DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left hallux abductovalgus.
2. Left second interspace neuroma.
3. Left hammertoe deformity, second digit.
POSTOPERATIVE DIAGNOSES:
1. Left hallux abductovalgus.
2. Left second interspace neuroma.
3. Left hammertoe deformity, second digit.
OPERATIONS PERFORMED:
1. Left bunionectomy with distal metatarsal osteotomy and internal screw fixation.
2. Left second interspace neurectomy.
3. Left proximal interphalangeal joint arthroplasty, second digit.
SURGEON: John Doe, DPM
ANESTHESIA: MAC with local (24 mL of 2% lidocaine plain and 0.5% Marcaine plain mixed in a 1:1 fashion) injected in a posterior tibial and ankle block fashion.
PATHOLOGY: Left second interspace neuroma sent for pathological analysis.
HEMOSTASIS: Left pneumatic ankle tourniquet set at 250 mmHg.
ESTIMATED BLOOD LOSS: Less than 5 mL.
MATERIALS: 2.0 fully threaded cortical screws x2.
INJECTABLES: None.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: Under mild IV sedation, the patient was brought back to the operating room and placed on the operating table in a supine position. A well-padded left pneumatic ankle tourniquet was placed about the patient’s left ankle. Prior to the tourniquet placement, local anesthetic was injected for local anesthesia as described earlier. The left foot was then scrubbed, prepped and draped in the usual aseptic manner. The foot was then elevated and exsanguinated using an Esmarch bandage. The tourniquet was inflated and the surgery began. Attention was directed to the dorsal aspect of the patient’s left first metatarsal where, utilizing a #15 blade, a linear incision parallel to the medial and parallel to the extensor hallucis longus tendon was made, overlying the patient’s distal left first metatarsal and proximal phalanx. The incision was then deepened down through subcutaneous tissues in a layered fashion. Care was taken to retract any vital neurovascular structures. All bleeders were cauterized as necessary. Using a combination of sharp and blunt dissection, the incision was deepened down into the left first distal intermetatarsal space where, utilizing a combination of dissecting scissors and a #15 blade, a release was made of the lateral first metatarsal head attachments, including the deep transverse intermetatarsal ligament and the left abductor hallucis tendon. The lateral head of the flexor hallucis brevis was proximal and distal to the fibular sesamoid. A lateral L-shaped capsulotomy was performed in conjunction with this lateral release. The hallux, which had been tightly laterally deviated, was then put through transverse plane range of motion and adequate soft tissue correction was noted at this time.
Attention was then directed to the dorsal aspect of the left first metatarsal and base of the proximal phalanx where the incision was deepened down utilizing a #15 blade to the level of bone overlying the periosteum. The incision was in the same plane as the skin incision and utilized the entire length of the skin incision. Next, utilizing a combination of a #15 blade and a periosteal elevator, the periosteum was reflected off of the head of the first metatarsal, both medially, laterally and plantarly, and also including the capsule of the first metatarsophalangeal joint. Care was taken to not scar the head of the first metatarsal cartilage. Once the first metatarsal was free of its periosteal attachment, the large exophytic medial eminence of hypertrophic bone was noted and resected from the head of the first metatarsal. Once the medial eminence was resected, a 0.05 K-wire was utilized as an axis guide and driven into the head of the first metatarsal in line with the head of the third metatarsal to assist in guidance of lateral translocation of the capital fragment with slight lengthening and plantar flexion of the first ray. Next, utilizing a sagittal saw, a chevron-type osteotomy, with the dorsal wing twice as long as the plantar wing, was made through the head of the first metatarsal. The first metatarsal head was then translocated laterally to achieve the desired correction. The forefoot was then loaded, and the hallux was put through sagittal plane range of motion which was deemed more than adequate. The lateral deviation of the hallux had been corrected and the hallux was in a more rectus fashion. Utilizing a mini C-arm for intraoperative fluoroscopy, the correction was checked and also deemed adequate.
