DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Midfoot posttraumatic arthritis, including the naviculocuneiform; the inner cuneiform; the tarsometatarsal joints, first and second; and the calcaneocuboid joint.
POSTOPERATIVE DIAGNOSIS:
Midfoot posttraumatic arthritis, including the naviculocuneiform; the inner cuneiform; the tarsometatarsal joints, first and second; and the calcaneocuboid joint.
OPERATION PERFORMED:
Right foot mid fusion, including the naviculocuneiform, the inner cuneiform joint, the tarsometatarsal joints one and two, and the calcaneocuboid joint.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This is a (XX)-year-old African-American male who suffered a severe fracture dislocation of his midfoot and was initially treated nonoperatively because of severe skin injury. He was noted to have fracture blisters and eventually required skin grafting. The patient was treated with closed management. He was noted to have a plantigrade foot but continued to have pain. X-rays do show posttraumatic arthritis. Risks and benefits of the fusion procedure were discussed, and the patient consented for surgical treatment.
DESCRIPTION OF OPERATION: The patient was prepped and draped in a routine sterile manner. The procedure was started with an iliac aspiration by prepping the left ilium and placing a Jamshidi needle into the iliac crest and taking approximately 5 mL via three different bony locations. This was taken to the back table and mixed with 5 mL of AlloMatrix graft and also the local bone graft, which was taken through the procedure.
The left lower extremity was also prepped and draped in a routine sterile manner. A tourniquet was applied. The tourniquet was raised to 300 mmHg, and of note, 1 gram of Ancef was given prior to the incision. A medial incision was made first just medial to the anterior tibialis tendon insertion on the cuneiforms, and this was taken distally and proximally distally to the tarsometatarsal joints and naviculocuneiform joints. The inner cuneiforms in the first and second tarsometatarsal joints were dissected out. All of the now reduced fracture fragments were debrided. The joint spaces were debrided down to the subchondral bone using rongeurs and bur and elevators and curettes.
The procedure was started first proximally with a naviculocuneiform fusion, and this was held with the tenaculum clamp, and a screw was placed from the navicular bone into the middle cuneiform. Next, the inner cuneiform fusion was noted to be stable, and this was held with the bone clamp and that was locked into place with a screw from the first metatarsal into the middle cuneiform. Finally, a screw was placed from the medial cuneiform into the second metatarsal holding the second tarsometatarsal joint, and the Lisfranc joint is stable. Once all of these joints were stable, the lateral side was fixed.
Of note, the lateral side was exposed prior to the fixation. The lateral side was exposed by making an incision from the tip of the fibula distally to just to the end of the cuboid. The incision was carried down the extensor digitorum brevis. Muscle belly was elevated from its origin, which easily showed us the calcaneocuboid joint. The calcaneocuboid joint was noted to be subluxated. The joint was debrided, and because of the mild deformity, a lateral column lengthening was decided to be proceeded with.
An iliac crest allograft bone was taken and cut into a wedge so that the outer aspect would be approximately 4 mm and tapering down to a 1 mm wedge graft. This fit nicely into the lengthened calcaneocuboid column, and this was impacted into place. Prior to impacting the bone graft, the calcaneocuboid joint was debrided of all its cartilaginous elements and was burred to get down to the subchondral bone.
Once this was completed, two screws were placed from the cuboid into the calcaneus through the bone graft and fixated with two 3.5 mm screws. At this point, we had good fixation, plantigrade foot with good fusion from the naviculocuneiform, the inner cuneiform, the first and second tarsometatarsal joints, and the calcaneocuboid joint. The mini C-arm was used throughout the case to help position the foot and position the hardware, and final x-rays were taken and noted to have good position.
The wounds were irrigated. The bone graft mixture was then packed into all the fusion spaces. The wounds were closed on the lateral side. The extensor digitorum brevis was sutured back into its bed with 3-0 Monocryl. The medial wound at the periosteum was closed using 3-0 Monocryl. The skin was also closed with 3-0 Monocryl, and skin staples were placed. The patient was placed into a short leg splint with the foot into extension and placed in the neutral position, taken to recovery room in stable condition. Estimated blood loss was minimal. Tourniquet time was less than 2 hours.
