to the operating room table, and after delivering her IV sedation, the preoperative injection was given. She was prepped and draped in the usual and aseptic manner and, after appropriate surgical scrub, the right foot was exsanguinated with a Martin bandage, tourniquet maintaining hemostasis at the right ankle 1 cm proximal to the ankle joint on top of Webril with that same Esmarch bandage.
A curvilinear skin incision was made over the subtalar joint and the calcaneocuboid joint approximately 7 cm in length. This incision was deepened into the superficial tissue, making sure to cauterize any other venous bleeding structures at the site. Neurovascular structure of the intermediate dorsal cutaneous nerve was in the superior skin flap, and the sural nerve was in the inferior skin flap. Both nerves were identified and retracted appropriately. Dissection was carried down through the deep tissue until the level of the extensor digitorum brevis muscle belly. The muscle belly was lifted from its inferior origin on the calcaneus in superior fashion using the Bovie to cauterize as lifting the muscle belly. This allowed for exposure of the anterior process of the calcaneus. A small fracture fragment was noted at the lateral aspect of the calcaneus, which was removed.
Next, the anterior process of the calcaneus was inspected, and a small fracture fragment on the dorsal aspect was removed. The calcaneus surrounding the calcaneocuboid joint was inspected and the bone appeared to be quite soft. There was a deficit seen on the CAT scan, which corresponded specifically with this area, of a possible bone cyst, which may have caused this pathological type of fracture. This bone cyst and fracture line paralleled the calcaneocuboid joint subchondral to the calcaneus articular surface. Fracture fragments, which were removed, were perpendicular to the calcaneal articular surface, which one would see in an inversion injury like the patient had. This possible pathological fracture was filled with decorticated bone, which allowed a Freer elevator to be pushed directly through it. The site was curetted to help the hard cortical and calcaneus bone. The site was flushed and inspected under FluoroScan.
Next, right medical allograft with bone morphogenic protein putty was packed into the delayed union/bone cyst site. It was copiously irrigated once again, and closure was performed with 2-0 Vicryl, closing the muscle belly back to its origin, 3-0 Vicryl to close the subcutaneous tissue, and 4-0 nylon via simple and horizontal interrupted sutures. Betadine-soaked Adaptic as well as a dry sterile dressing were applied after the dexamethasone phosphate injection. Tourniquet was removed. Immediate warmth and perfusion was noted to return to all the digits, one through five, on the right foot. A posterior mold was then formed and applied to the patient with a soft dressing.
The patient had the popliteal block then performed via the anesthesia department, and she was transferred from the operating room table to the cart to the postanesthesia care unit. She is to be admitted for 23-hour observation. She is to be nonweightbearing and given pain medicines p.r.n.
