DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left second hammertoe deformity.
2. Ingrown right fifth toenail.
POSTOPERATIVE DIAGNOSES:
1. Left second hammertoe deformity.
2. Ingrown right fifth toenail.
PROCEDURE PERFORMED:
1. Left second proximal interphalangeal joint arthroplasty.
2. Removal of right fifth toenail.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
SEDATION: Local/MAC.
HEMOSTASIS: Pneumatic ankle tourniquet at 250 mmHg on the left ankle.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
PREPARATION: Betadine scrub.
INDICATIONS FOR PROCEDURE: Per H&P.
DESCRIPTION OF PROCEDURE: The patient was taken to the OR and placed supine on the operating room table. After adequate IV sedation and 1 gram IV Ancef, a total of 6 mL of 0.5% Marcaine plain was injected above the base of the left second toe and the base of the right fifth toe. The feet were then prepped and draped in the usual sterile manner. An Esmarch bandage was utilized to exsanguinate the left foot, and the ankle tourniquet was inflated to 250 mmHg.
Attention was then directed to the dorsal aspect of the left second digit where a linear longitudinal incision was made. The incision was deepened through the subcutaneous tissues using sharp dissection. All bleeders were ligated and cauterized as necessary. A transverse extensor tenotomy was the performed at the proximal interphalangeal joint. The soft tissues were then freed from the head of the proximal phalanx, and the head was resected with a sagittal saw and passed from the operative field. This reduced the deformity, and the wound was irrigated with copious amounts of sterile normal saline. The extensor tendon was repaired with 3-0 Vicryl suture. The skin was then closed with 4-0 nylon suture in horizontal mattress fashion. Upon completion of the procedure, the incision was dressed with Adaptic gauze, and a sterile compressive dressing was applied to the left foot.
Attention was then directed to the right foot where the right fifth toenail was freed with an elevator, and a total nail avulsion was performed. There was no gross infection encountered. The toe was then dressed with antibiotic ointment and a dry sterile compressive dressing. The patient tolerated the procedure and anesthesia well and was transported to the PACU with vital signs stable. The patient will be discharged to home with written and oral postoperative instructions.
