DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Hallux abductovalgus, left foot.
2. Hallux interphalangeus, left foot.
3. Contracted extensor hallucis longus tendon, left foot.
4. Contracted adductor hallucis tendon, left foot.
5. Hammer digit, third toe, left foot.
POSTOPERATIVE DIAGNOSES:
1. Hallux abductovalgus, left foot.
2. Hallux interphalangeus, left foot.
3. Contracted extensor hallucis longus tendon, left foot.
4. Contracted adductor hallucis tendon, left foot.
5. Hammer digit, third toe, left foot.
OPERATIONS PERFORMED:
1. Modified Austin bunionectomy with AO fixation.
2. Proximal phalangeal osteotomy with monofilament wire fixation, left hallux.
3. Adductor hallucis tendon release, left foot.
4. Extensor hallucis longus tendon lengthening, left foot.
5. PIPJ arthroplasty with K-wire fixation, third digit, left foot.
SURGEON: John Doe, DPM
DESCRIPTION OF OPERATION: The patient was brought to the OR and placed on the operating table in the supine position. IV was intact for IV sedation. Ancef 1 g was delivered IVPB preoperatively. The patient discontinued 81 mg ASA three days preoperatively. Local anesthesia was obtained using 2% Carbocaine. The left foot was prepped and draped in the usual aseptic manner. Hemostasis was obtained using Esmarch tourniquet to the left ankle.
Attention was directed over the dorsal aspect of the first MPJ where an 8 cm curvilinear incision was made medial to the extensor hallucis longus tendon. A medial converging semi-elliptical incision was made, and encompassed section of skin was excised. The incision was deepened using sharp and blunt dissection technique and vital structures retracted medially and laterally. Superficial vessels were cauterized.
Inverted L capsulotomy was performed, and extension of the proximal phalanx and the capsule and periosteum were freed from the head and neck of the first metatarsal and base of the proximal phalanx. The lateral adductor hallucis tendon release was performed. Fibular sesamoid was further freed proximally, laterally and distally. Medial eminence on the first metatarsal head was excised and flushed. Osteotomy was then performed from medial to lateral with the apex pointing distally and the base proximally in a chevron fashion with a longer dorsal hinge. The head was then transposed into a more rectus position laterally and then fixed using two 2.7 mm cortical screws using AO lag technique. The first metatarsal was further remodeled using power saw, rongeur and rasp.
Attention was then directed towards the base of the proximal phalanx where an osteotomy was performed from dorsal to plantar with the apex pointing laterally and the base medially, and the encompassed section of bone was excised. The osteotomy was reduced and fixed using 20 gauge monofilament wire fixation in figure-of-eight fashion. At this time, the contracted extensor hallucis tendon was lengthened using V sliding tendon lengthening procedure that was stabilized using 4-0 Vicryl mattress suture. The site was copiously flushed. A medial capsulorraphy was performed. Deep closure was obtained using 2-0 Vicryl simple interrupted sutures, subcutaneous closure with 4-0 Vicryl mattress suture and skin closure with 4-0 Monocryl subcuticular running suture, tincture of benzoin and Steri-Strips.
Attention was then directed towards the third digit of the left foot where two converging semi-elliptical incisions were made over the PIPJ of the third toe of the left foot. The encompassed section of skin was excised. Transverse incision was made over the extensor apparatus and capsule over the PIPJ, and the head of the proximal phalanx was delivered dorsally and excised in total. The site was copiously flushed. K-wire was delivered in retrograde fashion to middle and distal phalanx and back to the proximal phalanx and third metatarsal.
Deep closure was obtained using 4-0 Vicryl simple interrupted suture in such a fashion that the distal end of the proximal portion, the extensor apparatus and capsule were tucked in void created by the excision of the head of the proximal phalanx. Subcutaneous closure made with 4-0 Vicryl mattress suture and skin closure with 4-0 nylon simple interrupted suture. Postoperatively, 0.5% Marcaine and dexamethasone were administered. The site was dressed with Adaptic, Polysporin, sterile gauze, sterile Kling, Kerlix, and Coban compression dressing applied. Upon releasing the tourniquet, normal color returned to all digits of the left foot. The patient tolerated the procedure well.
