DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left hallux abductovalgus.
2. Left accessory navicular bone.
POSTOPERATIVE DIAGNOSES:
1. Left hallux abductovalgus.
2. Left accessory navicular bone.
OPERATION PERFORMED:
1. Left bunionectomy with first metatarsal osteotomy and screw fixation.
2. Left Kidner procedure.
SURGEON: John Doe, MD
ANESTHESIA: Local with MAC.
HEMOSTASIS: Left pneumatic ankle tourniquet set at 250 mmHg.
ESTIMATED BLOOD LOSS: Less than 10 mL.
MATERIALS: Two 2.0 AO cortical screws.
INJECTABLES: 20 mL of 50:50 mixture of 1% lidocaine plain and 0.5% Marcaine plain.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This is a (XX)-year-old female patient who has been experiencing left bunion and left navicular/midfoot pain for quite some time. The patient has attempted conservative measures, which have all failed. The patient opts for surgical correction at this time. The patient has been medically cleared. The patient has signed consent for surgery, and the patient confirms n.p.o. status since last midnight. The patient understands the risks and benefits of surgical correction as explained preoperatively.
DESCRIPTION OF OPERATION: Under mild sedation, the patient was brought to the operating room and placed on the operating room table in the supine position where a well-padded left pneumatic ankle tourniquet was placed. Next, the above-mentioned cocktail was injected in a Mayo block fashion in and about the left foot navicular bone. The foot was then prepped and draped in the usual aseptic manner. The foot was then elevated at an approximately 45-degree angle for about 4 minutes and then the tourniquet was inflated to 250 mmHg.
Attention was directed to the first metatarsophalangeal joint where approximately a 6 cm dorsal linear incision was made medial and parallel to the extensor hallucis longus tendon. Sharp and blunt dissection was carried down through the subcutaneous tissues, retracting all neurovascular structures and ligating all necessary bleeders. Next, dissection was utilized medially to free up all subcutaneous tissue layers off of the medial capsule. Next, dissection was carried down into the first intermetatarsal space were a lateral release was performed by transecting the deep transverse metatarsal ligament, conjoined tendon, fibular sesamoidal ligaments, followed by a lateral capsulotomy. The hallux was put into a transverse plane range of motion, and it was noted that adequate release was accomplished.
Next, an inverted type capsulotomy was performed. All periosteal tissue layers were freed up with a Freer elevator. All soft tissue attachments were reflected off the medial eminence. The medial eminence was then resected with an oscillating saw. Next, a 0.045 K wire was inserted directly medially into first metatarsal head for slight elongation and mild plantar flexion. A twice as long dorsal chevron osteotomy was then performed with the oscillating saw. The K-wire was removed and the capital fragment was translocated laterally into a corrected anatomical position.
Next, two 2.0 AO cortical screws were inserted across the osteotomy site using strict lag screw technique. Fluoroscopy was utilized to confirm proper screw fixation, and it was noted to be in excellent position. Next, all redundant medial capsular tissue was removed. The wound was flushed and irrigated using copious amounts of normal sterile saline. Deep closure of the capsule was done and reapproximated using 4-0 Vicryl suture. The skin was closed and reapproximated using 5-0 Prolene suture in a horizontal mattress interrupted suture technique.
Attention was then directed to the medical aspect of the midfoot where approximately a 5 cm slight S-type incision was made about the navicular tuberosity. Sharp and blunt dissection was carried down through the subcutaneous tissues, retracting all neurovascular structures and ligating all necessary bleeders. Dissection was carried down to the posterior tibial tendon sheath where it was carefully incised and was tagged for later closure.
Next, the posterior tibial tendon was identified as attachment at the navicular tuberosity. An incision was made through the superior aspect of the tendon and freed off of the navicular. Fluoroscopy was utilized to visualize the os navicularis. The accessory bone was then removed with an oscillating saw and osteotome. It was noted that the bone had a blackish discoloration appearance and a segment of bone was sent for pathology.
Following removal of the accessory bone, the wound was flushed and irrigated using copious amounts of normal sterile saline. The tendon was reapproximated using Vicryl suture and the remaining deep closure was reapproximated with 4-0 Vicryl suture. Next, the skin was closed and approximated using 4-0 Prolene suture in a horizontal mattress interrupted suture technique. All wounds were dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4, Kling, and an Ace bandage. The tourniquet was deflated.
The patient tolerated the anesthesia and procedure well and returned to the PACU with vital signs stable and hyperemia noted to all left foot digits.
