PREOPERATIVE DIAGNOSIS: Mucoid cyst of the left 2nd digit.
POSTOPERATIVE DIAGNOSIS: Same.
NAME OF PROCEDURE:
1. Excision of cyst to left 2nd digit.
2. Arthroplasty of the left 2nd distal interphalangeal joint.
FINDINGS: Upon dissection of the cyst, there was a noted stalk that tracked proximally
to the distal phalangeal joint. It was then dissected to the level of the DIPJ at
which time the arthroplasty was performed to facilitate complete resection and prevent
recurrence of the cyst.
RATIONALE FOR PROCEDURE: This patient had originally been seen for the mucoid cyst
which was recurrent in nature for several years. In October an attempt was
performed in the office to excise the lesion. Initially she healed up well;
however, approximately 1 month prior she noted recurrence of the cyst as well as
increased pain. I discussed continued treatment options at this time. Due to
failure of prior in-office procedures, I recommended we go to the operative suite
for a more aggressive approach to prevent recurrence. Discussed the risks and
benefits of the procedure in great detail with the patient.
PROCEDURE IN DETAIL: Under mild sedation the patient was brought into the operating
room and placed on the operating room table in supine position. Following IV
anesthesia, local anesthesia was obtained about the left 2nd digit using 7 mL of
0.25% Marcaine plain. The left foot was scrubbed, prepped, and draped in standard
fashion. An Esmarch was then used to exsanguinate the foot and the tourniquet was
inflated to 250 mmHg.
Attention was directed to the dorsum of the 2nd digit where the cyst was identified
slightly proximal to the proximal nail fold of the 2nd digit. Two longitudinal
semielliptical incisions were then made. The incisions were carried full thickness
to ensure adequate excision of the soft tissue mass. A portion of this also include
the lateral aspect of the nail. This portion was dissected, resected, and then sent
to pathology for further evaluation. The site was inspected and noted to have a
stalk that tracked proximally to the distal interphalangeal joint. It was then
traced at this time to the level of the joint. It was decided that the arthroplasty
would be necessary to help prevent recurrence of the lesion. A horizontal incision
to the DIPJ was then performed. A capsulotomy was performed at the distal
interphalangeal joint at this time. After exposure of the head of the metatarsal as
well as base of the proximal phalanx, the bone saw was then used to resect a portion
of them to facilitate arthroplasty. Inspection confirmed complete removal at this
time. The site was flushed with copious amounts of sterile normal saline and
bacitracin. Electrocautery was then used to debase where the cyst previously was to
help continue to reduce the rate of recurrence. After copious amounts of sterile
normal saline and bacitracin, the deep and subcutaneous tissues were then reapproximated with 3-0 Vicryl. The skin was then reapproximated with 4-0 Prolene
in a combination of simple sutures as well as horizontal mattresses.
THINKING
28285 T1
28092 T1 59
POSTOPERATIVE DIAGNOSIS: Same.
NAME OF PROCEDURE:
1. Excision of cyst to left 2nd digit.
2. Arthroplasty of the left 2nd distal interphalangeal joint.
FINDINGS: Upon dissection of the cyst, there was a noted stalk that tracked proximally
to the distal phalangeal joint. It was then dissected to the level of the DIPJ at
which time the arthroplasty was performed to facilitate complete resection and prevent
recurrence of the cyst.
RATIONALE FOR PROCEDURE: This patient had originally been seen for the mucoid cyst
which was recurrent in nature for several years. In October an attempt was
performed in the office to excise the lesion. Initially she healed up well;
however, approximately 1 month prior she noted recurrence of the cyst as well as
increased pain. I discussed continued treatment options at this time. Due to
failure of prior in-office procedures, I recommended we go to the operative suite
for a more aggressive approach to prevent recurrence. Discussed the risks and
benefits of the procedure in great detail with the patient.
PROCEDURE IN DETAIL: Under mild sedation the patient was brought into the operating
room and placed on the operating room table in supine position. Following IV
anesthesia, local anesthesia was obtained about the left 2nd digit using 7 mL of
0.25% Marcaine plain. The left foot was scrubbed, prepped, and draped in standard
fashion. An Esmarch was then used to exsanguinate the foot and the tourniquet was
inflated to 250 mmHg.
Attention was directed to the dorsum of the 2nd digit where the cyst was identified
slightly proximal to the proximal nail fold of the 2nd digit. Two longitudinal
semielliptical incisions were then made. The incisions were carried full thickness
to ensure adequate excision of the soft tissue mass. A portion of this also include
the lateral aspect of the nail. This portion was dissected, resected, and then sent
to pathology for further evaluation. The site was inspected and noted to have a
stalk that tracked proximally to the distal interphalangeal joint. It was then
traced at this time to the level of the joint. It was decided that the arthroplasty
would be necessary to help prevent recurrence of the lesion. A horizontal incision
to the DIPJ was then performed. A capsulotomy was performed at the distal
interphalangeal joint at this time. After exposure of the head of the metatarsal as
well as base of the proximal phalanx, the bone saw was then used to resect a portion
of them to facilitate arthroplasty. Inspection confirmed complete removal at this
time. The site was flushed with copious amounts of sterile normal saline and
bacitracin. Electrocautery was then used to debase where the cyst previously was to
help continue to reduce the rate of recurrence. After copious amounts of sterile
normal saline and bacitracin, the deep and subcutaneous tissues were then reapproximated with 3-0 Vicryl. The skin was then reapproximated with 4-0 Prolene
in a combination of simple sutures as well as horizontal mattresses.
THINKING
28285 T1
28092 T1 59
