DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Status post left calcaneus heel ulcer.
POSTOPERATIVE DIAGNOSIS: Status post left calcaneus heel ulcer.
OPERATION PERFORMED:
1. Irrigation and debridement, left calcaneus heel ulcer, with debridement of the calcaneal tuberosity.
2. Rotation of a reversed fasciocutaneous flap.
3. Application of a 4 x 10 Integra dressing over the donor site.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male status post injury to the above-noted area. The patient was felt to be indicated for operative surgery. The risks, benefits, and alternatives of the procedure were discussed with the patient, including musculoskeletal or neurovascular damage, bleeding, infection, loss of life or limb. All questions were answered to the patient’s satisfaction.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, and under general endotracheal anesthesia, the patient was placed in the supine position. The left heel was pre-prepped and draped. The patient was placed in the prone position. The left lower extremity was pre-prepped and draped in the usual fashion.
First, debridement of the heel ulcer over the posterior aspect was performed with thorough curettage of all the dead, devitalized soft tissue and bone. Next, a 4 x 5 cm fasciocutaneous flap was raised up approximately 10 cm proximal to the Achilles tendon insertion. This was taken up along with the fascia and carried back along the fasciocutaneous line, rotated into the heel ulcer, and sutured with nylon suture. The remaining wounds were tagged with Integra dressing.
The plan will be to admit the patient for observation, take his dressing down within 36-48 hours, determine the viability of the fasciocutaneous flap, and then allow the patient to go home. The patient has to lie on his side or on his belly until further followup. We will follow up with the patient in two weeks.
