PROCEDURES PERFORMED:
- Austin bunionectomy with first metatarsal osteotomy with internal screw fixation, left foot.
- Akin hallux osteotomy with internal fixation, left foot.
- Second metatarsal shortening osteotomy, Weil, with internal screw fixation, left foot.
- Dorsal capsulotomy, second metatarsophalangeal joint, left foot.
- Dorsal capsulotomy, third metatarsophalangeal joint, left foot.
- Dorsal capsulotomy, fourth metatarsophalangeal joint, left foot.
- Arthrodesis, proximal interphalangeal joint, second digit, left foot with OsteoMed digital implant.
- Arthroplasty, third digit, proximal interphalangeal joint, left foot.
- Arthroplasty fourth digit, proximal interphalangeal joint, left foot.
PREOPERATIVE DIAGNOSES:
- Hallux abductovalgus, left foot.
- Hallux abductus interphalangeus, left foot.
- Dorsally contracted/subluxed second metatarsophalangeal joint, left foot.
- Dorsally contracted/subluxed third metatarsophalangeal joint, left foot.
- Dorsally contracted/subluxed fourth metatarsophalangeal joint, left foot.
- Elongated second metatarsal, left foot.
- Hammertoe deformity, second digit, left foot.
- Hammertoe deformity, third digit, left foot.
- Hammertoe deformity, fourth digit, left foot.
POSTOPERATIVE DIAGNOSES:
- Hallux abductovalgus, left foot.
- Hallux abductus interphalangeus, left foot.
- Dorsally contracted/subluxed second metatarsophalangeal joint, left foot.
- Dorsally contracted/subluxed third metatarsophalangeal joint, left foot.
- Dorsally contracted/subluxed fourth metatarsophalangeal joint, left foot.
- Elongated second metatarsal, left foot.
- Hammertoe deformity, second digit, left foot.
- Hammertoe deformity, third digit, left foot.
- Hammertoe deformity, fourth digit, left foot.
SURGEON: John Doe, D.P.M.
ASSISTANTS:
- (XX), D.P.M.
- (XY), MS4.
ANESTHESIA: MAC with local.
HEMOSTASIS: Pneumatic ankle tourniquet.
ESTIMATED BLOOD LOSS: Minimal.
DETAILS OF PROCEDURE: The patient was placed on the operating table in the supine position. Following IV sedation, a local anesthetic block was obtained utilizing 20 mL of 0.5% Marcaine plain. The left lower extremity was scrubbed and draped sterilely, an Esmarch was utilized for exsanguination, and the pneumatic tourniquet was inflated to 250 mmHg.
PROCEDURE 1: AUSTIN BUNIONECTOMY WITH FIRST METATARSAL OSTEOTOMY WITH INTERNAL SCREW FIXATION, LEFT FOOT.
A 65 cm linear longitudinal incision was made at the dorsomedial aspect of the first metatarsophalangeal joint running with the contour of the deformity. The incision was deepened through the subcutaneous layers, taking care to preserve and retract neurovascular structures.
Dissection was continued down into the first interspace where a lateral release was performed, including a lateral capsulotomy and release of the transverse intermetatarsal ligament and release of the conjoint hallux adductor tendon. The fibular sesamoid was also released both laterally, distally and proximally, and the sesamoid apparatus was noted to float into a more corrected medial position.
A linear periosteal and capsular incision was performed, which was reflected medially and laterally exposing the head of the first metatarsal.
After resecting the medial eminence and placing an access guidewire, a chevron osteotomy was performed in the head of the first metatarsal from medial to lateral. Upon completion of the osteotomy, the capital fragment was shifted laterally into a more corrected position. A K-wire was driven from dorsal proximal to plantar distal, and following AO principles and technique, an FRS DePuy screw, 22 mm in length, was placed over the K-wire and excellent compression was noted. The K-wire was removed. The remaining medial eminence was resected with a sagittal saw. The power rasp was used to smooth all bony prominences. The wound was irrigated with normal saline solution. A medial capsulorrhaphy was performed in order to reduce the redundancy of the medial capsule. The periosteal and deep facial layer was reapproximated with 3-0 Vicryl, the subcutaneous layer with 4-0 Vicryl and the skin closed with 4-0 Monocryl in a running subcuticular suture technique. Benzoin and Steri-Strips were applied to reinforce the skin closure.
Although the IM angle was noted to be appropriately reduced, the hallux abductor interphalangeus deformity remained. The decision was made to perform the Akin hallux osteotomy in order to appropriately reduce this deformity.
