Calcaneonavicular Coalition Excision Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Calcaneonavicular coalition, left.
POSTOPERATIVE DIAGNOSIS: Calcaneonavicular coalition, left.
OPERATION PERFORMED:
1. Excision of calcaneonavicular coalition.
2. Intraoperative fluoroscopy.
SURGEON: John Doe, MD
ANESTHESIA: General.
IMPLANTS: None.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed supine on the operating room table. A general anesthetic was given without any difficulty. A pause was taken to confirm the correct operative site, and a gram of Ancef antibiotic was given before the start of the operative procedure. The left lower extremity was prepped and draped in the standard surgical fashion.
We made the oblique incision in the area of the calcaneonavicular joint through the sinus tarsi. We dissected down and identified the digitorum brevis. We also identified the long extensor tendons. The digitorum brevis was reflected, and we dissected down onto the anterior process of the calcaneus at the left of the coalition. Fibrous coalition with significant bony overgrowth was noted.
We freed up scar tissue. A rongeur was used to remove some of the fibrous coalition. We then used an osteotome and an oscillating saw to resect a wedge of bone. We had a 1 cm gap between the navicular and the calcaneus after resection was completed.
We copiously irrigated out the site of the coalition excision. We had good motion and increased motion after the coalition was excised. We placed bone wax on the ends of the bleeding bone. Some of the local fat was then placed into the coalition site.
Tourniquet was released. Hemostasis was maintained. We prepared the extensor digitorum brevis muscle. Subcutaneous tissues were reapproximated with 2-0 Vicryl, and a 3-0 nylon suture was used on the skin incision. Bulky dressings, including Xeroform, 4 x 4, ABD pads, and cast padding were applied. A postoperative splint was applied.
The patient was able to be awakened from the general anesthetic and taken to the recovery room in stable condition without any specific complications during the operative procedure. All counts were correct at the end of the case.
