DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Hallux abductovalgus.
2. Degenerative joint disease, first metatarsophalangeal joint, right foot.
3. Plantarflexed prominent and painful second, third, fourth, fifth metatarsophalangeal joints, metatarsal heads, right foot.
POSTOPERATIVE DIAGNOSES:
1. Hallux abductovalgus.
2. Degenerative joint disease, first metatarsophalangeal joint, right foot.
3. Plantarflexed prominent and painful second, third, fourth and fifth metatarsophalangeal joints, metatarsal heads, right foot.
OPERATION PERFORMED:
1. Total joint replacement, first metatarsophalangeal joint, right foot.
2. Metatarsal head resection, second, third, fourth and fifth, right foot.
3. Retrieval bone screw, first metatarsal, left foot.
SURGEON: John Doe, DPM
DESCRIPTION OF OPERATION: The patient was prepped and draped in the usual aseptic fashion. Anesthesia was accomplished via 2% lidocaine and 0.5% Marcaine along with intravenous sedation. Hemostasis was accomplished via pneumatic tourniquet applied to the ankle and inflated to 250 mmHg pressure following exsanguination of the foot with Esmarch bandage. The patient received 1 g of Ancef, preoperative prophylactic antibiotic intravenously prior to tourniquet inflation. The following surgical procedures were performed.
Total joint replacement, first metatarsophalangeal joint, right foot: Attention was directed to the dorsal medial aspect of the first metatarsophalangeal joint area of the right foot. A linear longitudinal incision, approximately 5 cm in length, was made parallel to and medial to the tendon of the extensor hallucis longus beginning distal one-third of the first metatarsal shaft and extending distally to the distal aspect of the head of the proximal phalanx.
The excision was deepened via blunt and sharp dissection. Vital structures were identified and preserved. Bleeding vessels were clamped and coagulated. The incision was carried down to the capsular apparatus of the first metatarsophalangeal joint. The capsule was incised via longitudinal converging semielliptical incisions placed over the dorsal medial aspect of the capsule. The encompassed wedge of capsular tissue was removed in toto. Noted were whitish tophaceous deposits consistent with gouty arthritis.
Capsular and periosteal tissues were then resected away from the head and neck of the first metatarsal and the base of the proximal phalanx. Hypertrophic bone was resected dorsal, medial and laterally from the head of the metatarsal. The distal articular cartilage portion of the first metatarsal head was then resected transversely and removed in toto. The proximal one-third of the proximal phalanx was resected transversely and removed in toto. Care was taken to maintain the integrity of the flexor hallucis longus. A canal was then fashioned into the base of the proximal phalanx in a longitudinal direction to accept the distal stem of the hinge implant, and a similar canal was fashioned in longitudinal direction into the shaft of the first metatarsal to accept the shaft of the proximal phalanx.
The wound was flushed with sterile saline and Neosporin irrigant. A size 5S flexible hinge Swanson design implant was found to fit appropriately. Titanium grommets were placed distally and proximally, and a flexible hinge implant was inserted. Fluoroscopic examination demonstrated excellent range of motion and implant placement. The capsule was closed with 2-0 Vicryl and the subcutaneous tissues with 3-0 Vicryl and the skin with 5-0 Prolene.
Metatarsal head resection, second metatarsal, right foot: Attention was directed to the dorsal aspect of the second metatarsal of the right foot. A linear longitudinal incision was made overlying the base of the proximal phalanx of the second digit extending to the distal aspect of the metatarsal neck. The incision was deepened via blunt and sharp dissection. Vital structures were identified and preserved. Bleeding vessels were clamped and coagulated.
The incision was carried down through the subcutaneous tissues. Dorsal aspect of the second metatarsophalangeal joint was identified. It was incised longitudinally. Tendons of the extensor digitorum longus and brevis were isolated and tenotomized. Capsular tissue was then thoroughly dissected away from the head of the second metatarsal.
An osteotomy was then performed in the neck of the metatarsal from dorsal distal to proximal plantar. Upon completion of the osteotomy, the metatarsal head was then removed in toto. The wound was flushed with sterile saline followed by Neosporin irrigant. The capsule was closed via hour glass technique utilizing 2-0 Vicryl, deep tissues were closed with 2-0 Vicryl, subcutaneous tissues were closed with 3-0 Vicryl, and skin with 5-0 Prolene.
Metatarsal head resection, third metatarsal, right foot: A similar procedure, as described above, was performed on the third metatarsal of the right foot.
Metatarsal head resection, fourth metatarsal, right foot: A similar procedure, as described above, was performed on the fourth metatarsal of the right foot.
Metatarsal head resection, fifth metatarsal, right foot: A similar procedure, as described above, was performed at the fifth metatarsal, right foot.
Retrieval bone screw, first metatarsal, left foot: Attention was directed to the dorsal medial aspect of the first metatarsal of the left foot. A longitudinal incision was made overlying the medial dorsal aspect of the first metatarsal distal shaft area, the site of prior osteotomy and site of palpable screw head. The incision was placed medial to the tendon of the extensor hallucis longus. The incision was approximately 2.5 cm in length.
The incision was deepened via blunt and sharp dissection. Vital structures were identified and preserved. Bleeding vessels were clamped and coagulated. The head of the screw was then palpable, and surrounding soft tissues were then thoroughly reflected away exposing the head of the screw. The screw head was then engaged and then removed in toto. The wound was flushed with sterile saline followed by Neosporin irrigant. Fluoroscopic examination demonstrated complete retrieval of the bone screw. Subcutaneous tissues were closed with 3-0 Vicryl and skin with 5-0 Prolene.
Postsurgically, all sites were injected with dexamethasone phosphate 4 mg per mL. The patient received a second dose of Ancef 1000 mg intravenously. Each incision site was covered with 0-1 silk. Dry sterile compression dressing was applied. A Coban wrap was applied. Tourniquets were released and circulation returned to normal with palpable pedal pulses and capillary return less than 3 seconds. The patient tolerated the procedures well and left the operating room in good condition.
Presurgical evaluation for the bunion deformity demonstrated an intermetatarsal angle of 15 degrees, pain with range of motion of the first metatarsophalangeal joint, left foot.