PROCEDURE 2: AKIN HALLUX OSTEOTOMY WITH INTERNAL FIXATION, LEFT FOOT.
A 3 cm linear longitudinal incision was made over the dorsomedial aspect of the proximal phalanx of the hallux. The incision was deepened through the subcutaneous tissues with care being taken to identify and retract neurovascular structures. All bleeders were cauterized as necessary.
A linear periosteal and capsulotomy incision was performed, which was reflected medially and laterally exposing the proximal phalanx.
Access guidewire was placed from dorsal to plantar and a transverse closing wedge osteotomy was performed after protecting all surrounding soft tissue structures, including the flexor hallucis longus tendon. The wedge of bone was removed and the hallux was reduced appropriately.
An OS staple, 9 mm, was placed across the osteotomy, and after using the heating unit, excellent compression was noted. The wound was irrigated with normal saline solution. The periosteal layer was reapproximated with 3-0 Vicryl, the subcutaneous layer with 4-0 Vicryl and the skin closed with 4-0 Monocryl in a running subcuticular suture technique. Benzoin and Steri-Strips were applied to reinforce the skin closure.
PROCEDURE 3: SECOND METATARSAL SHORTENING OSTEOTOMY, WEIL, WITH INTERNAL SCREW FIXATION, LEFT FOOT.
A 3.5 to 4 cm linear longitudinal incision was made over the dorsal aspect of the second metatarsophalangeal joint. The incision was deepened through the subcutaneous layers with care being taken to identify and retract neurovascular structures. All bleeders were cauterized as necessary. The extensor tendon was freed from the dorsal hood apparatus and reflected medially in order to expose the underlying head of the second metatarsal. A liner capsular and periosteal incision was performed, which was reflected medially and laterally.
A sagittal saw was used to perform the Weil osteotomy from dorsal distal to plantar proximal. Upon completion of the osteotomy, the capital fragment was distracted into a proximal position. A K-wire was driven from across the osteotomy site from dorsal to plantar to serve as temporary fixation. A 0.045 K-wire was driven from dorsal to plantar to serve as the drill guide. Upon removal of this K-wire, a 12 mm FRS twist-off screw was driven across the osteotomy site from dorsal to plantar and tightened into position. Good stabilization was noted. The other K-wire was then removed. A rongeur was used to resect the overhanging dorsal ledge. A power rasp was then used to smooth all bony prominences. Intraoperative fluoroscopy was obtained, as was also obtained in the first two procedures, to confirm the position and correction of the deformity and position of the internal fixation. This was confirmed to be excellent. The wound was irrigated with normal saline solution. The deep fascial and capsular layer was reapproximated with 3-0 Vicryl, the subcutaneous layer with 4-0 Vicryl and the skin closed with 4-0 Monocryl in a running subcuticular suture technique. Benzoin and Steri-Strips were applied.
A Kelikian push-up test was performed and the second metatarsophalangeal joint was still noted to be in a dorsally contracted/subluxed position. The decision was made to perform a dorsal capsulotomy at the second metatarsophalangeal joint.
PROCEDURE 4: DORSAL CAPSULOTOMY, SECOND METATARSOPHALANGEAL JOINT, LEFT FOOT.
A transverse dorsal capsulotomy was performed with a #15 blade at the second metatarsophalangeal joint.
The Kelikian push test was again performed in the dorsal contracture/subluxation. The second metatarsophalangeal joint was noted to be appropriately reduced. The dorsal contracture/subluxation was noted to be reduced; however, a hammertoe deformity of the second digit remained. The decision was made to perform an arthrodesis of the second digit proximal interphalangeal joint with an OsteoMed digital implant.
PROCEDURE 5: ARTHRODESIS, PROXIMAL INTERPHALANGEAL JOINT, SECOND DIGIT, LEFT FOOT WITH OSTEOMED DIGITAL IMPLANT.
A 3 cm linear longitudinal incision was made over the dorsal aspect of the second digit centered over the PIPJ. The incision was deepened through the subcutaneous layers and with careful retraction, a transverse tenotomy and capsulotomy was performed at the level of the PIPJ. All ligamentous and capsular structures were freed from the head of the proximal phalanx and an oscillating saw was used to resect the head of the proximal phalanx, which was passed from the operative field.
The drill from the OsteoMed digital implant set was used to perform the appropriate 15 and 10 mm length drill holes in the proximal and middle phalanx. Once this was performed, the digital implant was placed in normal saline with Kantrex solution and placed into the second digit proximal interphalangeal joint.
