DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Painful bunion deformity of the left foot.
POSTOPERATIVE DIAGNOSIS: Painful bunion deformity of the left foot.
OPERATION PERFORMED:
1. Closed base wedge osteotomy of the first metatarsal of the left foot with screw fixation.
2. Reverdin-Green osteotomy of the first metatarsal of the left foot with screw fixation.
SURGEON: John Doe, DPM
ANESTHESIA: General and local anesthesia.
HEMOSTASIS: Pneumatic ankle tourniquet of the left ankle at 250 mmHg.
ESTIMATED BLOOD LOSS: Minimal, less than 50 mL.
INDICATION FOR OPERATION: This is a (XX)-year-old male who presents with painful bunion deformity of the left foot of many years’ duration. The patient had bunion surgery done almost 18 years ago. The patient has tried different shoe gear, orthotics, and different pain medications with minimal help. The patient has opted for surgical correction. All the benefits, risks, and complications of the procedure were discussed with the patient. The patient agreed to proceed with surgery. The consent was obtained and is included in the chart.
DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed on the operating table in the supine position. Pneumatic ankle tourniquet was then placed around the patient’s left ankle. Following general anesthesia, local anesthesia was obtained around the patient’s first three utilizing 20 mL of 1:1 mixture of 0.25% Marcaine plain and 1% lidocaine plain. The foot was then scrubbed, prepped, and draped in the usual aseptic manner. Left leg elevation was obtained for 2 minutes to exsanguinate the patient’s left foot, and pneumatic ankle tourniquet was then inflated at 250 mmHg.
Attention was directed to the dorsal aspect of the first metatarsal head of the right foot where an 8 cm linear longitudinal skin incision was made medial and parallel to the tendon of the extensor hallucis longus. The incision was deepened through the subcutaneous tissue using sharp and blunt dissection. Care was taken to identify, retract all vital neurovascular structures. All bleeders were ligated and cauterized as necessary.
Attention was then directed to the first interspace via the original skin incision where the tendon of the extensor hallucis brevis was initially identified and tenectomized. The dissection was continued deep using a blunt dissection down to the level of the fibular sesamoid, which was freed of its attachments proximally, laterally, and distally. The conjoined tendon of the abductor hallucis muscle was then identified and transected at its attachments to the base of the proximal phalanx of the hallux.
Then a Z-type tendon lengthening procedure was obtained to the extensor hallucis longus tendon. At this time, the lateral contracture presented toward the hallux was noted to be reduced. Next, a linear longitudinal capsulotomy was performed over the dorsal aspect of the first metatarsophalangeal joint. The periosteal and capsular structures were then carefully dissected free of the osseous attachments, and they reflected medially and laterally thus exposing the head as well as the shaft of the first metatarsal at the operative site.
Attention was directed to the dorsal aspect of the base of the first metatarsal where a 0.045 inch K-wire was driven from dorsal to plantar aspect perpendicular to the weightbearing surface of the foot and at the medial cortex of the first metatarsal shaft about 1 cm distal to the first metatarsal cuneiform joint. K-wire was used as a guide for the osteotomy cut.
Next, utilizing the surgical bone saw, two oblique osteotomy cuts were obtained, oriented from lateral, distal, to medial proximal, care was taken to keep the medial cortex intact. Upon completion of the osteotomy cuts, a 3 mm bone wedge was removed and passed from the operating field. At this time, the distal segment was shifted more laterally and to more corrected position.
Next, a bone clamp was utilized. The K-wire was then removed and passed from the operating site. Following the AO principles and technique, 2.5 x 24 mm cannulated self-tapping cortical bone screws were inserted across the C-arm site with excellent compression noted.
The first metatarsophalangeal joint range of motion was reevaluated and noticed to have laterally denuded articular surface. A decision was taken to do the Reverdin-Green procedure to correct for the denuded articular cartilage. Attention was then redirected to the medial aspect of the first metatarsal head where a through-and-through linear longitudinal plantar osteotomy was created in the metaphyseal region of this bone utilizing the sagittal bone saw in order to protect the sesamoid apparatus.
The second transverse osteotomy cut was obtained in the metaphyseal region of the first metatarsal head from medial to lateral and parallel to the articular surface with care being taken to keep the lateral cortex intact. Then, a third transverse osteotomy cut was obtained in the metaphyseal region of the first metatarsal head from medial to lateral perpendicular to the longitudinal axis of the first metatarsal with care being taken to keep the lateral cortex intact.
Upon completion of all three osteotomy cuts, 3 mm bone wedge was excised and removed and passed from the operating field. Then, the capital fragment was distracted and shifted into a more corrected position and then impacted a bone, the first metatarsal shaft.
At this time, 0.045 inch K-wire was driven from dorsal proximal aspects of the shaft to the distal plantar aspect of the first metatarsal head across the osteotomy site to act as temporary fixation as well as the guide for screw fixation. Then, following the AO principles and technique, 2.5 x 20 mm cannulated self-tapping Vilex cortical bone screw was inserted across the osteotomy site with excellent compression noted. K-wire was removed and passed from the operative field. Attention was then directed to the remaining medial bone saw, which was resected utilizing the sagittal bone saw and passed from the operative site. Correction of the deformity was assessed at this time and noted to be excellent.
The wound was then irrigated with copious amount of normal saline. The capsular structures were reapproximated and coapted utilizing 2-0 Vicryl. The extensor hallucis longus tendon was reapproximated utilizing 2-0 Vicryl. The periosteal structure were reapproximated and coapted utilizing 3-0 Vicryl. The subcutaneous tissue was then reapproximated and coapted utilizing 4-0 Vicryl. The skin was then reapproximated and coapted utilizing 4-0 nylon in a continuous running interlocking suture technique.
Upon completion of the procedure, a total of 1 mL of Decadron was infiltrated around the incision site. A postoperative block consisting 10 mL of 0.25% Marcaine plain was also injected. The incision was dressed with Betadine-soaked Adaptic and covered with sterile compressive dressing consisting of 4 x 4s and Kling. Pneumatic ankle tourniquet was then deflated and prompt hyperemic response was noted to all digits of the left foot. A below-knee cast was then applied.
The patient tolerated the procedure and anesthesia very well. The patient was transferred to the recovery room with vital signs stable and vascular status intact to all digits of the left foot.
