DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Hallux limitus, left first metatarsophalangeal joint, tight extensor hallucis longus tendon, as well as painful left fourth digit.
POSTOPERATIVE DIAGNOSIS: Hallux limitus, left first metatarsophalangeal joint, tight extensor hallucis longus tendon, as well as painful left fourth digit.
OPERATION PERFORMED:
1. First metatarsophalangeal joint, left foot, revision.
2. Extensor hallucis longus lengthening, as well as arthrodesis, fourth toe, left foot.
SURGEON: John Doe, DPM
ANESTHESIA: Local monitored anesthesia care.
HEMOSTASIS: Left pneumatic ankle tourniquet.
ESTIMATED BLOOD LOSS: Less than 10 mL.
MATERIALS: One 0.045 inch Kirschner wire.
INJECTABLES: None.
DESCRIPTION OF OPERATION: Under mild sedation, the patient was brought to the operating room and placed on the operative table in supine position. A well-padded pneumatic ankle tourniquet was placed at the left ankle. Following IV sedation, local anesthesia was obtained at the left foot with approximately 12 mL of 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain. The left foot was then scrubbed, prepped, and draped in aseptic manner. The left foot was exsanguinated and a left pneumatic ankle tourniquet was inflated to 250 mmHg.
Attention was directed to the plantar lateral aspect of the left fourth digit, where two converging semielliptical incisions encompassing the entire plantar callus was then performed. The incision was then deepened through deep and subcutaneous tissue using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were cauterized and ligated as necessary.
The skin island involving the hypertropic tissue was then removed from the operative field in toto. Next, a straight lateral periosteal incision was then made in the proximal interphalangeal area of the left fourth digit and it was then exposed. Next, the previous implant of the left PIPJ fourth digit was removed. Opposing bone edges were then cleaned up utilizing oscillating bone saw for fusion site. Hypertrophic plantar and lateral aspects of the proximal phalanx were also rongeured as necessary. Next, utilizing 0.045 inch Kirschner wire, it was then antegraded out the middle phalanx out the distal end of the toe, then retrograded back to the proximal phalanx across MPJ to serve as temporary fixation. The wound was then flushed with copious amounts of normal sterile saline. FluoroScan was used to guide the alignment and placement of pin; all noted to be excellent. Periosteal and deep tissues were reapproximated and coapted utilizing 4-0 Vicryl. The skin was then reapproximated and coapted utilizing 5-0 Prolene.
Attention was directed to the dorsal medial aspect of the left foot, where an approximately 4 cm incision was made encompassing and removing the scar from the previous bunion incision. The scar, central skin island, was then removed from the operative site in toto. Dissection was carried down through the deep subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were cauterized and ligated as necessary.
Next, a straight periosteal incision was then made and exposure to the first MPJ of the left foot was then performed. At this time, there was noted to be some bony bridging and some osteophytic bone in the joint. Implant was removed, grommets were also removed, and a rongeur was used to remove the hypertrophic bone in the area. The MPJ joint was then cleaned up. Implant was then replaced, leaving out the grommets to allow for more motion.
At this time, the wound was then flushed with copious amounts of normal saline with bacitracin solution. Also, while the implant was out of the joint, it was placed in saline-soaked bacitracin solution. Deep and subcutaneous tissues were then reapproximated and coapted utilizing 4-0 Vicryl. The skin was then reapproximated and coapted utilizing 5-0 Prolene.
Attention was directed to the dorsal aspect of the left foot, along the extensor hallucis longus tendon. Incision was then deepened to the deep subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were cauterized and ligated as necessary.
The extensor longus tendon was then dissected free and a Z-type lengthening was performed. The tendon was then placed in physiological tension and much more relaxed then previously seen and sutured utilizing 4-0 Vicryl in place. The wound was then flushed with copious amounts of normal sterile saline. Tendon sheath was then reapproximated and coapted utilizing 4-0 Vicryl. The skin was then reapproximated and coapted utilizing 5-0 Prolene.
All wounds were then dressed with Steri-Strips, bandage, Adaptic, 4 x 4s, Kling, and Ace. The left pneumatic ankle tourniquet was then deflated with prompt hyperemic response noted to all digits and soft tissue areas of the left foot. The patient tolerated the procedure and anesthesia well.
