Foot/toe experts...how would you code the scenerio below?
PREOPERATIVE DIAGNOSIS:
1. Bunion deformity, left foot.
2. Contracture, extensor tendon, extensor hallucis longus, L1.
3. Hammertoe deformity, L2, 3 and 4.
4. Hyperostosis/Exostosis, left fifth toe.
POSTOPERATIVE DIAGNOSIS: Same with contracture, extensor tendon, L2, 3, 4 and 5.
SURGICAL PROCEDURES:
1. Modified McBride bunionectomy, left foot.
2. Closing wedge osteotomy, left hallux, with external fixation.
3. Z-plasty, extensor hallucis longus, L1.
4. Arthroplasty, L2.
5. Arthroplasty, L3.
6. Arthroplasty, L4.
7. Subcutaneous tenotomy and capsulotomy, L2, 3, 4 and 5, extensor tendon at MPJ.
PROCEDURE IN DETAIL: The patient was seen in the holding area. All preoperative workup was satisfactory for the case to proceed. The patient was taken to the operative theatre and placed on the table in the supine position. Anesthesia provided IV sedation. She did very well with anesthesia with no variance or complications of any kind. The foot was then prepped and draped in the usual aseptic fashion. After appropriate exsanguination from distal to proximal, a very well padded pneumatic cuff was elevated to a pressure of 240 mmHg. I had confirmed that she had been given the IV antibiotic, in case a K-wire would be necessary.
We then made an incision with a #15 blade, approximately 4-6 cm medial to the extensor hallucis longus tendon, but superior to the plantar weightbearing area. With a fresh #15 blade, this was carried deeper, that incision went from a proximal to distal one-third of the metatarsal, all the way close to the IPJ of the hallux. Superficial vessels were bovied as necessary. We went down to the capsule and incised the capsule. There were some degenerative changes in the joint, as some of the fluid had been erosive of the bone, and had gelatinous type material consistent with arthritis in the area. We used a surgical sagittal saw and resected the appropriate amount of bone from the medial aspect of the bunion, the hyperostosis dorsally, and remodeled a little bit of the first metatarsal on the lateral component as well. I did a modified McBride, going into the first intermetatarsal space, releasing the adductor hallucis tendon. The sesamoid was quite deep and scarred, and I felt it would not be reasonable to take the sesamoid out. It wasn't visible in dissection, and it was quite scarred from the arthritic changes. It was best to leave it at that time. We did a complete release in the first space so we could reduce the IM angles as well. We then went up and did a Z-plasty, effectively lengthening the extensor hallucis longus tendon to drop the hallux. We then went with a little bit of saline and remodeled with a power rasp, flushed and suctioned copiously with sterile saline. We then went more distally onto the hallux and did a closing wedge osteotomy where the base of the wedge would be proximal, and the apex was such that the wedge would go to the medial
component, thereby closing the wedge and bringing the hallux into a more adducted position. It was extremely stable, and I felt a K-wire was not necessary. I could externally split and stabilize it, which was the patient's desire in our preoperative conference, as well. We then bovied superficial vessels and closed the deep structures with 3-0 Vicryl undyed, a combination of 4-0 Vicryl for the closing of sub-q, and the skin in 4-0 nylon. It did very, very well. The alignment was very good.
We then did incisions on the second, third and fourth toes, encompassing the proximal interphalangeal joint, consistent with an atrioplasty. We went down to the extensor tendon, ligated it in transverse fashion, reflecting it proximally and distally, releasing the collateral ligaments from the head of the proximal phalanx, medially and laterally, and delivered the head into our field. Using a power saw, we then resected the appropriate amount of bone. Very meticulously, with quite a bit of time and detail, I remodeled the segments that were left with a rongeur. We flushed and suctioned copiously with sterile saline, using a Bovie were necessary, for superficial cautery. I closed the deep structures with 4-0 Vicryl, and just one subcuticular of 5-0 Vicryl to try and keep our scarring to as minimum as possible. I closed the skin in simple interrupted fashion of 4-0 Prolene.
