Cats3
Contributor
I'm brand new to ortho coding and I'm wondering if anyone can help me with the following! TIA!
PREOPERATIVE DIAGNOSES:
Chronic turf toe with insufficiency plantar plate, dislocation of sesamoids, tibial tendinopathy, retained hardware, left ankle equinus deformity.
POSTOPERATIVE DIAGNOSIS:
Chronic turf toe with insufficiency plantar plate, dislocation of sesamoids, tibial tendinopathy, retained hardware, left ankle equinus deformity.
PROCEDURES:
Reconstruction plantar plate great toe, release flexor hallucis longus, removal of hardware medial malleolus left ankle, release posterior tibial tendon, gastroc slide.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room after preop discussion of the risks and benefits of the procedure including damage to nerves, blood vessels, infection, and incomplete relief from pain, understanding there were no guarantees as well as having a number of comorbidities including obesity, patient and family consented to the outlined procedure, with the addition of the removal of the hardware and the gastroc slide amended on the date of surgery.
After adequate general anesthesia and preoperative prophylactic antibiotics, the patient's left lower extremity was exsanguinated with an Esmarch bandage and tourniquet inflated to 300 mmHg. Limb was then prepped with an alcohol prep, followed by ChloraPrep prepping and draped in the normal sterile fashion. A posteromedial incision was made at the gastroc-soleus junction. Dissection was carried down through the abundant subcutaneous tissue. Bleeding controlled with electrocautery. The fascia was split longitudinally. The gastroc soleus junction was identified, sural nerve protected and then the gastroc-soleus junction was released in a V-shaped fashion allowing lengthening. The wound was irrigated. Bleeding was controlled with electrocautery. Fascia repaired with 2-0 Vicryl as was the subcutaneous tissue. Skin was closed with 3-0 nylon. Her medial incision was then opened. Dissection was carried down through the subcutaneous tissue. The deltoid was identified. The anterior screw was readily identified. Although there was some bony overgrowth, minor ostectomy was performed to remove the screw. The 2nd screw was actually buried within the posterior tibial tendon sheath. The posterior tibial tendon sheath was then opened. The tendon showed evidence of inflammation, but was generally felt to be intact. The tendon was pulled out away. The screw was deeply imbedded. The head just turned out at a slight angle, so that it was impinging on the tendon. The screw was removed with great difficulty as it was stripped out, but ultimately was able to be extricated with the hardware removal set. The wound was copiously irrigated. Bleeding was controlled with electrocautery. Subcutaneous tissue was closed with 2-0 Vicryl. Skin was closed with 3-0 nylon.
An extensile plantar medial incision was made over the great toe. This started on the medial aspect of the toe and hooked over at the IP joint. This was then reflected back. The medial digital nerve was identified and retracted. The flexor hallucis was then opened and mobilized to either side to fully expose the plantar plate. The plantar plate was then released from the proximal phalanx. Minimal synovectomy was carried out and she noted some clicking in her joint and it was felt likely related to the flexor hallucis and its subsequent release was felt to address this. The articular surfaces were grossly intact. A rongeur was used to debride the plantar surface of the proximal phalanx. Two Q-Fix anchors were then placed within the proximal phalanx. The sutures were then put through the plantar plate and through the insertions of the flexor hallucis brevis. The sutures were placed circumferential around the sesamoids to further pull them up into place. The sutures, however, were not tied down. The great toe was then stabilized with a longitudinal K-wire in a slightly plantar flexed position. Then the sutures securing the plantar plate in the sesamoid complex were then tightened on either side of the flexor hallucis, making sure that it was not entrapped. At this point, the tourniquet was released. Wounds were copiously irrigated. Bleeding was controlled with electrocautery. The fascia was tacked over the flexor hallucis. Subcutaneous tissue was closed with 3-0 Vicryl. Skin was closed with 3-0 nylon. The K-wire in the great toe was cut flush after being bent over. The wounds were infiltrated with 0.25% Marcaine with epinephrine. A bulky sterile dressing was applied, followed with a posterior splint. The patient was returned to the postanesthesia room in satisfactory condition. Neurovascular status noted to return on release of the tourniquet.
X-ray: Multiple x-rays of the right ankle were obtained, identifying location of the retained medial screws and then showing subsequent removal of the same screws. The ankle mortise appears intact. No complicating factors are identified. Multiple x-rays of the forefoot were also obtained. The patient previously had identified proximal displacement of her sesamoids. Interval x-rays show a longitudinal wire crossing the IP and MP joints of the great toe with the MP joint being reduced. Evidence of drill holes in the proximal phalanx. Sesamoid complex appears in a reduced position. No complicating factors are identified in these radiographs obtained from the mini C-arm intraoperatively.
