DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Hallux abductovalgus deformity, first metatarsal and metatarsophalangeal joint, left foot.
2. Retained foreign body, first metatarsal, right foot.
POSTOPERATIVE DIAGNOSES:
1. Hallux abductovalgus deformity, first metatarsal and metatarsophalangeal joint, left foot.
2. Retained foreign body, first metatarsal, right foot.
OPERATION PERFORMED:
1. Austin bunionectomy with screw fixation, left foot.
2. Removal of deep retained foreign body, first metatarsal, right foot.
SURGEON: John Doe, MD
ANESTHESIA: Local monitored anesthesia care.
GROSS FINDINGS: Pain and functional debility of the right foot when wearing shoe gear secondary to prominence of retained foreign body in the bone of the first metatarsal, right foot, pushing into the soft tissues dorsally. Also, painful hallux abductovalgus deformity in the left foot. Conservative attempts at dealing with symptoms and signs failed, and the patient elected surgical intervention to improve chances of improved function and to lessen discomfort.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating table in the supine position. An ankle pneumatic tourniquet was applied to both ankles. The patient was given local anesthesia in the form of a Mayo block of both feet. The patient was then prepped and draped in the usual sterile manner on both lower extremities. The left lower extremity was elevated and exsanguinated with an Esmarch bandage, and the ankle tourniquet of the left lower extremity elevated to a pressure of 250 mmHg.
At this time, a dorsomedial incision of approximately 6 cm was made over the first metatarsal and metatarsophalangeal joint of the left foot. Subcutaneous neurovascular layer was sharply and bluntly dissected, with care being taken to protect all nerves, retracting, ligating, cauterizing all vessels as appropriate.
The periosteum and capsule were then visualized and incised in line with the original skin incision and augmented with an inverted-L capsulorrhaphy. The periosteum and capsule were then reflected medially and laterally from the metatarsal and its head. The hypertrophic bone of the first metatarsal, dorsal medial eminence, was resected with a sagittal saw and two transverse plain V osteotomies were then fashioned utilizing standard 0.45 guidewire technique.
The osteotomies were performed and the dorsal distal fragment mobilized laterally to the precise position to resolve the intermetatarsal angle of abnormality and proximal articular set angle. These were held in fixation with two 14 mm x 2.4 mm Osteomed cortical screws, placed in the standard Osteomed technique. The redundant bone was then removed with a sagittal saw and smoothed with a rotary bur and the wound flushed with copious sterile saline solution.
The periosteum and capsule were then sutured with 4-0 Vicryl in the subcutaneous layer, 4-0 Vicryl in the skin with a running intracuticular stitch of 5-0 Prolene augmented with regular staples. The left foot was then reanesthetized with 0.5% Marcaine plain, and wound was dressed with Silvadene-impregnated Owens silk, sterile 4 x 4s, Kerlix, Kling, and Ace wrap for retention. The left ankle tourniquet was deflated after a total time of approximately 70 minutes.
The right lower extremity was then elevated and exsanguinated with an Esmarch bandage and ankle tourniquet elevated to the pressure 250 mmHg. An incision was made in the skin, approximately 2 cm in length, over the prominent foreign body. Subcuticular neurovascular layer was dissected in the same manner previously described and the periosteum incised. The head of the screw was evident and was removed with a Synthes screwdriver that fit the 4.0 cancellous bone screw. The foreign body was removed intact.
The wound was flushed with copious sterile saline solution and the periosteum and subcutaneous layers sutured with 4-0 Vicryl and the skin with simple interrupted sutures of 5-0 Prolene. The wound was dressed in the same manner as previously described for the left lower extremity, and the tourniquet was deflated after a total time of 8 minutes.
The patient tolerated the surgeries on both lower extremities well and left the operating room for the recovery room with stable vital signs and vascular status intact to both lower extremities and digits.
