OPERATION: Endoscopic plantar fasciotomy, right foot.
DESCRIPTION OF OPERATION: Under mild sedation, the patient was brought into the operating room and placed on the operating table in supine position. A pneumatic ankle tourniquet was then placed about the patient's right ankle. Following IV sedation, a posterior tibial and sural nerve block was performed to the right foot utilizing 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine. The foot was then scrubbed, prepped, and draped in the usual aseptic manner. An Esmarch bandage was then utilized to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet was then inflated.
Attention was then directed to the medial aspect of the right calcaneus where a 1 cm linear incision was made from superior to inferior, approximately 4 cm anterior to the posterior aspect of the calcaneus and approximately 2 cm superior from the plantar surface of the calcaneus. This incision was then deepened through the subcutaneous tissues, being careful to identify and retract all vital neural and vascular structures. All bleeders were cauterized and ligated as necessary. At this time, a probe was inserted through the medial incision and directed laterally just plantar to the plantar fascia, which could be palpated with the probe. A plane was created between the plantar fascia and the plantar fat pad. The probe was then continued laterally until tenting was noted in the skin over the lateral aspect of the heel.
At this time, the probe was removed and an obturator with a sliding cannula was inserted in its place through the medial incision and directed laterally in the plane between the plantar fascia and the plantar fat pad. Tenting was noted on the lateral aspect of the calcaneus and a #15 blade was then used to make a second 1-cm incision over the tented skin on the lateral surface of the calcaneus. The obturator and sliding cannula were then continued laterally through the lateral incision. The obturator was removed leaving the sliding cannula in place.
An endoscope was then inserted into the cannula through the medial incision and a probe was used to identify the medial band of the plantar fascia through the lateral incision. The probe was removed and a retrograde knife was inserted through the lateral aspect of the cannula and the medial one third of the plantar fascia was incised from medial to lateral, through and through. This required several swipes with the blade. The toes were then dorsiflexed to stretch the cut ends of the fascia away from one another. On doing this, the belly of the flexor digitorum brevis could be visualized through the scope. The endoscope was then removed and reinserted through the lateral opening in the cannula and the medial one third of the plantar fascia was noted to be completely severed. The scope was then removed, and with the cannula in place, the wound was flushed with copious amounts of sterile normal saline. Next, the obturator was reinserted into the cannula, and the obturator and cannula removed as one unit.
Both incisions were then reapproximated and coapted utilizing 5-0 Prolene using interrupted horizontal mattress suture techniques. On completion of the procedure, a total of 1 cc of Decadron phosphate was infiltrated about the incision site. The incisions were dressed with Betadine-soaked Adaptic and covered with sterile compressive dressings consisting of 4 x 4's and Kling. The pneumatic ankle tourniquet was then deflated and prompt hyperemic response was noted to all digits of the right foot. An Ace wrap was then applied.
The patient tolerated the procedure and anesthesia well. She was transferred to the recovery room with vital signs stable and vascular status intact to all digits of the right foot.
DATE OF OPERATION: MM/DD/YYYY
1. Tarsal coalition with subtalar joint degeneration, left.
2. Equinus deformity, left.
1. Tarsal coalition with subtalar joint degeneration, left.
2. Equinus deformity, left.
1. Subtalar joint arthrodesis, left.
2. Gastroc recession, left.
SURGEON: John Doe, DPM
ASSISTANT: Jane Doe, DPM
HEMOSTASIS: Pneumatic thigh tourniquet 300 mmHg x 92 minutes. The tourniquet was then deflated and reinflated for an additional 92 minutes.
ESTIMATED BLOOD LOSS: Less than 10 mL.
MATERIALS: Grafton bone graft substitute. Free straight iliac crest bone graft and one 7.3 Synthes partially threaded cannulated screw.
INJECTABLES: 20 mL of 0.5% Marcaine plain postoperatively.
