DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Hallux abductovalgus, hammertoe, fourth toe on the right.
2. Neuroma, third interspace on the right foot.
POSTOPERATIVE DIAGNOSES:
1. Hallux abductovalgus, hammertoe, fourth toe on the right.
2. Neuroma, third interspace on the right foot.
OPERATION PERFORMED: Simple bunionectomy of the first metatarsal head on the right foot; arthroplasty of the fourth toe, right foot.
SURGEON: John Doe, DPM
DESCRIPTION OF OPERATION: The patient was brought to the operative room and placed on the operating room table in the supine position for simple bunionectomy of the first metatarsal head on the right foot and arthroplasty of the fourth toe, right foot.
Ancef 1 g was given IV piggyback in the preoperative holding area. A pneumatic tourniquet was placed on the right ankle and local block was done by the surgeon, 16 mL of 50:50 mix of 0.5% Marcaine plain and 2% lidocaine plain. The right foot was prepped and draped in the usual aseptic manner. An Esmarch bandage was used to exsanguinate the right foot. Pneumatic tourniquet was insufflated to 250 mmHg. The Esmarch bandage was removed.
Attention was directed to the dorsomedial aspect of the first metatarsal for simple bunionectomy. A linear longitudinal, approximately 4 cm in length incision was made. It was deepened via sharp and blunt dissection, taking care to retract all vital structures and ligate any bleeding vessels. At this time, a linear longitudinal incision was made into the capsule and periosteum at the first metatarsal joint and head.
The capsule and periosteum was reflected taking care to retract all vital structures and ligate any bleeding vessels. It was noted that there was an enlarged medial eminence with osteophytic formation medially and dorsally at the first metatarsal head. The cartilage was intact. The medial eminence was excised using power equipment, and at this time, it was found the bone was extremely soft.
I was able to compress the bone easily with forceps. It was determined at this time that the bone was too soft for any kind of osteotomy, for the bone to be able to hold any kind of an implant. The dorsal aspect of the first metatarsal head was excised using power equipment and hence was directed to the lateral interspace where the fibular sesamoid was released from all of its attachments, except for those most plantar medial to allow for the first metatarsal head to sit over the sesamoids in a better position.
At this time, the area was flushed with copious amounts of sterile saline and then gentamicin, GU irrigant. The capsule and periosteum reapproximated attempting to tighten the medial capsule to allow for the hallux to sit in a more straight position over the first metatarsal head. This was done as best as possible without having performed an osteotomy.
The subcutaneous structures were reapproximated using 3-0 Vicryl. The skin was reapproximated using 5-0 nylon simple interrupted in horizontal mattress-type suture. The alignment was adequate at best due to the inability to attempt an osteotomy or implant to totally correct the position of the first metatarsal. Attention was directed to the fourth digit where a longitudinal incision was made and a semi-elliptical incision with the ellipse excised in toto.
The incision was deepened via sharp and blunt dissection taking care to retract all vital structures and ligate any bleeding vessels. A transverse incision was made into the proximal interphalangeal joint. The proximal head of the fourth digit was excised in toto using power equipment. The region was flushed with gentamicin, GU irrigant. The capsule was tightened and reapproximated to offer more corrected position of the fourth toe.
Skin was reapproximated using 5-0 nylon simple interrupted suture. At this time, 1 mL of dexamethasone phosphate was infiltrated into the third interspace on the right foot. Bacitracin ointment was applied and 1 mL dexamethasone phosphate was infiltrated around the first metatarsal area with 5 mL of 0.5% Marcaine plain. Adaptic was then placed over the incisions and a sterile gauze compression dressing was applied with Coban wrap.
The tourniquet was released and it was 50 minutes on tourniquet time. There was instantaneous return of blood flow to all digits on the right foot. The patient tolerated simple bunionectomy of the first metatarsal head, other procedures, and anesthesia well without complications, with vital signs stable and capillary refill time less than 2 seconds to all the digits on the right foot.