Next, utilizing a stepwise standard AO technique, two 2 mm fully threaded cortical screws were inserted into the head of the first metatarsal through the chevron osteotomy to achieve rigid internal fixation. Once these screws were inserted, all remaining K-wires were removed from the left first metatarsal. The hallux was then placed through full ranges of motion in all cardinal planes, and the correction was deemed adequate. All redundant bone was then resected from the medial and dorsal aspects of the first metatarsal. All prominences were reduced utilizing a combination of the sagittal saw and a power rasp. The periosteum was then closed, including the capsule, utilizing 4-0 Vicryl in a running suture fashion. Subcutaneous tissues were also closed utilizing 4-0 Vicryl, and the skin was closed utilizing 5-0 Prolene in a running subcuticular fashion.
Attention was then directed to the dorsal aspect of the patient’s left second digit where a lazy-S incision of approximately 6 cm in length was made overlying the left second digit just distal to the proximal interphalangeal joint, extending proximally over the left dorsal second metatarsophalangeal joint where the incision then curved laterally and then it continued to extend proximally overlying the distal aspect of the left second intermetatarsal space. The incision was then deepened down through the layers utilizing a #15 blade. All care was taken to carefully retract all vital neurovascular structures. All bleeders were cauterized as necessary. Attention was specifically directed to the left second intermetatarsal space where the incision was deepened down through the subcutaneous tissues to the level of the deep transverse intermetatarsal ligament, which was sectioned utilizing a dissecting scissor. Once the ligament was sectioned, the intermetatarsal space was inspected and a hypertrophic nerve stalk was noted in the area. The nerve was then transected as distally and as proximally as possible and removed from the patient’s left foot. The nerve and additional soft tissue mass surrounding the nerve were set aside to be sent to Pathology for analysis. Once all neuroma-appearing soft tissue was removed from the left second intermetatarsal space, attention was then directed to the dorsal aspect of the left second digit where, utilizing a #15 blade, the medial and lateral collateral ligaments and left second proximal interphalangeal joint were transected. Next, a linear horizontal tenotomy and capsulotomy were made overlying the left second proximal interphalangeal joints. The extensor digitorum longus slip was reflected off of the head of the proximal phalanx, exposing the entire head from its soft tissue attachments. Once the head was exposed, it was transected at the surgical neck and removed in toto utilizing a sagittal saw.
Next, attention was then directed to the left dorsal aspect of the second metatarsophalangeal joint where the medial and lateral capsulotomy was performed to reduce the contracture of that joint. The extensor digitorum longus slip to that digit was also freed up from its vascular attachments beginning from the proximal interphalangeal joint, extending proximal to the left second metatarsophalangeal joint to achieve lengthening of this tendon through fascial release. The forefoot was then loaded and both the left second metatarsophalangeal joint and left second proximal interphalangeal joint were noted to be rectus in all planes. The digit was no longer contracted and also rectus. The tendon was reapproximated over the dorsal aspect of the left second proximal interphalangeal joint utilizing 4-0 Vicryl in a simple running stitch fashion. Subcutaneous tissues were closed with 4-0 Vicryl in a running suture fashion, and the skin was closed utilizing 5-0 Prolene in a running subcuticular fashion.
Next, the intraoperative fluoroscopy was utilized once again to take final pictures of the left foot, and solid compression and fixation were noted at the distal first metatarsal osteotomy and rectus joints were noted at the left second digit. The incisional areas were then dressed with Steri-Strips and splinted in proper position utilizing Betadine-soaked 4 x 4s. The remaining dressings consisted of additional 4 x 4s, 2 inch Kling, Kerlix, sterile Webril dressing, an EBIce pack cooling system, and 4 inch Ace bandage. The tourniquet was deflated and prompt capillary response was noted to all digits of the left lower extremity. The patient was then sent to recovery where she will be monitored for a sufficient period of time before being discharged home.