DESCRIPTION OF OPERATION: The patient was consented for the procedure and brought to the operating room, where the name and allergy bands were rechecked. The patient was then brought to the operating room and placed on the table in a modified lateral decubitus position. Attention was then directed to the posterior aspect of the left leg, where a 3 cm incision was made at the gastroc-soleal junction. Care was taken to protect all neurovascular structures. Dissection was carried bluntly down to the gastroc aponeurosis. The aponeurosis was then transected from medial to lateral in toto and good dorsiflexion capability was noted following the procedure. The wound was copiously flushed with normal sterile saline. The subcutaneous tissue was reapproximated with 4-0 Vicryl and skin was reapproximated with 4-0 PDS in intracuticular fashion.
Next, attention was directed to the lateral aspect of the left foot where an incision was made from the distal tip of the fibula, extending up to the base of the fourth metatarsal. A blunt dissection was carried down and all neurovascular structures were identified and protected. The peroneal tendons were freed and retracted distally. Next, the extensor digitorum brevis muscle belly was reflected dorsal and distal and the contents of the sinus tarsi were evacuated. The subtalar joint was unable to be accessed, was opened with a lamina spreader. The cartilage on the calcaneal and talar surface were then denuded and removed with curved osteotome and curettes.
Once we were down to subcondylar bone, subcondylar drilling was performed with a 0.062 K-wire both to the talus and calcaneus and fish scaling was performed with the osteotome. The foot was then placed in an erect position and identified both on lateral and calcaneal axial views. The guide pin for the 7.3 screw was driven from the calcaneus into the talus under fluoroscopic guidance. Care was taken not to invade the ankle joint surface. Next, the 7.3 cannulated screw was inserted in the standard technique. Bone graft substitute was then packed into the subtalar joint. Good stability was noted. There were attempts made to place the second screw. However, due to the nature of the size of the talus, it was impossible. We determined at that point that one screw did provide significant stability across the arthrodesis site.
The wound was copiously flushed with normal sterile saline. The extensor digitorum brevis muscle belly was reapproximated to its anatomical position. Deep structures were reapproximated with 3-0 Vicryl, subcutaneous with 4-0 Vicryl, and the skin reapproximated with skin staples. The screw holes were then reapproximated with 3-0 nylon in a simple interrupted fashion. Wounds were then dressed with Xeroform. Dry sterile, 4 x 4s multilayered Jones compression bandage was applied postoperatively. The patient tolerated the procedure and anesthesia well and left the OR and to the recovery room with vital signs stable and vascular status intact. No complications were noted. The patient will be admitted for postoperative convalescence and pain management.
1. Clayton procedure, left foot, panmetatarsal head resection of 2 through 5.
2. Left correction of bunion.
3. Left second digit arthroplasty.
PROCEDURE IN DETAIL: Under mild sedation, the patient was brought to the operating room and placed on the operating table in a supine position. A well-padded pneumatic ankle tourniquet was placed about the patient’s left ankle. MAC anesthesia was given as well as a local block consisting of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain. Foot was then scrubbed, prepped, and draped in the usual aseptic manner. The limb was then elevated. Ankle tourniquet was then inflated. Attention was then directed to the second and fourth interspace, where approximately 3-cm linear longitudinal incision was made encompassing a past scar. The incision was deepened using sharp and blunt dissection. Care was taken to retract all vital neurovascular structures. The second metatarsal head was then identified through the second interspace incision. This was freed of all attachments using sharp and blunt dissection as well as the McGlamry elevator. The second, third, fourth, and fifth metatarsal heads were all freed in the same fashion. Next, utilizing the oscillating bone saw, the heads of the metatarsals were transected (the second, third, fourth, and fifth) and passed from the operative site in toto.
Next, attention was then directed to the first metatarsal where a linear longitudinal incision was made medial and parallel to the extensor tendon along the first metatarsal. Incision was deepened using sharp and blunt dissection. Care was taken to retract all vital neurovascular structures. The head of the metatarsal was freed and identified, and using a crescentic blade, the head of the metatarsal was transected. The sesamoids were left in position. All cartilaginous surfaces and medial bump prominence were resected and passed from the operative site.
