Thanks for the input. Here is the operative report.
PREOPERATIVE DIAGNOSES:
1. Hallux valgus, left foot.
2. Tenosynovitis, first intermetatarsal space, left foot.
POSTOPERATIVE DIAGNOSES:
1. Hallux valgus, left foot.
2. Tenosynovitis, first intermetatarsal space, left foot.
PROCEDURE:
1. Austin bunionectomy, first metatarsal, left, fixated with Mini Opus.
2. Tenosynovectomy of the first intermetatarsal space, left.
PROCEDURE: The patient was brought on the operating room table and placed in the supine position. The left foot, ankle, and leg were prepped and draped in the usual sterile manner. Using a skin marker, a planned incision was marked on the foot. Beginning along the medial side of the first metatarsal, a 5.5-cm incision, beginning along the mid aspect of the first metatarsal crossing first metatarsophalangeal joint along the medial side of the dorsomedial aspect and along the base of the proximal phalanx. The incision was deepened using sharp and blunt dissection, ligating all bleeding and retracting all neurovascular structures as necessary. Careful dissection was performed from dorsal to plantar and along the medial aspect. We removed all the soft tissue along the first intermetatarsal space from medial to lateral. Then a T-shaped capsulotomy made, first a dorsal incision beginning at the first metatarsal midshaft dorsally and extending at the first metatarsal head and then the plantar incision beginning at the first metatarsal medially, plantar aspect to the dorsal incision. Incision was deepened using sharp and blunt dissection, ligating all bleeding, and straight down to bone. Careful dissection of the periosteum and capsule of the large bunion of the large bunion deformity was performed from distal to proximal and from dorsal to plantar. A very large bunion deformity was seen and a large and normal first metatarsophalangeal joint with just mild wear and tear was seen. Using a power saw, the bone was cut from medial to lateral along the medial side of the dorsomedial eminence of the first metatarsal left foot leaving the sagittal groove intact. Using a power burr, the area was smoothed down from distal to proximal and nice correction so far was seen.
Our attention turned to the first intermetatarsal space and a 4.5-cm incision was begun at the mid-aspect of the first metatarsal dorsally to the first intermetatarsal space. Incision was deepened using a sharp and blunt dissection, ligating all bleeding and retracting all neurovascular structures as necessary. Careful dissection was performed and arthrotomy was made and a curved hemostat was used to grab the abductor tendon. Then, the abductor tendon was ______ [inaudible] the medial aspect of the great toe and reflected proximally and then the lateral collateral and sesamoidal lateral ligaments were performed. Nice correction and release of the strong and soft tissue was now noted. Then, our attention turned to the first intermetatarsal space and released soft tissue of the second metatarsal. Significant inflammation over the long extensor tendon using a #15 blade, we removed the hypertrophic synovium of the second extensor tendon until completely removed all nonviable tissue, flushed and cleaned with normal saline and then repaired with 3-0 Vicryl.
Then, we removed all the soft tissue off the second proximal phalanx and that distal to the mid-aspect of the second metatarsal, and then using a right angle, we used it to grab the suture and wrapped it around the second metatarsal and held, and this was then overlapped and held in place. Then a drill was used into the first metatarsal lateral aspect. Using the C-arm, we advanced the screw to the medial surface to the first metatarsal not entering to the medial cortex. Then, using the power drill, a hole was made from lateral to medial and not entering to the medial cortex and then drilled out. Then the mini opus was placed into the first metatarsal lateral aspect through use of the C-arm and then using the apparatus, we brought the first metatarsal into normal alignment and a nice correction was now noted. With the use of C-arm, we saw the improvement of the bunion deformity. The wound was copiously lavaged with normal saline. The excessive suture was cut off the mini Opus device, both wounds were flushed with normal saline. Then subcutaneous and the first intermetatarsal space were repaired with 3-0 Vicryl. Skin was repaired with the running 4-0 nylon. Then the repair of the first metatarsal incision, periosteum, and capsule was repaired with 2-0 Vicryl from proximal to distal, then the medial capsulorraphy was performed and this was closed with 2-0 Vicryl. The subcutaneous was closed with 3-0 Vicryl and the skin was closed with running 4-0 nylon. Nice correction was seen of the bunion deformity and then the aforementioned dose of local anesthesia was given. Adaptic, 4 x 4, and Kerlix were applied. Tourniquet was inflated at the beginning of the case using Esmarch bandage, exsanguinated from toes to ankle, and tourniquet was released at the end of the case with excellent neurovascular status returned to all digits of the left foot. The forefoot cast was made and bivalved and held in place with an ACE bandage. The patient tolerated the both the anesthesia and procedure well and left the OR to the recovery room with vital signs stable and neurovascular status intact.
