PREOPERATIVE DIAGNOSES:
1. Right severe flatfoot deformity
2. Right PTTD
3. Right Hallux valgus
4. Hallux elevatus
POSTOPERATIVE DIAGNOSES:
Same
PROCEDURE:
1. Right triple arthrodesis 28715
2. Right 1st Tarsal-metatarsal joint arthrodesis 28740
3. Right medial calcaneal displacement osteotomy 28300
4. Right Gastrocnemius recession, Strayer procedure 27687
5. Stress xrays, Right ankle
ANESTHESIA:
General
HEMOSTASIS:
A well padded tourniquet was placed about the right thigh set at 350mmHg for a total duration of 120 minutes.
ESTIMATED BLOOD LOSS:
100 mL
MATERIALS:
1. Synthes 6.5mm headless cannulated screws x 2
2. Synthes 4.5mm headless cannulated screws x 2
3. Synthes 4.0mm headed screws
4. Synthes 2.4mm locking variable angle plate
INJECTABLES:
Pre-op nerve block per anesthesia.
FLUIDS:
1300 mL of Normal Saline
SPECIMENS:
None
COMPLICATIONS:
None.
DISPOSITION:
Stable.
SUMMARY:
The patient was brought to the operating room, placed on the table on a supine position. After adequate induction of anethesia, the extremity was scrubbed, prepped, and draped in the usual aseptic technique. A time-out was performed reconfirming the patient's identity, planned procedure, and procedure site. Appropriate antibiotics were given to the patient based on SCIP protocol for the prevention of surgical site infections prior to surgical incision. All team members identified themselves. The tournique was elevated to 350 mmHg.
OPERATION:
Attention was directed to the posterior right calf. The achilles tendon was identified and marked with a marker. Palpating proximally, the gastrocnemius aponeurosis was identified and a skin marker was used to pre-mark a 3 cm linear incision straight midline. A number 15 blade was used to incise the skin. Blunt disection was carried down to the peritendon, bleeding was controlled with electrocautery. Army/navy retractors were used to retract the neurovascular bundle and provide visualization. The peritenon/deep fascia was excised with a #15 blade. The retractors were repositioned to expose the gastrocnemius aponeurosis. A Strayer type transverse incision was created from medial to lateral across the aponeurosis. It was deeped down to the gastrocnemius muscle, taking care to avoid cutting any muscle. Approximately 2cm of length was obtained with the foot dorsiflexed.
A 5 cm incision was placed at the medial aspect of the left foot between the TA tendon and the PT tendon. Incision was deepened through subcutaneous tissues utilizing sharp and blunt dissection. Neurovascular structure were identified and retracted out of the way. Hemostasis was obtained throughout the procedure. The deep tissue was bluntly dissected without complication. The capsule is identified for the talonavicular joint, it was sharply incised with a linear capsulotomy. Additional soft tissue was reflected off the joint. Hinterman retractors were utilized in order to visualize the entire joint. A curette was then used in order to remove all cartilage off the talar head and the navicular joint without complication.
Attention was then drawn to the lateral aspect of the left foot, where a 6 cm incision was placed from the tip of the fibula, to the base of the fourth metatarsal. Incision was deepened through subcutaneous tissues utilizing sharp and blunt dissection. Neurovascular structure were identified and retracted out of the way. Hemostasis was obtained throughout the procedure. The deep tissue was bluntly dissected without complication. The EDB muscle belly was identified and a linear incision through the muscle belly was completed in order to reflected and find the calcaneal cuboid joint. It was identified, and all soft tissue was reflected off the joint. The subtalar joint was then identified with retraction, without complication. The Hinterman retractors were then used to open the calcaneal cuboid joint, and cartilage was removed without complication. The area was copious lavage with normal saline. Attention was drawn to the subtalar joint, and a curette was used in order to remove all cartilage from the posterior facet without complication. The area was copiously lavaged with normal saline. All 3 joints were then drilled with a 2.0 mm drill bit for subchondral bleeding.