Next, attention was then directed to the second digit, which was contracted and elongated and a 2-cm linear longitudinal incision was made over the extensor tendon. The extensor tendon was transected. The collateral ligaments were released. The head of the proximal phalanx was exposed. It was transected utilizing an oscillating bone saw and passed from the operative site in toto. The foot was reassessed now and found to be in a more corrected position with less plantar pressure in a retrograde fashion. A 0.045 K-wire was passed through the second digit into the remaining metatarsal stump as well as in the fourth digit into the remaining metatarsal stump and into the first digit into the metatarsal. All wounds were then irrigated with copious amounts of normal sterile saline. The foot was then checked under C-arm and adequate alignment was noted at this time. A TLS drain was placed.
All wounds were closed in a layered fashion and dressed with Steri-Strips, Betadine-soaked Adaptic, as well as sterile compressive dressing consisting of 4 x 4's and Kling. A posterior splint was applied. The pneumatic ankle tourniquet was released. Prompt hyperemic response was noted to all digits of the left foot following a period of postoperative monitoring. The patient tolerated the procedure well. The patient was transferred from the OR to the recovery room. Vital signs were stable, and neurovascular status was intact to all digits of the left foot.
1. Left third distal interphalangeal joint arthroplasty with K-wire fixation.
2. Flexor digitorum longus tenotomy, left third digit.
3. Right hallux interphalangeal joint condylectomy.
DESCRIPTION OF PROCEDURE: Under mild sedation, the patient was brought to the operating room and placed on the operating room table, where left and right well-padded pneumatic ankle tourniquets were placed. Next, the above-mentioned cocktail was injected on the left third digit, in a digital block and a hallux block about the right foot. Both feet were prepped and draped in the usual aseptic manner. The left foot was then elevated in an approximately 45-degree angle and exsanguinated using an Esmarch bandage.
Next, a semi-elliptical incision was made dorsally about the third distal interphalangeal joint. The skin was reflected and removed. The sharp and blunt dissection continued down to the subcutaneous tissue, retracting all neurovascular structures and ligating all necessary bleeders. Dissection was carried down to the extensor digitorum longus tendon, which was identified and reflected both proximally and distally.
Next, all soft tissue attachments were reflected off of the intermediate phalanx head. An oscillating saw was then utilized to resect the intermediate phalanx head. Dissection was carried down plantarly to identify the flexor digitorum longus tendon, which was then tenotomized. The wound was flushed and irrigated using copious amounts of normal sterile saline.
Next, a 0.045 K-wire was inserted through the base of the distal phalanx and was inserted in the intermediate phalanx and to the proximal phalanx in a retrograde fashion. Fluoroscopy was utilized to confirm proper K-wire placement, which was noted to be adequate. Deep closure was obtained using Vicryl suture. Skin was closed and reapproximated using Novafil suture. The wound was dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4 gauze, Kling, and an Ace bandage. The left tourniquet was then deflated.
Next, the right foot was elevated at an approximately 45-degree angle and exsanguinated using an Esmarch bandage. Attention was then directed to the medial aspect of the hallux interphalangeal joint, where an approximately 2.5 cm incision was made. Sharp and blunt dissection was carried down to the subcutaneous tissue retracting all neurovascular structures and ligating all necessary bleeders. Careful dissection continued until the condyles of the base of the distal phalanx medially and condyle of the proximal phalanx distally was exposed. Dissection was utilized to free up all soft tissue attachments by paying careful attention to preserve the flexor and extensor tendons.
Next, an oscillating saw was utilized to resect the condyles at the interphalangeal joint. A rongeur was utilized to remove any other excessive hypertrophic bone. It was noted that no hypertrophic bony prominences remained. The wound was flushed and irrigated using copious amounts of normal sterile saline. Fluoroscopy was then utilized to confirm proper resection of bone. It was noted that adequate resection was achieved. Deep closure was obtained using Vicryl suture, and skin was closed and reapproximated using Novafil suture.
The wound was dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4 gauze, Kling, and Ace bandage. The tourniquet was deflated. The patient tolerated the anesthesia and procedure well, returned to the PACU with vital signs stable and hyperemia to all digits.