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Chronic hallux limitus with chronic pain, first metatarsophalangeal joint right foot.

POSTOPERATIVE DIAGNOSIS: Chronic hallux limitus with chronic pain, first metatarsophalangeal joint right foot.

PROCEDURE: Realignment osteotomy with bone removal of first metatarsophalangeal joint with 2.0 screws x2, fixation of first metatarsal.

ANESTHESIA: Intravenous sedation with local block with 2% Xylocaine plain intraoperatively and postsurgical ankle block with 0.5% Marcaine with epinephrine.


INDICATIONS: The patient was brought to the Greater Cincinnati Surgery Center due to chronic pain and discomfort in the right first metatarsophalangeal joint. Previous evaluation indicated chronic bone exostosis and spurring, restricted motion causing patient's ambulation gait pain. The patient elected to undergo surgery and was evaluated presurgically and found to be medically stable. The patient was seen prior to surgery and had no questions on surgery as discussed prior, and also was given prophylactic antibiotic coverage.

DESCRIPTION OF PROCEDURE: The patient was brought back into the operating room in the supine position at which time IV sedation was administered along with a block to the first metatarsophalangeal joint of the right foot. A tourniquet was applied to the patient's right ankle. The right foot was then prepped and draped in the usual aseptic and sterile manner. Prior to surgery, the extremity was elevated. The ankle cuff was inflated for hemostasis to 250 mmHg.

Attention was directed at the right first metatarsophalangeal joint where a dorsal linear incision was made at the joint area. The incision was deepened down through the skin to subcuticular tissue. Bleeders identified were bovied. Other neurological and vascular structures were retracted either dorsal or plantar. The capsule was identified. A linear capsular incision was made, and exposure to the joint completed. On the dorsal aspect of the joint, there were several loose bodies of bone which were removed in toto, and there was significant exostosis of bone on the metatarsal head which was also then resected with a power saw on the dorsal, medial, and lateral aspects. During all bone cutting procedures, copious amounts of sterile saline were used for flush and irrigation.

Attention was then directed at the base of the proximal phalanx where there was a significnat exostosis of bone which was also resected with the power saw and a rongeur until there was removal of this dorsal exostosis.

Evaluation indicated there was still restricted motion of the joint, and therefore a plantar flexor osteotomy of the hallux was deemed appropriate. The K-wire cutting guide was placed through the metatarsal from medial to lateral, angled dorsal medial to plantar lateral, perpendicular to the shaft of the second metatarsal to avoid excessive shortening. With this K-wire cutting guide in place, both cuts of the osteotomy were completed with the plantar cut exiting away from the sesamoid apparatus and a longer dorsal arm for planned fixation. Once completed, the distal part of the metatarsal was freed up and place in a more lateral position, but reducing the intermetatarsal angle and also the plantar flexor recut lowered the metatarsal to allow better dorsiflexion of the hallux. The osteotomy was otherwise unremarkable, impacted upon the shaft of the metatarsal, and fixated with the K-wire. Redundant medial bone was resected. Additional bone was remodeled around the metatarsal head with additional bone removal and also hand rasping.

The cartilaginous surface of the metatarsal head showed significant erosion at the dorsal aspect, and drill holes were completed with a K-wire for pseudocartilaginous development. The base of the proximal phalanx showed minimal cartilaginous changes. Range of motion was significantly increased relative to presurgical findings.

Attention was then directed at the osteotomy site where fixation was then completed with 2.0 screws x2 with traditional AO technique. The temporary K-wire was removed. The screw heads and exit threads were unremarkable with good alignment and compression at the osteotomy site. Range of motion was completed with the foot loaded and non-loaded, and again, there was significant increased motion relative to the presurgical findings. The patient was advised strongly prior to surgery that the joint would never move as effectively as the left foot, but surgery would be completed as noted.

Deep copious flushing of the wound was completed. The tourniquet was deflated with immediate return of vascular status. Bleeders identified were bovied. No significant bleeders were evident. Additional deep flushing was completed, and final evaluation with the foot loaded and non-loaded showed significant increased motion of the joint with removal of the dorsal bone exostosis in particular and no further bone removal necessary. The capsule was realigned and closed in layers. Capsular closure was done was 3-0 Vicryl, subcuticular closure with 4-0 Vicryl, and skin closed with a 5-0 PDS. Benzoin Steri-Strips were applied. An additional block was completed proximal to the incision with 0.5% Marcaine with epinephrine. Xeroform and a dry sterile dressing was applied to the right foot. The tourniquet was removed, and ankle block also completed dorsal, medial, and lateral with 0.5% Marcaine with epinephrine. Final dressing was applied to the right foot. The patient was taken from the operating room to recovery in satisfactory and stable condition. The patient will ambulate with the surgical shoe or boot walker. He was previously given home care directions orally and in writing and pain medication. In recovery, the patient was medically stable with exposed toes to the right foot, especially the hallux, warm and viable.