The talonavicular joint was then reduced manually, and temporarily fixated with the guidewires for the Synthes 4.5 mm screws. Fluoroscopy was used to identify the calcaneal tuberosity on lateral radiographs. Once adequate positioning of the osteotomy was completed, a 5 cm incision was made over the calcaneal tuberosity on the lateral aspect of the foot. The incision was taken down through the subcutaneus tissue to the periosteal layer. A key elevator was used to remove the periosteum at the site of the osteotomy. Two baby hohmann retractors were placed at the super and inferior portion of the calcaneal tuberosity and in good position on fluoroscopy ensuring all neurovascular structures were retracted out of the way. A 50mm sawblade was then used to make the calcaneal osteotomy from lateral to medial, ensure no damage to soft tissue medially. Lamina spreader was used to separate the osteotomy and stretch the soft tissue. The osteotomy was medially translated approximately 5-8 mm and a temporary guidewire was placed perpindicular to the osteotomy. The alignment of the temporary fixation and correction of the deformity was confirmed clinically and with fluoroscopy. Permanent fixation was then achieved using 6.5 mm headless cannulated cancellous screws according to company protocol, and compression was noted at the site.
Attention was then drawn to the subtalar joint, where guidewires for the 6.5 mm screws were placed parallel x2 from the calcaneus into the talus. Radiographs were utilized in order to ensure that the screws were not in the ankle joint, and were in good alignment. Screws were then inserted x2, Synthes 6.5 mm headless cannulated screws, according to company protocol. There was compression at the subtalar joint. Attention was then drawn to the talonavicular joint, where 2 Synthes 4.5 mm cannulated headless screws were inserted according to company protocol and compression was noted across the talonavicular joint. Finally, a wire for the 6.5 mm screws was then inserted across the calcaneal cuboid joint, from a posterior to anterior position. Radiographs revealed that the wire was within the bone and in good alignment. One Synthes 6.5 mm cannulated headless screw was then inserted according to company protocol with good compression noted.
A 4 cm linear longitudinal incision in the dorsomedial aspect of the right foot overlying the 1st tarsal-metatarsal joint, medial to the extensor hallucis longus tendon. Incision was deepened through subcutaneous tissues down to the layer periosteum and capsule, retracting all neurovascular structure and ligating all bleeders. The first metatarsal cuneiform joint was identified and capsule was incised with a dorsal linear incision. The joint was curetted of all remaining cartilage, and a 2.0mm drill was used for subchondral drilling of the joint. The first metatarsal was then manipulated into anatomic alignment and temporarily fixated with a K-wire. Area was checked underneath fluoroscopy to determine adequate reduction of the intermetatarsal angle. The above fixation was placed per AO technique with locking plate and screws.
The hallux was examined and a lateral release was not deemed necessary.
The medial eminence was deemed unnecessary to remove any eminence as it was no longer prominent.
Stress xrays were then taken to test the lateral collateral and medial deltoid ligaments. It was noted to be within normal range, and almost no tilt was noted for any varus or valgus deformity. At that time it was deemed unnecessary to repair the deltoid or lateral collateral ligaments.
The tourniquet was Deflated and a prompt, hyperemic response was noted to all digits of the lower extremity. The incision(s) were closed using standard technique to include the deep, subcutaneous tissue, subcuticular tissue, and skin. A sterile dressing was then applied. The patient was transferred to the postanesthesia care unit with vital signs stable and vascular status intact to the lower extremity. After adequate monitoring, the patient will be admitted to the hospital for 23 hour observation with the following instructions and prescriptions:
