DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Dislocating midtarsal and tarsometatarsal and lesser tarsal joints and tarsal joints associated with a very flexible dislocating flatfoot.
POSTOPERATIVE DIAGNOSIS: Dislocating midtarsal and tarsometatarsal and lesser tarsal joints and tarsal joints associated with a very flexible dislocating flatfoot.
OPERATION PERFORMED:
1. Calcaneal displacement osteotomy, Gleich osteotomy.
2. Evans calcaneal osteotomy.
3. Cotton cuneiform osteotomy.
SURGEON: John Doe, DPM
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating room table in the left lateral position for the right foot to be operated on. The patient was given 500 mg of Ancef preoperatively IV for antibiotic prophylaxis. The patient was then placed on the operating room table and the patient prepped and draped in the usual manner. A thigh tourniquet was placed around the thigh. After exsanguination of the leg, the following procedures were performed.
A curvilinear incision was made on the lateral aspect of the calcaneus of the right foot, just below the peroneal tendons, and the incision parallel to the peroneal tendons was approximately 8 cm in length. Incision was deepened by sharp and blunt dissection down to the level of the calcaneus. Care was taken to avoid the sural nerve. The periosteum was incised with an incision paralleling the skin incision. The position of the anticipated osteotomy was checked with a FluoroScan and found to be triplanar and in excellent position. As soon as the osteotomy of the calcaneus was made at that level and the proximal osteotomized segment displaced both medially and inferiorly, temporary fixation was achieved with a 0.062 K-wire to the posterior aspect of the heel into the proximal calcaneus. Next, utilizing calcaneal plate offset by 6 mm, the plate was placed over the osteotomy and the three screws were placed inferiorly and two screws placed superiorly. The position of the plate was checked prior to insertion of the plate. The plate was inserted with 2.5 mm screws, nonlocking, and measured 18 to 20 mm in length, five screws total were placed into the plate; this being a five-hole plate. The wound was irrigated with solution of Betadine and saline. The periosteum over the osteotomy was closed utilizing 7 interrupted sutures of 2-0 Vicryl. Subcutaneous tissue was placed in that position and maintained with several sutures of 3-0 Vicryl. Skin was placed in that position and maintained with a subcuticular suture of Monocryl. The wound was then steri-stripped with half-inch Steri-Strips.
Next, attention was directed to the dorsal lateral aspect over the sinus tarsi and the calcaneocuboid joint. An insertion above the peroneal tendons and below the extensor brevis muscle belly on its lateral surface was made. The incision began at the sinus tarsi and terminated approximately 5 cm distal and occupied the dorsal lateral aspect of the calcaneocuboid joint and the sinus tarsi. The incision was deepened by blunt and sharp dissection, taking care to avoid the peroneal tendons and the sural nerve, which were reflected inferiorly. The muscle belly of the extensor digitorum brevis was dissected off the floor of the sinus tarsi. The tendon sheath of the peroneals were reflected inferiorly and the tendons were retracted along with the sural nerve plantarly and the muscle belly dorsally exposing the calcaneocuboid joint. An osteotomy was created 1.5 cm proximal to the calcaneocuboid joint. The osteotomy was a vertical osteotomy and was made to the medial cortex of the calcaneus. The osteotomy was spread utilizing a bone distractor and a 6 mm wedge of bone of cortical allograft was inserted into the graft. After the insertion of this graft, it was found to reduce the dislocation of the talonavicular joint and realign and reduce the deformity. The distractor was removed along with K-wires, and the wound was flushed with a solution of Betadine and saline. Care was noted that the graft did not extrude dorsally or plantarly and was in proper placement. FluoroScan was utilized to check the position of the graft. Next, the wound was flushed with a solution of Betadine and saline. The periosteum over the graft and the calcaneus was closed utilizing 7 interrupted sutures of 2-0 Vicryl. The subcutaneous tissue over the peroneal tendons was placed in that position and maintained with several interrupted sutures of 3-0 Vicryl. The skin was placed in that position and maintained with a subcuticular suture of 4-0 Monocryl. Steri-Strips were placed over the wound.
Next, attention was directed to the third procedure, Cotton osteotomy. The osteotomy was made into the dorsal medial aspect of the first cuneiform. An incision was made on the dorsal medial aspect of the foot beginning at the level of the talar neck and terminating distally over the base of the first metatarsal. The incision measured approximately 7 cm in length. The incision was deepened by blunt and sharp dissection, taking care to identify the anterior tibial tendon. The medial branch of the common peroneal nerve was protected along with the saphenous nerve. The anterior tibial tendon was retracted dorsally. The extensor tendon was on the dorsal aspect of the wound, not in the surgical site. Dissection was carried down to the body of the cuneiform, and the joints distal and proximal to it were identified as the navicular cuneiform joint and the first metatarsocuneiform joint. A guide pin was placed in the first cuneiform at the level of the osteotomy to be performed and checked with the FluoroScan, found to be midbody of the cuneiform. A transverse osteotomy was created and opened utilizing a bone distractor with two 0.062 K-wires. At this point, a 6 mm wedge of allograft was placed into the wedge after being modified and found to plantar flex and reduce the deformity of metatarsus primus elevatus and the navicular cuneiform folds. Ensured the osteotomy did not protrude above the level of the bone and was quite secure once the distractor and pins were removed. The wound was irrigated with solution of Betadine and saline. The position of the graft was checked with fluoroscopy and found to be in adequate and in excellent position. The periosteum over the first cuneiform was placed in that position and maintained with simple interrupted sutures of 2-0 Vicryl. The subcutaneous tissue over the anterior tibial tendon was placed in that position and maintained with 7 interrupted sutures of 3-0 Vicryl. The skin was placed in that position and maintained with a subcuticular suture of 4-0 Monocryl. Steri-Strips were applied over the wound.
Each one of the wounds was dressed with Betadine dressing and an Adaptic. A large fluffy, bulky dressing was applied along with a Coban dressing. A posterior splint was applied to the leg once the tourniquet was removed, and the digital color returned immediately. The posterior splint was applied with the foot at 10 degrees short of 90 degrees as far as dorsiflexion is concerned. The patient tolerated the operative procedure well and left the operating room in stable condition.
