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Thread: Foot expert!!!Help

  1. #1

    Default Foot expert!!!Help

    AAPC: Back to School
    INDICATIONS: The patient is a 65-year-old male with polio who has had increasing difficulty ambulating on his right foot, his less affected lower extremity. It is the extremity that he uses to bear weight. The patient was seen and evaluated in the office where after a physical exam and radiographs it was determined that his main problem is he is unable to heel-to-toe weightbear. It was discussed with the patient at great length the treatment options including percutaneous versus open heel cord lengthening, and open osteophyte excision. The patient was under the understanding that for complete correction he would probably also require a posterior tibialis lengthening and/or transfer and possible hindfoot arthrodesis. The patient, however, day of surgery stated that he absolutely needed to bear full weight on the extremity. It was determined in a discussion with him that both osteophyte excision and an open heel cord lengthening that protected weightbearing would need to be continued. Understanding the limitations of strictly a percutaneous heel cord lengthening consented and wished to proceed. He understands that it may limit his amount of correction obtainable. It also may limit and require a modification of his current AFO. Understanding all these risks and benefits he consented and wished to proceed.

    He was taken to the operating room and placed in the supine position. After adequate IV antibiotics were administered, general anesthesia was induced. The right foot and leg was then prepped and draped in the usual sterile fashion. A tourniquet was placed on the upper thigh but no inflated. At this point once he was adequately anesthetized, initially three and eventually four percutaneous puncture holes were made along the posterior aspect of his Achilles. The first was approximately 1.5 cm above his calcaneal insertion and spaced approximately 1-2 cm proximally. Under direct palpation, a percutaneous hemiresection of the Achilles was performed in these four areas. Once they were performed, forced dorsiflexion of the foot allowed the foot to come in approximately 5 to 7 degrees of dorsiflexion. Direct palpation was then completed over the Achilles and there was felt to be an additional amount of hemiresection that could be performed. Therefore, additional resection was performed, primarily on the proximal two. This allowed again increased dorsiflexion to approximately 10 degrees with the knee flexed. At this point, it was felt that probably either anterior osteophytes or chronic posterior capsular contracture limited additional range of motion. Again under the limitations of being able to bear full weight on it immediately postoperatively, no additional operative procedure was performed.

    The wounds were then irrigated. They were closed with a 5-0 nylon. The skin was closed with the 5-0 Prolene. The incisional sites were injected 0.5% Marcaine. A sterile dressing was applied, including a range of motion boot locked at the neutral to 5-degree dorsiflexed position. Overall he tolerated the procedure satisfactorily. He will be discharged to home. He will be allowed to weightbear as tolerated for transferring but should keep his leg elevated. A pain prescription will be administered. He should follow up in my office in approximately two weeks. He should call the office or on-call physician if any additional problems arise.

    I would like someones input

    27686 ?

  2. #2


    or 27606 x 3
    Last edited by ASC CODER; 12-18-2009 at 01:32 PM.

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