PREOPERATIVE DIAGNOSES:
Chronic turf toe with insufficiency plantar plate, dislocation of sesamoids, tibial tendinopathy, retained hardware, left ankle equinus deformity.
POSTOPERATIVE DIAGNOSIS:
Chronic turf toe with insufficiency plantar plate, dislocation of sesamoids, tibial tendinopathy, retained hardware, left ankle equinus deformity.
PROCEDURES:
Reconstruction plantar plate great toe, release flexor hallucis longus, removal of hardware medial malleolus left ankle, release posterior tibial tendon, gastroc slide.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room after preop discussion of the risks and benefits of the procedure including damage to nerves, blood vessels, infection, and incomplete relief from pain, understanding there were no guarantees as well as having a number of comorbidities including obesity, patient and family consented to the outlined procedure, with the addition of the removal of the hardware and the gastroc slide amended on the date of surgery.
After adequate general anesthesia and preoperative prophylactic antibiotics, the patient's left lower extremity was exsanguinated with an Esmarch bandage and tourniquet inflated to 300 mmHg. Limb was then prepped with an alcohol prep, followed by ChloraPrep prepping and draped in the normal sterile fashion. A posteromedial incision was made at the gastroc-soleus junction. Dissection was carried down through the abundant subcutaneous tissue. Bleeding controlled with electrocautery. The fascia was split longitudinally. The gastroc soleus junction was identified, sural nerve protected and then the gastroc-soleus junction was released in a V-shaped fashion allowing lengthening. The wound was irrigated. Bleeding was controlled with electrocautery. Fascia repaired with 2-0 Vicryl as was the subcutaneous tissue. Skin was closed with 3-0 nylon. Her medial incision was then opened. Dissection was carried down through the subcutaneous tissue. The deltoid was identified. The anterior screw was readily identified. Although there was some bony overgrowth, minor ostectomy was performed to remove the screw. The 2nd screw was actually buried within the posterior tibial tendon sheath. The posterior tibial tendon sheath was then opened. The tendon showed evidence of inflammation, but was generally felt to be intact. The tendon was pulled out away. The screw was deeply imbedded. The head just turned out at a slight angle, so that it was impinging on the tendon. The screw was removed with great difficulty as it was stripped out, but ultimately was able to be extricated with the hardware removal set. The wound was copiously irrigated. Bleeding was controlled with electrocautery. Subcutaneous tissue was closed with 2-0 Vicryl. Skin was closed with 3-0 nylon.
An extensile plantar medial incision was made over the great toe. This started on the medial aspect of the toe and hooked over at the IP joint. This was then reflected back. The medial digital nerve was identified and retracted. The flexor hallucis was then opened and mobilized to either side to fully expose the plantar plate. The plantar plate was then released from the proximal phalanx. Minimal synovectomy was carried out and she noted some clicking in her joint and it was felt likely related to the flexor hallucis and its subsequent release was felt to address this. The articular surfaces were grossly intact. A rongeur was used to debride the plantar surface of the proximal phalanx. Two Q-Fix anchors were then placed within the proximal phalanx. The sutures were then put through the plantar plate and through the insertions of the flexor hallucis brevis. The sutures were placed circumferential around the sesamoids to further pull them up into place. The sutures, however, were not tied down. The great toe was then stabilized with a longitudinal K-wire in a slightly plantar flexed position. Then the sutures securing the plantar plate in the sesamoid complex were then tightened on either side of the flexor hallucis, making sure that it was not entrapped. At this point, the tourniquet was released. Wounds were copiously irrigated. Bleeding was controlled with electrocautery. The fascia was tacked over the flexor hallucis. Subcutaneous tissue was closed with 3-0 Vicryl. Skin was closed with 3-0 nylon. The K-wire in the great toe was cut flush after being bent over. The wounds were infiltrated with 0.25% Marcaine with epinephrine. A bulky sterile dressing was applied, followed with a posterior splint. The patient was returned to the postanesthesia room in satisfactory condition. Neurovascular status noted to return on release of the tourniquet.
X-ray: Multiple x-rays of the right ankle were obtained, identifying location of the retained medial screws and then showing subsequent removal of the same screws. The ankle mortise appears intact. No complicating factors are identified. Multiple x-rays of the forefoot were also obtained. The patient previously had identified proximal displacement of her sesamoids. Interval x-rays show a longitudinal wire crossing the IP and MP joints of the great toe with the MP joint being reduced. Evidence of drill holes in the proximal phalanx. Sesamoid complex appears in a reduced position. No complicating factors are identified in these radiographs obtained from the mini C-arm intraoperatively.