DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Hallux limitus/hallux rigidus.
2. Severe degenerative joint disease, first metatarsophalangeal joint, right foot.
POSTOPERATIVE DIAGNOSES:
1. Hallux limitus/hallux rigidus.
2. Severe degenerative joint disease, first metatarsophalangeal joint, right foot.
OPERATIONS PERFORMED:
1. Cheilectomy, right foot.
2. First metatarsal osteotomy, modified Youngswick, right foot.
3. Autogenous graft, right foot.
4. Soft tissue interposition, first metatarsophalangeal joint, right foot.
SURGEON: John Doe, DPM
ASSISTANT: Jane Doe, DPM
ANESTHESIA: MAC with local.
HEMOSTASIS: Pneumatic ankle tourniquet.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: The patient was placed in supine position following IV sedation. A local anesthetic block was obtained utilizing 15 mL of 0.5% Marcaine plain in a Mayo block fashion. A pneumatic tourniquet was placed about the well-padded right ankle. The right lower extremity was scrubbed and draped. An Esmarch was utilized for exsanguination, and the pneumatic ankle tourniquet was inflated to 250 mmHg.
A 6 cm linear longitudinal incision was made medial and parallel to the tendon of the extensor hallucis longus and above the contour of the deformity. The incision was centered over the first metatarsal head and deepened through the subcutaneous tissues using blunt and sharp dissection. Care was taken to identify and retract all vital and neurovascular structures. All bleeders were cauterized as necessary. At this time, a linear capsulotomy was performed over the dorsal aspect of the first metatarsophalangeal joint. The periosteal and capsular structures were then carefully dissected free of the osseous attachments and reflected medially and laterally, thus exposing the head of the first metatarsal at the operative site.
Immediately, a large dorsal exostosis was noted on the first metatarsal head. Additionally, large loose joint mouse was noted within the dorsal aspect of the joint. This was dissected free and removed. A sagittal saw was utilized to resect the dorsal prominence, the medial and lateral prominences and from the first metatarsal head. A power rasp was utilized to smooth all bony prominences. A rongeur was utilized to resect the prominent base of the proximal phalanx to more of an anatomic size. A power rasp was also utilized to smooth all bony prominences.
Attention was directed to the first interspace via the original skin incision where the tendon of the extensor hallucis brevis was initially identified and tenectomized. The dissection was continued using blunt dissection down to the level of the fibular sesamoid, which was free of its soft attachments proximally, laterally and distally. The conjoined tendon at the adductor hallucis muscle was then identified and transected at its attachment to the base of the proximal phalanx of the hallux. At this time, the lateral contraction present on the hallux was noted to be reduced, and the sesamoid apparatus was noted to float into a more corrected medial position. Attention was directed to the medial aspect of the first metatarsal head where after placing an apical axis guidewire, a through and through V-type osteotomy was created in the metaphyseal region of this bone utilizing a sagittal bone saw to the apex of the osteotomy point distally.
Utilizing the bone, which was resected from the dorsal prominent exostosis previously and after carefully removing all cortical aspects of the bone with a rongeur and bone cutting forceps, a rectangular-shaped autogenous bone graft was inserted within the site of the plantar osteotomy in the first metatarsal head further plantar flexing the metatarsal head. At this time, two 0.062 inch K-wire was driven from dorsal, proximal to plantar distal across the osteotomy site to serve as internal fixation. The K-wires were then bent, cut, and turned against the shaft of the metatarsal. The power rasp was utilized to again remove all bony prominences. The wound was flushed with a copious amount of sterile normal saline.
An elliptical capsulotomy was performed at the medial aspect of the joint, and the capsule was pulled within the first metatarsophalangeal joint to serve as soft tissue interposition within the severely arthritic joint. It must be noted that the joint was completely devoid of cartilage, and subchondral drilling was not deemed an option. Subchondral cysts were noted as well as subchondral erosion. With the capsule interposed, a 3-0 Ethibond was utilized in a simple interrupted fashion to hold the capsule in its new proper position. The first metatarsophalangeal joint was placed through range of motion at this time, and the range of motion was noted to greatly increase. The range of motion at the start of the procedure approached 0 to 5 degrees and towards the end of procedure was noted to increase to approximately 40 to 50 degrees.
The wound was again flushed with normal saline solution. The periosteal and capsular structures were reapproximated and coaptated utilizing 3-0 Vicryl. The subcutaneous layer was reapproximated utilizing 4-0 Vicryl, and the skin was closed in a simple running subcuticular suture technique with 4-0 Monocryl. Benzoin and Steri-Strips were applied to reinforce the skin closure. Upon conclusion of the procedure, a mixture of 1 mL of Decadron phosphate and 9 mL of 0.5% Marcaine plain was also injected. The incision was dressed with Adaptic and covered with a sterile compressive dressing consisting of gauze, Kling, Kerlix, Coban, and Ace. The patient tolerated the procedure and anesthesia well. He was transferred to the recovery room in apparent satisfactory condition with vital signs stable and vascular status intact to the right foot.
