DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Hammertoes, fourth and fifth digits, bilateral.
POSTOPERATIVE DIAGNOSIS:
Hammertoes, fourth and fifth digits, bilateral.
OPERATION PERFORMED:
Arthroplasty, fourth and fifth digits bilaterally, as well as a V-Y skin plasty at the base of the left fourth ray.
SURGEON: John Doe, DPM
ASSISTANT: Jane Doe, DPM
ANESTHESIA: Combination of MAC with local, 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain, infiltrated preoperatively.
SPECIMENS: There were no specimens sent to pathology.
HEMOSTASIS: Maintained using bilateral pneumatic ankle tourniquets inflated to 250 mmHg.
ESTIMATED BLOOD LOSS: Less than 5 mL.
MATERIALS: Consist of absorbable pins as well as Vicryl and Prolene suture.
INJECTABLES: Postoperative injected with 0.5% Marcaine plain.
COMPLICATIONS: None in the perioperative period.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who presents today with hammertoes bilaterally, fourth and fifth digits. The patient presents today for surgical correction via arthroplasty of the fourth and fifth digits. Consent has been signed. The patient has been medically cleared and n.p.o. for the appropriate time. There are no contraindications for surgery and all questions regarding surgery have been answered for the patient prior to the procedure.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room lightly sedated and placed in the supine position on the operating room table under monitored anesthesia care for the arthroplasty. A 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain was infiltrated bilaterally at the bases of the fourth and fifth digits. Pneumatic ankle tourniquets were placed upon both ankles. Both ankles were draped and prepped in the normal sterile fashion, elevated and further exsanguinated using an Esmarch bandage at which time the pneumatic ankle tourniquets were inflated to 250 mmHg.
Attention was directed to the right foot where a longitudinal incision was made overlying the fourth digit. This was deepened down to the level of the subcutaneous tissue and fat, down to the level of the extensor tendon overlying the proximal interphalangeal joint. The extensor tendon was then transversely cut at the level of the proximal interphalangeal joint and the collateral ligaments were also severed at this time. The extensor tendon was then freed from the head of the proximal phalanx, as well as from the base of the middle phalanx in order to expose these areas. Bone saw was then used to resect the head of the proximal phalanx, as well as the base of the middle phalanx. K-wire was then used to drill holes into the remaining shafts of the middle and proximal phalanx and an absorbable pin was then placed in here to staple this digit. This was after copious irrigation.
The same procedure was done on digit four of the right and left foot without complications, variations, additions or deletions and all procedures were the same including the dissection as well as fixation. Closure and reapproximation of this was also the same, including Vicryl used to reapproximate the extensor tendon and closure of the skin was done with Prolene.
Next, attention was directed to the right fifth digit where 2 cm elliptical converging incisions were then made surrounding the proximal interphalangeal joint. These were oriented from distal medial to proximal lateral. This wedge of skin was removed and the extensor tendon underlying was identified. This extensor tendon was then transversely cut at the level of the proximal interphalangeal joint. The head of proximal phalanx was then freed from surrounding soft tissue and this was resected using a bone saw. Incision was then copiously irrigated with normal saline. Next, the extensor tendon was reapproximated using Vicryl. Skin edges reapproximated using Prolene. The same procedure was on digits five bilaterally without complications, additions, deletions or variations. All procedures were the same including the orientation of the cut, the closure. Note that prior to any closure, copious irrigation was performed on digits four and five bilaterally.
Next, attention was directed to the base of the fourth digit on the left side where the toe appeared to be veering more in the lateral aspect causing a gap between digits four and three. V-Y skin plasty was then performed in this area and also a dorsal and lateral capsulotomy was performed through this skin plasty. This skin plasty was performed with the apex oriented proximally. Copious irrigation was then performed and closure was performed using Prolene on this V-Y skin plasty, being careful to prevent any damage to the apex of this V-Y. Once again, copious irrigation was performed prior to any closure. Dressings consisted of tincture of benzoin and Steri-Strips, Adaptic, 2 x 2’s, sterile 4 x 4’s, Kling, and Ace wrap, at which time pneumatic ankle tourniquets were let down and removed. The patient tolerated the procedure with all vital signs stable and neurovascular status intact to digits 1 through 5 bilaterally and was placed in recovery where vitals were taken per routine. The patient is to keep the dressing clean, dry and intact, ice and elevate bilaterally and be partial weightbearing to tolerance, use surgical shin crutches and put weight mostly on the heels of bilateral feet.
