TITLE OF OPERATION: Amputation of toe, debridement of ulceration.
DESCRIPTION OF OPERATION: Under mild sedation, the patient was brought into the operating room and placed on the operating room table in the supine position. Following further intravenous sedation via the anesthesia department, local anesthesia was then obtained about the right second and third toes, utilizing approximately 10 mL total of the 1:1 mixture of 2% lidocaine plain plus 0.5% Marcaine plain injected in proximal digital style blocks, about the right second and third toes and metatarsal heads. The right foot was then scrubbed, prepped, and draped in the usual aseptic manner. Attention was then directed to the chronic ulceration, right second interdigital space, which was debrided to the level of the subcutaneous tissue of all nonviable fibrinous deposition and dysvascular tissue. The skin edges were also debrided to healthy petechial bleeding tissue. Next, utilizing a modified vertical fishmouth-type incision, overlying the right third digit and second interdigital space, these incisions were deepened down through subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures. These incisions were deepened down to the level of the right third metatarsophalangeal joint and the right third digit was disarticulated at the level of the metatarsophalangeal joint and passed from the operative field in toto. During this dissection, care was taken to carefully undermine the lateral flap of the right third digit which was modeled in fashion for primary closure. This flap was noted to be viable and vascular without signs of dysvascularity or necrosis. Next, deep wound cultures were taken at the level of the right third metatarsophalangeal joint and sent to Microbiology for culture and sensitivity, aerobic/anaerobic culturing, AFB, fungal, and Gram staining. Next, the decision was made to pursue with the distal cartilaginous cap of the third right metatarsal head, which was resected from a dorsal distal to plantar proximal fashion utilizing an osteotome and mallet, and the distal articular surface of the head of the right third metatarsal freed from its soft tissues surrounding and passed from the operating field in toto and sent to Pathology with the right third digit. It was noted that the right third digit’s entire medial aspect was gangrenous and completely nonviable. The surgical layer was then flushed with copious amounts of normal sterile saline solution. Deep capsular structures were then reapproximated and coapted utilizing 4-0 Vicryl in a deep gathering simple interrupted suture technique. Deep subcutaneous structures were also reapproximated and coapted in a similar fashion with 4-0 Vicryl. Prior to wound closure, the surgical field was flushed with copious amounts of normal sterile saline solution. The overlying skin was then reapproximated and coapted utilizing 4-0 Prolene in a horizontal mattress suture technique. All skin edges were well approximated when closed primarily and showed no signs of dysvascularity, necrosis, infection or ischemia. The right foot was then cleansed and a dry sterile dressing consisting of Bactroban ointment, Xeroform gauze, 4 x 4’s, Kerlix, and an Ace bandage lightly applied about the right foot. A prompt hyperemic response was noted to digits, one, two, four, and five of the right foot. The patient tolerated the procedures and anesthesia well and was transferred directly to the room following surgery, with vital signs stable and neurovascular status intact to digits, one, two, four, and five of the right foot. Following a brief period of postoperative monitoring, the patient was readmitted back to inpatient room with postoperative orders and Podiatric Surgery will continue to closely follow up on the care of this patient while in house and on an outpatient basis following discharge from the hospital. The patient understands she is to remain strictly nonweightbearing for at least a couple of weeks on her right foot to avoid dehiscence.
