PREOPERATIVE DIAGNOSIS: Achilles tendinitis and arthritis in the left foot causing pronation and pes planus to the left lower extremity.
POSTOPERATIVE DIAGNOSIS: Achilles tendinitis and arthritis in the left foot causing pronation and pes planus to the left lower extremity.
PROCEDURE PERFORMED: Achilles tendon lengthening with graft and calcaneal osteotomy with internal fixation left foot.
SURGEON: John Doe, DPM
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: This is a (XX)-year-old female who has significant discomfort and pain in her left lower extremity. Not only she has tightness in her Achilles tendon, which is not allowing her foot to go to a 90-degree angle, she also has severe pronation and medial arch collapse with arthritis in her midfoot and her calcaneal area according to the MRI. We discussed in detail with her 2-part procedure by which we correct the rear foot first, keep her nonweightbearing for 2 to 3 weeks and then correct her forefoot with first metatarsal correction, medial column fusion and digital correction as well. She understands all risks, complications, outcomes, and expectations involved with these types of procedures after we discussed in detail the risks and she willingly signs the consent form and would like to have surgery and a 23-hour observation, possibly placement in assisted living due to her living conditions.
DESCRIPTION OF OPERATION: The patient was brought into the operating room in a supine position and transferred to the operating room table in a lateral decubitus position on the right side. She was kept in that position with a seatbelt and a beanbag and we were able to access the posterior aspect of her left Achilles tendon as well as her calcaneus on the left side. Her left leg was dressed and draped in a proper aseptic technique. A thigh tourniquet set at 300 mmHg was placed on the left thigh and inflated. She also received 1 gram of Ancef prior to procedure for antibiotic prophylaxis.
Attention was first turned to the posterior aspect of her leg, where approximately a 6 to 7 cm incision was placed over the Achilles tendon at its relationship with the gastrocnemius at the myotendinous junction. The incision was carefully deepened. We identified the nerve as well as any other vital structures. They were identified and retracted. The paratenon was then gently reflected from the tendon itself, and immediately, we noticed the tendon at its insertion and its junction with gastrocnemius muscle. We were able to do a VY type tendinotomy, allowing the tendon then to release and allowing a dorsiflexion on her left lower extremity prior to repairing that tendon.
We then turned attention to the calcaneus, where in the lateral aspect of the calcaneus approximately a 4 cm incision was made. This was carefully deepened to the level of the periosteum of the calcaneus. Once we identified the regions of the calcaneus that needed to be identified, the body of the calcaneus, we did a through-and-through cut using proper orthopedic technique and instrumentation. We were able to slide the calcaneus a full centimeter medially, allowing the rear foot now to become more of a varus heel as opposed to a valgus heel.
We kept this osteotomy in place temporarily with K wires until we checked intraoperative fluoroscan imaging, which demonstrated a good slide and also a varus relationship to the rest of the foot. Permanent fixation of this osteotomy was achieved using some demineralized bone matrix and a Darco offset 1 cm plate. The plate was held in place with 4 AO fixation screws, two of them being 16 mm long and 2 of them being 18 mm long. We checked intraoperative fluoroscan imaging again, which demonstrated good offsetting of the calcaneus and a good varus correction of the calcaneus. This allowed the lengthening of the tendon to take place as well. We kept the foot at 90 degrees and I was able to reapproximate the Achilles tendon itself. I used 2-0 Vicryl suture to reapproximate the Achilles tendon.
We did a VY type cut; therefore, we did a Y type reapproximation. Over this approximation, we used a small piece of Artelon graft in order to reinforce the tendon itself. We used 2-0 Ethibond suture in order to keep the Artelon graft in place. We then used a 2-0 Vicryl suture and reapproximated the paratenon over the tendon itself and used a 2-0 Vicryl suture to reapproximate the deep tissues and subcutaneous tissues. The epidermal tissues were reapproximated using a nylon suture.
Attention was then turned to the calcaneal osteotomy. More of the DBM bone matrix was then used in this area. We were able to reapproximate the subcutaneous tissue using a 2-0 Vicryl suture, and the epidermal tissues were reapproximated using a nylon suture. Again, all vital structures and venous bleeders were retracted and venous bleeders were cauterized prior to closure. A sterile compressive dressing, including ABD pads, was used on both incisions and a splint. A posterior splint was then used to keep her foot in a good 90 degree corrected position.
Postoperatively, we used 0.5% Marcaine plain to inject into the incisional areas to keep the patient comfortable upon awakening. She will be placed in 23-hour observation here at the hospital and also evaluated for possible assisted living or rehab placement at the rehab center. We are also going to take x-rays later. She left the OR in good condition with vital signs stable and all her digits became pink and warm with good capillary refill times.
