DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Hallux rigidus, left foot.
2. Metatarsalgia, subacute, left.
3. Hammer toe, left.
POSTOPERATIVE DIAGNOSES:
1. Hallux rigidus, left foot.
2. Metatarsalgia, subacute, left.
3. Hammer toe, left.
OPERATION PERFORMED:
1. Osteotomy, first metatarsal, for angular correction.
2. Osteotomy, second metatarsal, for angular correction, left.
3. Resection arthroplasty, hammer toe repair, second toe, left.
4. Implant arthroplasty of the first metatarsophalangeal joint with a porous-coated medium/large BioPro implant.
ANESTHESIA: Local with monitored anesthesia care.
HEMOSTASIS: Ankle tourniquet at 250 mmHg.
DESCRIPTION OF OPERATION: The patient was identified and consent obtained. The patient was brought to the operating room and placed on the bed in supine position. Appropriate monitors were then placed, and IV sedation was initiated. Local anesthesia was infiltrated in a total forefoot block. Once this was done, the left ankle and foot were then prepped and draped in the usual sterile fashion. The leg was elevated, exsanguinated, and tourniquet inflated. Attention was directed to the medial aspect of the foot. Utilizing a linear incision on the midline of the first metatarsal ray, extending from the IP joint proximally, the incision was taken through the skin and subcutaneous tissues. Careful preservation of neurovascular structures was achieved. We maintained the dorsal and plantar neurovascular plane. We went ahead and dissected down to the capsule. The capsule was incised. We went ahead and exposed the first MTP joint, which had significant cartilaginous loss along the entire surface of both phalangeal site and the metatarsal site. Large bony osteophyte was appreciated on the dorsal aspect of the joint as well. We went ahead and removed all of the osteophytes without difficulty and also removed large prominence off the lateral aspect of the metatarsal as well. Using a McGlamry elevator, we freed up the lateral cancellous as well. We went ahead and resected the base of the proximal phalanx.
At this point, approximately 3 mm of bone was removed. We maintained the sesamoid attachment. Once this was done, we went ahead and centered out the central canal of the proximal phalanx. We used a central punch and then created the space for the implant stem. Once this was done, we placed different trial sizers in order to determine which size would be appropriate. The medium/large would provide the best placement. We went ahead and placed that particular implant in, press-fit in nature, without cement, without difficulty. Good position noted. Sesamoid range of motion was checked under fluoroscopy. Attention was now directed to the first metatarsal head. We went ahead and created an osteotomy of the first metatarsal, oblique in nature, starting at the head so as to allow for the head to plantar flex. The oblique cut was then performed through the head and out the proximal aspect of the plantar aspect from the metatarsal just proximal to the synovial fold. Once that was done, the capital fragment was then plantar flexed and then shortened. We went ahead and removed the overlying excess bone of the metatarsal head without difficulty. Once this was done, we went ahead and temporarily fixated that with a compression clamp and then placed two screws from the FRS set, 16 mm, without difficulty. This held the compression nicely. Once that was done, we went ahead and flushed the wound out and closed the capsule with a 0 Vicryl suture, followed by 3-0 Vicryl for subcutaneous, and then skin closure with 3-0 Prolene suture.
Attention was now directed to the dorsal aspect of the second metatarsal. Utilizing a linear incision starting at the DIP joint, extending proximally just past the MCP joint, the incision was taken through the skin and subcutaneous tissues. A transverse tenotomy was performed at the second PIP joint. Once this was done, we released the tendon and its hood apparatus from the proximal phalanx. MTP release was performed. Medial and lateral collateral were released. We went ahead and performed an oblique osteotomy of the second metatarsal as well in the Weil fashion, and the metatarsal head was shortened to allow for composition of the shortening of the first metatarsal. This was held in position and then secured with a single screw, 12 mm, from the FRS set without difficulty. The overhanging bone was also resected with a rongeur. Image intensification verified the positions of both the first and second metatarsal without any problems. We went ahead and resected the head of the proximal phalanx proximally 4 mm without problems. Once this was done, we went ahead and flushed the wound out and placed a Trim-It pin from Arthrex. This was a 2.0 mm pin, absorbable, placed into the base of the middle phalanx and then into the proximal phalanx. This helped to maintain the position of the toe in a rectus position. We went ahead and put a slight bend into the pin also to allow for more natural curvature of the toe. Once this was done, the wound was flushed copiously. We went ahead and closed the tendon structures with 3-0 Vicryl suture, subcutaneous with 3-0 Vicryl and then skin closed with 3-0 Prolene. The patient tolerated the procedure very well without any difficulties. Tourniquet was released. Instant color was noted of the foot. No complications were appreciated.