1. Leave the dressing clean, dry, and intact until follow up in the office. Do NOT get it wet.
2. Patient is to follow up in clinic in 7-10 days for re-evaluation.
3. Weightbearing status: NWB Right leg
4. Prescriptions: Oxycodone 5mg, Lovenox 40mg SQ for dvt prophylaxis, Tylenol 1000mg
1. Right severe flatfoot deformity
2. Right PTTD
3. Right Hallux valgus
4. Hallux elevatus
POSTOPERATIVE DIAGNOSES:
Same
PROCEDURE:
1. Right triple arthrodesis 28715
2. Right 1st Tarsal-metatarsal joint arthrodesis 28740
3. Right medial calcaneal displacement osteotomy 28300
4. Right Gastrocnemius recession, Strayer procedure 27687
5. Stress xrays, Right ankle
ANESTHESIA:
General
HEMOSTASIS:
A well padded tourniquet was placed about the right thigh set at 350mmHg for a total duration of 120 minutes.
ESTIMATED BLOOD LOSS:
100 mL
MATERIALS:
1. Synthes 6.5mm headless cannulated screws x 2
2. Synthes 4.5mm headless cannulated screws x 2
3. Synthes 4.0mm headed screws
4. Synthes 2.4mm locking variable angle plate
INJECTABLES:
Pre-op nerve block per anesthesia.
FLUIDS:
1300 mL of Normal Saline
SPECIMENS:
None
COMPLICATIONS:
None.
DISPOSITION:
Stable.
SUMMARY:
The patient was brought to the operating room, placed on the table on a supine position. After adequate induction of anethesia, the extremity was scrubbed, prepped, and draped in the usual aseptic technique. A time-out was performed reconfirming the patient's identity, planned procedure, and procedure site. Appropriate antibiotics were given to the patient based on SCIP protocol for the prevention of surgical site infections prior to surgical incision. All team members identified themselves. The tournique was elevated to 350 mmHg.
OPERATION:
Attention was directed to the posterior right calf. The achilles tendon was identified and marked with a marker. Palpating proximally, the gastrocnemius aponeurosis was identified and a skin marker was used to pre-mark a 3 cm linear incision straight midline. A number 15 blade was used to incise the skin. Blunt disection was carried down to the peritendon, bleeding was controlled with electrocautery. Army/navy retractors were used to retract the neurovascular bundle and provide visualization. The peritenon/deep fascia was excised with a #15 blade. The retractors were repositioned to expose the gastrocnemius aponeurosis. A Strayer type transverse incision was created from medial to lateral across the aponeurosis. It was deeped down to the gastrocnemius muscle, taking care to avoid cutting any muscle. Approximately 2cm of length was obtained with the foot dorsiflexed.
A 5 cm incision was placed at the medial aspect of the left foot between the TA tendon and the PT tendon. Incision was deepened through subcutaneous tissues utilizing sharp and blunt dissection. Neurovascular structure were identified and retracted out of the way. Hemostasis was obtained throughout the procedure. The deep tissue was bluntly dissected without complication. The capsule is identified for the talonavicular joint, it was sharply incised with a linear capsulotomy. Additional soft tissue was reflected off the joint. Hinterman retractors were utilized in order to visualize the entire joint. A curette was then used in order to remove all cartilage off the talar head and the navicular joint without complication.
Attention was then drawn to the lateral aspect of the left foot, where a 6 cm incision was placed from the tip of the fibula, to the base of the fourth metatarsal. Incision was deepened through subcutaneous tissues utilizing sharp and blunt dissection. Neurovascular structure were identified and retracted out of the way. Hemostasis was obtained throughout the procedure. The deep tissue was bluntly dissected without complication. The EDB muscle belly was identified and a linear incision through the muscle belly was completed in order to reflected and find the calcaneal cuboid joint. It was identified, and all soft tissue was reflected off the joint. The subtalar joint was then identified with retraction, without complication. The Hinterman retractors were then used to open the calcaneal cuboid joint, and cartilage was removed without complication. The area was copious lavage with normal saline. Attention was drawn to the subtalar joint, and a curette was used in order to remove all cartilage from the posterior facet without complication. The area was copiously lavaged with normal saline. All 3 joints were then drilled with a 2.0 mm drill bit for subchondral bleeding.
