DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Closed left tarsometatarsal dislocation.
POSTOPERATIVE DIAGNOSIS: Closed left tarsometatarsal dislocation.
OPERATION PERFORMED: ORIF of tarsometatarsal dislocation, left.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: Spinal and LMA.
INTRAVENOUS FLUIDS: 2500 mL lactated Ringer’s.
ESTIMATED BLOOD LOSS: 300 mL.
TOTAL TOURNIQUET TIME: 180 minutes.
DRAINS: None.
PATHOLOGY: None.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was identified and the operative site was marked in the preoperative holding area. He was taken back to the operating room on the hospital bed and carefully transferred from the hospital bed to the operating room table. The attending anesthesiologist administered a spinal anesthetic without any difficulty. The patient was then placed in a supine position and secured to the table with a safety strap. A bump was placed under the left hip to encourage neutral rotation of the left lower extremity. A well-padded, thigh-high tourniquet was placed and set to 280 mmHg. Biplanar fluoroscopy was utilized to ensure unimpeded access to the left foot for intraoperative imaging. The left lower extremity was then prescrubbed with chlorhexidine gluconate scrub brushes and then completely dried. The patient received 1 gram of cefazolin prior to the surgical skin incision. The left lower extremity was then prepared and draped in usual sterile fashion with Betadine.
A longitudinal incision was marked with a marking pen in the first web space as well as in line with the fourth metatarsal. A time-out was performed. A soft rubber Esmarch bandage was used to exsanguinate the left lower extremity and the tourniquet was inflated to 280 mmHg. Attention was first directed towards the medial incision. A skin incision was made with a 15 blade scalpel. Hemostasis was obtained with Bovie electrocautery. Blunt dissection was carried down to the fascia. The EHL was identified, preserved, and protected throughout the case. Dissection was carried down to the first tarsometatarsal joint capsule. The joint capsule was tagged for later repair. A subperiosteal dissection was utilized to expose the first and second tarsometatarsal joints. Care was taken to protect the dorsalis pedis and the neurovascular bundle. The joints were explored. There were no visual surface abrasions or full-thickness cartilage lesions noted. There was no bony debris.
Next, attention was directed towards open reduction of the first tarsometatarsal joint. Care was taken to ensure that the joint was concentrically reduced in both AP and sagittal planes. A 1.6 mm K-wire was used for provisional stabilization. Biplanar fluoroscopy confirmed appropriate joint reduction. Next, a high-speed bur was used to remove the upper part of the dorsal cortex of the first metatarsal approximately 15 mm distal to the joint. This was done to allow the screw head to be less prominent. A 2.5 mm drill bit was used to drill a path for the screw in a distal-to-proximal direction. A 3.5 mm fully-threaded cortical screw of appropriate length was then placed obtaining good purchase. Next, a second screw was placed from the medial cuneiform into the first metatarsal. A 2.0 mm drill bit was used to drill a path for the screw and a 2.7 mm fully-threaded cortical screw was placed obtaining good purchase.
Next, care was taken to ensure that the second tarsometatarsal joint was reduced. A 2.5 mm fully-threaded cortical screw was placed in a distal-to-proximal direction from the base of the second metatarsal from the proximal third of the second metatarsal into the middle cuneiform. Good purchase was obtained. An additional 2.7 mm fully-threaded cortical screw was placed from proximal-to-distal from the medial cuneiform into the proximal second metatarsal. Visual reduction was confirmed as well as with biplanar fluoroscopy. At this point, the tourniquet was deflated. Hemostasis was obtained with Bovie electrocautery. At this point, there was an increase in the amount of soft tissue swelling. Therefore, we felt that the risks of an additional incision outweighed the potential benefits. Therefore, the plan was for percutaneous pinning of the third tarsometatarsal joint as well as pin stabilization of the fourth and fifth tarsometatarsal joints. A closed reduction was obtained and verified with biplanar fluoroscopy. A 1.6 mm K-wire was placed from the distal aspect of the third metatarsal into the base of the lateral cuneiform. Biplanar fluoroscopy confirmed appropriate pin placement across the joint and into the lateral cuneiform. Next, the fourth and fifth tarsometatarsal joints were stabilized with a 1.6 mm K-wire as well. Biplanar fluoroscopy confirmed appropriate reduction of the tarsometatarsal joints and appropriate implant placement. Intraoperative plain radiographs were taken and demonstrated appropriate joint reduction and implant placement. The K-wires were cut short with a wire cutter, bent and protected with pin covers.
The wound was irrigated with sterile saline solution. The capsule was closed with 0 Vicryl in a figure-of-eight interrupted fashion. The deep fascia was closed with 0 Vicryl in a figure-of-eight interrupted fashion. The subcutaneous tissue was closed with a 2-0 Vicryl in a simple interrupted fashion. The skin was closed in a tension-free manner using 3-0 nylon with an Allgower modification of the Donati technique suture pattern. A sterile compressive dressing consisting of Xeroform, 4 x 4 gauze, ABDs, and sterile Webril were placed over the wounds. The patient was then placed into a well-padded, 3-sided, AO-type plaster splint with the ankle in neutral and dorsiflexion. LMA was required for the procedure and the patient was extubated without difficulty. He was taken to the postanesthesia care unit in stable condition.