The deformity was noted via fluoroscopy, which was noted to be excellent. The extensor tendon was reapproximated with 4-0 Vicryl and the skin was closed in a simple interrupted suture technique with 4-0 nylon. Again, the Kelikian push test was performed, and at this point, the hammertoe deformity was noted to be reduced.
PROCEDURE 6: ARTHROPLASTY, THIRD DIGIT, PROXIMAL INTERPHALANGEAL JOINT, LEFT FOOT.
A 3 cm linear longitudinal incision was made over the dorsal aspect of the third digit centered over the PIPJ. The incision was deepened through the subcutaneous layer, and with careful retraction, a transverse tenotomy and capsulotomy was performed at the level of the PIPJ. All ligamentous and capsular structures were freed from the head of the proximal phalanx, and using an oscillating saw, the head of the proximal phalanx was resected and passed from the operative field.
The wound was irrigated with normal saline solution. The extensor tendon was reapproximated with 4-0 Vicryl and the skin closed in a simple interrupted suture technique with 4-0 nylon.
The Kelikian push test was performed, and although the hammertoe deformity was partially reduced, the dorsal contracture/subluxation of the third metatarsophalangeal joint remained. The decision was made to perform a dorsal capsulotomy at the third metatarsophalangeal joint.
PROCEDURE 7: DORSAL CAPSULOTOMY, THIRD METATARSOPHALANGEAL JOINT, LEFT FOOT.
A 3 cm linear longitudinal incision was made at the dorsal distal aspect of the third intermetatarsal space. The incision was deepened through the subcutaneous layers with care being taken to identify and retract all vital neurovascular structures. All bleeders were cauterized as necessary.
Dissection was continued down to the dorsal aspect of the third metatarsophalangeal joint, and a dorsal transverse capsulotomy was performed.
Again, the Kelikian push test was performed, and the hammertoe deformity was noted to be reduced as well as the dorsal contracture/subluxation of the third metatarsophalangeal joint.
PROCEDURE 8: ARTHROPLASTY, FOURTH DIGIT, PROXIMAL INTERPHALANGEAL JOINT, LEFT FOOT.
A 3 cm linear longitudinal incision was made over the dorsal aspect of the fourth digit centered over the PIPJ.
With careful retraction and dissection through the subcutaneous layers, a traverse tenotomy and capsulotomy was performed at the dorsal aspect of the PIPJ. Ligamentous and capsular structures were reflected from the head of the proximal phalanx. An oscillating saw was used to resect the head of the proximal phalanx, which was passed from the operative field.
Irrigation was performed with normal saline solution. The extensor tendon was then reapproximated with 4-0 Vicryl and the skin closed in a simple interrupted suture technique with 4-0 nylon.
The Kelikian push test was performed and the dorsal contracture/subluxation of the fourth metatarsophalangeal joint remained. The decision was made to perform a dorsal capsulotomy at the fourth metatarsophalangeal joint in order to reduce this deformity.
PROCEDURE 9: DORSAL CAPSULOTOMY, FOURTH METATARSOPHALANGEAL JOINT, LEFT FOOT.
Dissection was continued down to the dorsal aspect of the fourth metatarsophalangeal joint and a transverse capsulotomy was performed with a #15 blade.
The Kelikian push test was performed and the dorsal contracture/subluxation of the fourth metatarsophalangeal joint was noted to be appropriately reduced. The wound was irrigated with normal saline solution. The subcutaneous layer reapproximated with 4-0 Vicryl and the skin closed in a running subcuticular suture technique with 4-0 Monocryl. Benzoin and Steri-Strips were applied.
Twenty mL of 0.5% Marcaine plain was injected for postoperative block. The incisions were dressed with dilute Betadine-soaked Adaptic, gauze, Kling, Kerlix, and Coban. The pneumatic tourniquet was deflated and a prompt hyperemic response was noted to all digits of the left foot.
The patient tolerated the procedure and anesthesia and was transferred to the recovery room in apparent satisfactory condition with vital signs stable and vascular status intact.
The patient was provided with postoperative instructions, which included;
- Partial weightbearing, heel weightbearing with surgical shoe with roll about or crutch assistance, left.
- Use the DonJoy Iceman Cold Therapy Unit during awake hours.
- Elevate left lower extremity above heart level.
- Keep dressing clean, dry and intact.
- Follow up with Dr. (XX) in his private office.
