DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left index finger central slip avulsion with early boutonniere deformity.
2. Left long finger proximal interphalangeal joint posttraumatic arthritis, severe.
OPERATION PERFORMED:
1. Left index finger central slip repair.
2. Left long finger proximal interphalangeal joint fusion.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General.
COMPLICATIONS: None.
TOURNIQUET TIME: Approximately 115 minutes.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: After informed consent was obtained from the patient, he was taken to the operating room, transferred from the gurney to the operating table, and placed in supine position. General anesthesia was administered, and he was intubated without complication or difficulty. The patient received Ancef 1 gram IV preoperatively for infection prophylaxis. The left upper extremity had a well-padded tourniquet placed in proximal of the left arm. The left arm was then sterilely prepped and draped in the usual fashion.
An Esmarch bandage was used to exsanguinate the left upper extremity, and the tourniquet was inflated to 250 mmHg prior to incision. Using a #15 scalpel blade, a longitudinal incision was first made overlying the PIP joint in dorsal aspect of the left long finger. The radial and ulnar collateral ligaments were taken down, and the PIP joint was evaluated. There were severe osteoarthritic changes with large osteophyte and significant cystic erosion of the joint, both distally and proximally. With a rongeur as well as a bone saw, the bony prominences were taken down and the surfaces refashioned. The surfaces were made to allow fusion at approximately 30- to 35-degree angle of the joint in flexion. An attempt to use Acutrak standard compression cannulated screw to pierce the joint was made. Upon trying to place the screw, after a guidewire was placed, the dorsal cortex of the distal portion of the proximal phalanx cracked and the fixation with the screw was not continued. The screw was removed.
We decided to do a K-wire tension banding of the PIP joint. This was performed, and adequate apposition of the joint surfaces and stability was noted. C-arm images confirmed the fixation and alignment of the PIP joint in left long finger in AP and lateral planes in acceptable position. The bony prominences, both radially and ulnarly, were significantly improved. Next, the wound was irrigated with copious amount of sterile normal saline. The extensor tendon mechanism was repaired over the PIP joint and covered with 4-0 Vicryl suture in running and interrupted fashion. The skin edges were reapproximated with 4-0 nylon suture in interrupted horizontal mattress fashion.
Next, attention was directed to the left index finger. A longitudinal incision overlying the PIP joint was made approximately 3 cm in length. Blunt dissection was carried down to subcutaneous tissues developing a skin flap both radially and ulnarly. Small superficial vessels were cauterized with bipolar cautery to derive hemostasis. The extensor mechanism was evaluated in dorsal aspect of the PIP joint. There was evidence of an avulsed fracture at the attachment of the central slip and migration of this fracture approximately 5-6 mm. There was early scar formation and attempted healing in the bed of the fracture site.
Using a #15 scalpel blade, a longitudinal incision was made between the lateral bands and the central slip, and the central slip was mobilized to be advanced distally. The fracture bed was debrided back to healthy-appearing bone and the avulsed fracture fragment was also cleaned of any early callus healing. A mini Mitek suture anchor was then placed into the proximal portion of middle phalanx at the fracture site. Using a 0.035 K-wire, two holes were made in the fragment and the sutures from the Mitek suture anchor were passed across the fragment.
A Bunnell type of stitch was then placed in the dorsal and proximal portion of the central slip to reinforce the repair. The joint did have a 0.062 K-wire placed across the joint holding in full extension prior to the repair of the central slip avulsion. C-arm images confirmed the alignment of the joint and the re-establishment of the avulsed fragment in its bed in appropriate position in AP and lateral projections. The wound was then irrigated with copious amount of sterile normal saline.
The central slip was then sutured to the lateral bands in its advanced position with 4-0 Vicryl suture in interrupted figure-of-eight fashion, both radially and ulnarly. The skin edges were reapproximated with 4-0 nylon suture in interrupted horizontal mattress fashion. Digital block was performed to both the left index and long fingers with total of 15 mL of half-half mixture of 1% Xylocaine and 0.5% Marcaine without epinephrine to provide postoperative analgesia.
Xeroform dressing was placed over the wounds, and sterile 4 x 4 and sterile cast were used to protect the wounds. A well-padded volar splint extending to the tips of the fingers was placed on the left upper extremity incorporating the index and long finger to provide immobilization for early postoperative recovery. It was held in position with light Ace wrap. General anesthesia was reversed at the conclusion of the case. The patient was extubated and returned to the recovery room in stable condition. Of note, the tourniquet was deflated at approximately 115 minutes of use with adequate perfusion in the left hand after tourniquet deflation with less than 2 seconds capillary refill felt in all digits.
DISPOSITION: Following observation in the recovery room, the patient will be discharged to home if comfortable and stable. The patient will be instructed for elevation of left upper extremity often at home, avoiding any use of the left hand. The patient is to keep his dressings clean, dry, and intact until his followup in 7 to 10 days. The patient was given Percocet for postoperative pain relief.