The talonavicular joint was then reduced manually, and temporarily fixated with the guidewires for the Synthes 4.5 mm screws. Fluoroscopy was used to identify the calcaneal tuberosity on lateral radiographs. Once adequate positioning of the osteotomy was completed, a 5 cm incision was made over the calcaneal tuberosity on the lateral aspect of the foot. The incision was taken down through the subcutaneus tissue to the periosteal layer. A key elevator was used to remove the periosteum at the site of the osteotomy. Two baby hohmann retractors were placed at the super and inferior portion of the calcaneal tuberosity and in good position on fluoroscopy ensuring all neurovascular structures were retracted out of the way. A 50mm sawblade was then used to make the calcaneal osteotomy from lateral to medial, ensure no damage to soft tissue medially. Lamina spreader was used to separate the osteotomy and stretch the soft tissue. The osteotomy was medially translated approximately 5-8 mm and a temporary guidewire was placed perpindicular to the osteotomy. The alignment of the temporary fixation and correction of the deformity was confirmed clinically and with fluoroscopy. Permanent fixation was then achieved using 6.5 mm headless cannulated cancellous screws according to company protocol, and compression was noted at the site.
Attention was then drawn to the subtalar joint, where guidewires for the 6.5 mm screws were placed parallel x2 from the calcaneus into the talus. Radiographs were utilized in order to ensure that the screws were not in the ankle joint, and were in good alignment. Screws were then inserted x2, Synthes 6.5 mm headless cannulated screws, according to company protocol. There was compression at the subtalar joint. Attention was then drawn to the talonavicular joint, where 2 Synthes 4.5 mm cannulated headless screws were inserted according to company protocol and compression was noted across the talonavicular joint. Finally, a wire for the 6.5 mm screws was then inserted across the calcaneal cuboid joint, from a posterior to anterior position. Radiographs revealed that the wire was within the bone and in good alignment. One Synthes 6.5 mm cannulated headless screw was then inserted according to company protocol with good compression noted.
A 4 cm linear longitudinal incision in the dorsomedial aspect of the right foot overlying the 1st tarsal-metatarsal joint, medial to the extensor hallucis longus tendon. Incision was deepened through subcutaneous tissues down to the layer periosteum and capsule, retracting all neurovascular structure and ligating all bleeders. The first metatarsal cuneiform joint was identified and capsule was incised with a dorsal linear incision. The joint was curetted of all remaining cartilage, and a 2.0mm drill was used for subchondral drilling of the joint. The first metatarsal was then manipulated into anatomic alignment and temporarily fixated with a K-wire. Area was checked underneath fluoroscopy to determine adequate reduction of the intermetatarsal angle. The above fixation was placed per AO technique with locking plate and screws.
The hallux was examined and a lateral release was not deemed necessary.
The medial eminence was deemed unnecessary to remove any eminence as it was no longer prominent.
Stress xrays were then taken to test the lateral collateral and medial deltoid ligaments. It was noted to be within normal range, and almost no tilt was noted for any varus or valgus deformity. At that time it was deemed unnecessary to repair the deltoid or lateral collateral ligaments.
The tourniquet was Deflated and a prompt, hyperemic response was noted to all digits of the lower extremity. The incision(s) were closed using standard technique to include the deep, subcutaneous tissue, subcuticular tissue, and skin. A sterile dressing was then applied. The patient was transferred to the postanesthesia care unit with vital signs stable and vascular status intact to the lower extremity. After adequate monitoring, the patient will be admitted to the hospital for 23 hour observation with the following instructions and prescriptions:
1. Leave the dressing clean, dry, and intact until follow up in the office. Do NOT get it wet.
2. Patient is to follow up in clinic in 7-10 days for re-evaluation.
3. Weightbearing status: NWB Right leg
4. Prescriptions: Oxycodone 5mg, Lovenox 40mg SQ for dvt prophylaxis, Tylenol 1000mg