We then went down to the metatarsophalangeal joints and made approximately a 8-9 mm incision, went down to the capsule and brought our extension tendon to the field, ligating it in transverse fashion. We went down to the capsule and released some of the contractures dorsally to allow the digits to plantar flex. She has a very pes cavus foot with very strict, rigid, nonreducible hammertoe deformities, as you can see in the preoperative films. We had done her other foot very similarly in 2001, some eight years ago. She was extremely pleased with the results, which is why we are doing the other foot now, eight years later, so I know that she was pleased with what had been done, and we did very consistent work on the left to support how the right foot had been done.
I used a 5 cc block of 2% Xylocaine to reinforce my areas. I did my dressings with Adaptic on the incision lines, topical antibiotics on the Adaptic, wet-to-dry, damp saline dressings as splints, fluffs and cling. Then I added additional padding and used a sterile tongue blade, incorporated along the axes of the first metatarsal onto the hallux, both phalanges and encased that with the padding and an additional layer of cling. I then used Webril as a modified soft tissue cast and went all the way above the malleoli, reinforcing that with an Ace bandage. So I really have almost a soft cast going on to help our case, with a tremendous amount of padding to support all of the procedures that had been done. The pneumatic cuff was released. Capillary filling time was within normal limits.
Our estimated surgical working time was 82-90 minutes. To the best of my knowledge, the cuff time was 92 minutes. We did have to wait a couple of minutes for sutures and some energies with anesthesia, so we are well into our field of normalcy for time. There were no complications or problems of any kind, and no variance. I expect a very nice result for Mrs. Ford.
At this time, she is alert and oriented times three. She is speaking with us very, very nice. She had good capillary filling time in all digits. There is no bleeding or drainage in the dressing of any kind. We will follow with her next week, postoperatively, as already planned.
Thank you all in advance!!
PREOPERATIVE DIAGNOSIS:
1. Bunion deformity, left foot.
2. Contracture, extensor tendon, extensor hallucis longus, L1.
3. Hammertoe deformity, L2, 3 and 4.
4. Hyperostosis/Exostosis, left fifth toe.
POSTOPERATIVE DIAGNOSIS: Same with contracture, extensor tendon, L2, 3, 4 and 5.
SURGICAL PROCEDURES:
1. Modified McBride bunionectomy, left foot.
2. Closing wedge osteotomy, left hallux, with external fixation.
3. Z-plasty, extensor hallucis longus, L1.
4. Arthroplasty, L2.
5. Arthroplasty, L3.
6. Arthroplasty, L4.
7. Subcutaneous tenotomy and capsulotomy, L2, 3, 4 and 5, extensor tendon at MPJ.
PROCEDURE IN DETAIL: The patient was seen in the holding area. All preoperative workup was satisfactory for the case to proceed. The patient was taken to the operative theatre and placed on the table in the supine position. Anesthesia provided IV sedation. She did very well with anesthesia with no variance or complications of any kind. The foot was then prepped and draped in the usual aseptic fashion. After appropriate exsanguination from distal to proximal, a very well padded pneumatic cuff was elevated to a pressure of 240 mmHg. I had confirmed that she had been given the IV antibiotic, in case a K-wire would be necessary.
