DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Hallux abductovalgus, left foot.
2. Tailor’s bunion deformity, left foot.
POSTOPERATIVE DIAGNOSES:
1. Hallux abductovalgus, left foot.
2. Tailor’s bunion deformity, left foot.
OPERATIONS PERFORMED:
1. First metatarsal osteotomy with internal screw fixation, left foot.
2. Tailor’s bunionectomy, left fifth metatarsal.
SURGEON: John Doe, DPM
ASSISTANT: Jane Doe, DPM
ANESTHESIA: General anesthetic with local block consisting of a total of 20 mL of 2% lidocaine plain.
HEMOSTASIS: Pneumatic ankle tourniquet at 250 mmHg.
MATERIALS: DePuy FRS 18 mm screw x 1; Vicryl suture, 3-0 and 4-0; Prolene suture, 4-0; and a 5-0 Monocryl suture.
DESCRIPTION OF OPERATION: The patient was brought from the preoperative area and placed on the operating room table in the supine position. Following induction of a general anesthetic, the patient’s left lower extremity was elevated 60 degrees and a pneumatic ankle tourniquet was placed on the patient’s well-padded left ankle. At this time, a local block consisting of 20 mL and 2% lidocaine plain was administered to the first and fifth rays in a Mayo block fashion. The patient’s left lower extremity was then scrubbed, prepped, and draped in the usual sterile manner. An Esmarch was then utilized to exsanguinate the patient’s left foot.
At this time, attention was directed towards the patient’s left foot. A wet sponge was utilized to remove all Betadine prep from the patient’s left foot. At this time, approximately, a 6 cm linear incision was made just medial to the long extensor tendon. This incision was created with a #15 blade. Dissection was carried down to the level of the subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures during this dissection. All venous tributaries were isolated, clamped, cut and electrocoagulated as encountered. Dissection was carried down to the level of the deep fascia. At this time, the deep fascia was incised the full length of the original incision. Blunt dissection was then carried down into the first intermetatarsal space in order to perform a soft tissue release.
At this time, the deep transverse intermetatarsal ligament was isolated with a curved hemostat. It was then transected with a #15 blade near its insertion to the lateral aspect of the first MPJ capsule. The adductor tendon was then clearly visualized. The adductor tendon was then released from its insertion of the first MPJ capsule. The great toe was grasped and pulled distally, exposing the tenting on the lateral capsule. A #15 blade was then inserted in this tenting, and the lateral collateral and fibular sesamoidal ligaments were then released both dorsally, distally, and proximally. Upon completion of this soft tissue release, the previously mentioned lateral contracture present on the great toe was reduced. Attention was directed towards the medial aspect of the joint.
At this time, capsular periosteal incision was made full length of the original incision. The capsular and periosteal structures were meticulously reflected off the head of the first metatarsal both dorsally, medially, and plantarly. Once adequate soft tissue exposure had been achieved, the articular cartilage was visually inspected. It was white and glistening in appearance with no osteochondral deficits noted. At this time, attention was directed towards the dorsomedial eminence. This was transected with a power saw from dorsal distal to proximal plantar with care being taken to preserve the sagittal groove. This portion of bone was then freed from any soft tissue attachments, extirpated in toto from the surgical site. At this time, a 0.045 K-wire was driven into the head of the first metatarsal from medial to lateral to act as an apical access guide. Care was taken to preserve the length of the first metatarsal and slightly plantarflex the osteotomy with creation of this access guide.
At this time, an Austin-type osteotomy was created utilizing the 0.045 K-wire with guide. The plantar arm of the osteotomy was created utilizing a sagittal saw from medial to lateral. Care was taken to exit proximal to the sesamoid apparatus and exiting the cortex. The dorsal arm was then created so that there was a 60-degree V cut. The dorsal arm of the cut was equal in length of the plantar arm of the cut. Upon completion of this, the K-wire was removed, and the capital fragment was transposed approximately 3 mm laterally. The first MPJ was put through range of motion. There was no osseous bridging or gapping noted. There was no crepitus noted. Satisfied with the correction, the capital fragment was impacted. Attention was directed towards fixation. At this time, a guidewire from the FRS system was used to temporarily fixate the osteotomy driven from dorsal proximal to distal plantar across the apex of the osteotomy site. C-arm fluoroscopy was utilized to confirm excellent reduction and placement of the guidewire. At this time, utilizing AO fixation principles and lag technique, a DePuy FRS 18 mm screw was inserted over the guidewire. The guidewire was then removed. The first MPJ was put through range of motion. There was no crepitus noted. There was no osseous bridging or gapping noted. C-arm fluoroscopy was utilized to confirm reduction of the deformity.
Satisfied with this correction, attention was now directed towards remaining medial cortical site creation created from the transposition of the osteotomy. This was then transected with a power saw. The entire osteotomy site was then rasped free of all bony irregularities of the first metatarsal head to retain a smooth anatomical contour. At this time, the wound was flushed with copious amounts of normal sterile saline as had been done periodically throughout the procedure and attention was directed towards wound closure. At this time, utilizing a #15 blade, a linear wedge of capsule was taken from the medial aspect in order to pull the sesamoid apparatus underneath the first metatarsal head. The capsular and periosteal structures were then repaired utilizing a 3-0 Vicryl suture in a running-type stitch. The subcutaneous tissues were reapproximated and maintained using a 4-0 Vicryl suture in a simple interrupted suture technique. The skin incisions were reapproximated and maintained using a 5-0 Monocryl suture in a running subcuticular stitch. Upon completion of this, attention was then directed towards the next procedure.
At this time, attention was directed towards the patient’s left foot where a tailor’s bunion deformity was noted to be present. At this time, an approximately 4 cm linear incision was made just lateral to the long extensor tendon. This incision was created with a #15 blade. Dissection was carried down to the level of the subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures during the dissection. All venous tributaries were ligated, clamped, cut and electrocauterized as encountered. Dissection was carried down to the level of the capsular structures. At this time, a capsular periosteal incision was made the full length of the original incision to expose the head of the fifth metatarsal. At this time, there was a significant amount of exostosis noted on the dorsolateral aspect of the fifth metatarsal head. At this time, utilizing a power saw, the lateral one-third of the metatarsal head was resected. It was then extirpated in toto from the surgical site. A power rasp was utilized to remodel the fifth metatarsal head so it retained its smooth anatomic contour.
The wound was then flushed with copious amounts of normal sterile saline as was done periodically throughout the procedure. Attention was directed towards wound closure. The capsular structures were closed utilizing 3-0 Vicryl suture in a simple interrupted suture technique. The subcutaneous tissue was reapproximated using 4-0 Vicryl in a simple interrupted suture technique. The skin incision was reapproximated utilizing 4-0 Prolene suture in a simple interrupted suture technique. Upon completion of wound closure, postoperative injection consisting of 20 mL of 0.5% Marcaine plain was administered throughout the surgical incision site. Then, 1 mL of Decadron was placed in the interspace of the first metatarsal head. The wounds were then dressed with Betadine-soaked Adaptic, Mastisol, Steri-Strips, sterile 4 x 4s, 4 x 8s, sterile Kerlix, and a sterile Kling. A final C-arm was taken and it confirmed excellent reduction of the deformities. The tourniquet was then released. A prompt instantaneous hyperemic response was noted to all digits of the left foot. Coban was then applied and a postoperative shoe will be dispensed. The patient tolerated the procedure and anesthesia well. The patient left the OR with vital signs stable and vascular status intact to all digits of the left foot.
