1. Rt ankle arthroscopy w/synovectomy- either inclusive to #2 or 29895
2. Arthroscopic distal tibial bone spur excision- 29894
3. medial malleolar osteotomy w/ repair- 28302 ? or 27766 or both?
4. open debridement and microfracture OCD lesion, rt medial talar dome ?? not sure
5. open exostosis excision, dorsal talus- 28100

PROCEDURE: The patient was brought into the operating room and placed supine
on the operating room table. After institution of adequate general
endotracheal anesthesia, a preoperative dose of IV antibiotics was given
prior to initiation of the procedure. A popliteal nerve block had been
previously placed by the anesthesia team in the holding area. This was done
under ultrasound guidance. The patient was then repositioned with all bony
prominences well padded. A leg holder was placed under the right thigh
holding the hip and knee in flexion. A pad was used to cover the leg holder
to protect the peroneal nerve. Tourniquet was placed on the distal thigh.
The entire right lower extremity was prepped and draped in the usual sterile

The bony landmarks were palpated and the superficial peroneal nerve also
identified and drawn out on the skin. A lateral portal was created first
with the introduction of an 18-gauge needle. The insufflation of the joint
was about 20 mL of saline. With the capsule distended, the skin was incised
with a #15 blade and a mosquito clamp used to spread down to the capsular
layer. This was then penetrated and the blunt cannula introduced. A
diagnostic arthroscopy was then performed. The portal had been created in
the standard anterolateral position. There was an extremely large amount of
synovium throughout the ankle, which limited visualization. This was
especially true across the front of the ankle where the impingement was. The
dome of the talus itself looked good and there were no lesions on the distal
fibula. The medial malleolus also looked good once the synovium had been
cleared. There was a large spur off the front of the distal tibia, but with
the foot in traction since a gentle traction device had been used to distend
the joint and had been applied to the table in standard fashion, the
exostosis on the talus was not visualized. At that point, a standard medial
portal was created under direct visualization. Limited synovectomy was
performed at that time. The lesion in the medial talar dome was just barely
visualized since it was over the back; a full glimpse was not obtainable. At
that point, the decision was made that a medial malleolar osteotomy was

The surgical portion of the arthroscopy involved extensive synovectomy of the
entire front of the ankle and both gutters. This was done with a 2.9
full-radius shaver. A motorized bur was then used to take off the distal
tibial spur. This was checked with large fluoroscopic guidance to make sure
enough was resected. Once this was done, final arthroscopic pictures were
taken and medial malleolar osteotomy performed.

A 4-5 cm slightly curved incision was made over the medial malleolus and
taken down to the deeper subcutaneous tissue with a combination of blunt and
sharp dissection. Bovie electrocautery was used throughout the case for
hemostasis. Care was taken not to straighten to forward distally or
posteriorly and injure the posterior tibial nerve. Two threaded guidewires
were passed up through the medial malleolus into the distal tibial under
fluoroscopic guidance and these were over drilled with the
cannulated drill. Two 44-mm partially threaded screws were then advanced
into the bone and these were done before the osteotomy was made so afterwards it
could be anatomically reduced. Once this was done, these were then removed
and saved on the back table. Guidewire was then passed obliquely coming down
from proximal to distal and from medial to lateral to enter the joint space
at roughly the medial angle. At that point, a small drill was used to make
drill holes in the bone and an osteotome used to complete the osteotomy.
This is then reflected distally, carefully teasing soft tissue off the
anterior and posterior aspects allowing to reflect. This opened up the joint
space nicely. The lesion on the talus was clearly visualized. It was
roughly a comma shaped and was probably just over 1 cm, maybe closer to 1.5
cm in length. It was longer than it was wide. The widest portion extended
onto the medial aspect, but also up on to the top of the dome where most the
damage was. Actually had very good borders and a curette was used to sharpen
these borders further down to bone. A 0.62 K-wire was then used to drill
into the bone creating stable base. Once this was done, wound was copiously
irrigated. The osteotomized medial malleolus was then put back in place and
two guidewires passed back through the drill holes. Both screws were then
re-advanced with excellent compression across the osteotomy site. C-arm
confirmed this with a good reduction of the joint surface. At that point, it
was determined that the distal bone spur on the dorsal talus had to be
excised independently. A 3-cm incision was made directly over this and was
done roughly middle portion of the ankle centered over the spur. This was
probably a little bit more medial then midline. Blunt dissection was used
under the skin taking care not to injure the neurovascular bundle or any of the underlying tendons, which were encountered. These were retracted out of
the place. The spur was easily palpable and visualized and was removed with
a rongeur. No residual bump or evidence of impingement was noted with a full
range of motion. At that point, final fluoroscopic pictures were taken.

Both wounds and the portals were then closed. A 0 Vicryl and 2-0 Vicryl was
used for the deeper, then subcutaneous tissues, with 3-0 Prolene used for the
skin. A dry sterile dressing was applied with a trilaminar splinted in
neutral position. The patient was then transferred to the recovery room in
satisfactory condition without complication.