We then made an incision with a #15 blade, approximately 4-6 cm medial to the extensor hallucis longus tendon, but superior to the plantar weightbearing area. With a fresh #15 blade, this was carried deeper, that incision went from a proximal to distal one-third of the metatarsal, all the way close to the IPJ of the hallux. Superficial vessels were bovied as necessary. We went down to the capsule and incised the capsule. There were some degenerative changes in the joint, as some of the fluid had been erosive of the bone, and had gelatinous type material consistent with arthritis in the area. We used a surgical sagittal saw and resected the appropriate amount of bone from the medial aspect of the bunion, the hyperostosis dorsally, and remodeled a little bit of the first metatarsal on the lateral component as well. I did a modified McBride, going into the first intermetatarsal space, releasing the adductor hallucis tendon. The sesamoid was quite deep and scarred, and I felt it would not be reasonable to take the sesamoid out. It wasn't visible in dissection, and it was quite scarred from the arthritic changes. It was best to leave it at that time. We did a complete release in the first space so we could reduce the IM angles as well. We then went up and did a Z-plasty, effectively lengthening the extensor hallucis longus tendon to drop the hallux. We then went with a little bit of saline and remodeled with a power rasp, flushed and suctioned copiously with sterile saline. We then went more distally onto the hallux and did a closing wedge osteotomy where the base of the wedge would be proximal, and the apex was such that the wedge would go to the medial
component, thereby closing the wedge and bringing the hallux into a more adducted position. It was extremely stable, and I felt a K-wire was not necessary. I could externally split and stabilize it, which was the patient's desire in our preoperative conference, as well. We then bovied superficial vessels and closed the deep structures with 3-0 Vicryl undyed, a combination of 4-0 Vicryl for the closing of sub-q, and the skin in 4-0 nylon. It did very, very well. The alignment was very good.
We then did incisions on the second, third and fourth toes, encompassing the proximal interphalangeal joint, consistent with an atrioplasty. We went down to the extensor tendon, ligated it in transverse fashion, reflecting it proximally and distally, releasing the collateral ligaments from the head of the proximal phalanx, medially and laterally, and delivered the head into our field. Using a power saw, we then resected the appropriate amount of bone. Very meticulously, with quite a bit of time and detail, I remodeled the segments that were left with a rongeur. We flushed and suctioned copiously with sterile saline, using a Bovie were necessary, for superficial cautery. I closed the deep structures with 4-0 Vicryl, and just one subcuticular of 5-0 Vicryl to try and keep our scarring to as minimum as possible. I closed the skin in simple interrupted fashion of 4-0 Prolene.
We then went down to the metatarsophalangeal joints and made approximately a 8-9 mm incision, went down to the capsule and brought our extension tendon to the field, ligating it in transverse fashion. We went down to the capsule and released some of the contractures dorsally to allow the digits to plantar flex. She has a very pes cavus foot with very strict, rigid, nonreducible hammertoe deformities, as you can see in the preoperative films. We had done her other foot very similarly in 2001, some eight years ago. She was extremely pleased with the results, which is why we are doing the other foot now, eight years later, so I know that she was pleased with what had been done, and we did very consistent work on the left to support how the right foot had been done.
I used a 5 cc block of 2% Xylocaine to reinforce my areas. I did my dressings with Adaptic on the incision lines, topical antibiotics on the Adaptic, wet-to-dry, damp saline dressings as splints, fluffs and cling. Then I added additional padding and used a sterile tongue blade, incorporated along the axes of the first metatarsal onto the hallux, both phalanges and encased that with the padding and an additional layer of cling. I then used Webril as a modified soft tissue cast and went all the way above the malleoli, reinforcing that with an Ace bandage. So I really have almost a soft cast going on to help our case, with a tremendous amount of padding to support all of the procedures that had been done. The pneumatic cuff was released. Capillary filling time was within normal limits.
Our estimated surgical working time was 82-90 minutes. To the best of my knowledge, the cuff time was 92 minutes. We did have to wait a couple of minutes for sutures and some energies with anesthesia, so we are well into our field of normalcy for time. There were no complications or problems of any kind, and no variance. I expect a very nice result for Mrs. Ford.
At this time, she is alert and oriented times three. She is speaking with us very, very nice. She had good capillary filling time in all digits. There is no bleeding or drainage in the dressing of any kind. We will follow with her next week, postoperatively, as already planned.
Thank you all in advance!!