DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Severe fixed pes planovalgus abductus right foot deformity.
2. Equinus contracture, right lower extremity.
3. Degenerative arthrosis, right mid foot.
4. Right forefoot varus deformity.
5. Obesity.
6. Venous insufficiency.
POSTOPERATIVE DIAGNOSES:
1. Severe fixed pes planovalgus abductus right foot deformity.
2. Equinus contracture, right lower extremity.
3. Degenerative arthrosis, right mid foot.
4. Right forefoot varus deformity.
5. Obesity.
6. Venous insufficiency.
OPERATION PERFORMED:
1. Extensive right foot and ankle soft tissue/capsular release.
2. Right triple arthrodesis with internal fixation.
3. Right first tarsometatarsal arthrodesis with internal fixation.
4. Right Achilles tendon lengthening.
5. Right distal tibial autogenous cancellous bone graft.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATION FOR OPERATION: This is a (XX)-year-old female with history of severe progressive pain and deformity involving the right foot and ankle. She has developed a severe fixed pes planovalgus abductus foot deformity. She has begun to have valgus tilting of her tibiotalar joint. She does have degenerative changes involving her mid foot with collapse and instability with fixed forefoot varus deformity. She is significantly overweight and does have chronic lymphedema. Arterial perfusion appeared satisfactory. Conditions were discussed at length, including treatment alternatives, both nonoperative and operative, as well as associated risks and benefits. The patient wished to proceed with surgical treatment as indicated above. Informed consent was obtained. All questions were answered.
OPERATIVE FINDINGS AND PROCEDURE DESCRIPTION: After satisfactory general anesthesia was obtained with the patient in the supine position, pneumatic tourniquet was placed to the right proximal thigh with appropriate padding. She was given 2 grams of intravenous Ancef as prophylaxis prior to the start of procedure. Right side was bolstered upward and supported with beanbag. All bony prominences were carefully padded. Great care was taken in patient positioning. The right foot, ankle, and leg were gently exsanguinated with Esmarch bandage and tourniquet inflated to 275 mmHg.
An Achilles tendon lengthening was performed in a standing Hoke fashion. Three skin stab incisions were used, each placed 3 to 4 cm apart. Step cuts were made in the Achilles tendon and controlled lengthening carried out. Care was taken to avoid over-lengthening. Achilles tendon was palpable and intact at the conclusion of lengthening.
A lateral oblique incision was made over the lateral ankle/hindfoot. It was started just distal and posterior to the tip of the fibula and directed toward the base of 4th metatarsal. Sharp and blunt dissections were performed. Hemostasis was obtained with electrocautery. Extensive soft tissue release was performed, including release of the transtarsal and subtalar capsule, as well as part of the tibiotalar capsule. Calcaneofibular ligament was released. Interosseous ligaments were released.
Attention was then turned medially where a dorsal medial incision was made over the ankle/hindfoot staying medial to the tibialis anterior tendon. Sharp and blunt dissections were performed. Hemostasis was obtained with electrocautery. Additional soft tissue release was performed to allow correction of the fixed preoperative severe deformity. Midfoot and hindfoot release was performed as well as ankle. The foot was gradually mobilized. Limited lengthening of the peroneals in a fractional-type fashion was required to achieve correction.
Attention was then turned to the right calcaneocuboid joint, which was exposed in a subperiosteal fashion. Arthrodesis surfaces were carefully prepared with the aid of osteotome, chisels, curettes, and rongeur. Meticulous preparation was achieved preserving overall bony architecture. The surfaces were fish scaled.
Attention was turned to the subtalar joint. It was then prepared in a similar fashion. Articular cartilage was carefully removed. Care was taken to preserve overall bony architecture. Preparation included posterior and medial facets. The surface was fish scaled. Wound was irrigated with normal saline solution.
Attention was then turned to the talonavicular arthrodesis site, which was carefully prepared in a similar fashion. Intentional shortening of the talus was carried out removing the distal portion of the talar head in order to aid in correction of preoperative deformity. Good overall preparation of arthrodesis surface was carried out. The wounds were irrigated with copious amounts of normal saline solution.
Foot was then carefully reduced and provisional fixation obtained using K-wires and guidepins. Satisfactory reduction was felt to have been achieved. This was confirmed clinically and fluoroscopically. Screw fixation was then accomplished using AO titanium partially threaded cannulated cancellous screws. Then, 4.0 mm screws were used for the talonavicular and calcaneocuboid arthrodesis sites. Two screws were used at each site. Talonavicular screws were inserted in a retrograde fashion. Calcaneocuboid screws were inserted in anterograde fashion. A single 7.3 mm cannulated screw was used for fixation of the subtalar joint directed from the dorsal talar head into the posterior body of the calcaneus. The talocalcaneal screw was not initially tightened fully due to the bony defect present in the lateral aspect of the joint.
A dorsal longitudinal incision was then made over the 1st tarsometatarsal joint. Sharp and blunt dissection was performed. Hemostasis obtained with electrocautery. Care was taken to protect the sensory cutaneous nerves. Deep fascia was incised in line with the incision. The 1st tarsometatarsal joint was then exposed in a subperiosteal fashion. Moderate degenerative changes were noted. Joint was noted to be markedly unstable.
Arthrodesis surfaces were carefully prepared using osteotomes, chisels, and curettes. A plantar-based wedge was removed in order to aid in the correction of deformity. Good overall preparation was achieved. Surfaces were fish scaled. Joint was carefully reduced in the forefoot into adduction and the 1st ray at the plantarflexion to obtain a plantigrade foot. Provisional fixation was obtained using a K-wire and a guidepin from AO cannulated screw set. It was inspected and felt to be satisfactorily aligned. FluoroScan demonstrated satisfactory pin placement. Screw fixation was then accomplished using a 4.0 mm titanium partially threaded AO cannulated cancellous screw inserted in a retrograde fashion. A 2nd screw was then used (4.0 mm fully threaded noncannulated screw) in an anterograde fashion. Both screws were countersunk and inserted in lag fashion. Good interfragmentary compression was achieved with good fixation, despite relative soft bone quality. FluoroScan demonstrated satisfactory alignment and hardware placement throughout.
A medial longitudinal incision was made over the medial distal tibial metaphysis over the length of approximately 4 cm. Sharp and blunt dissection was performed. Hemostasis was obtained with electrocautery. Sharp and blunt dissection was performed exposing the underlying periosteum, which was incised longitudinally. It should be noted that throughout the procedure, there was significant lymphedema type of fluid within the soft tissues. Medial distal tibial metaphysis was exposed in a subperiosteal fashion. K-wires were placed in the medial distal tibia and position confirmed with fluoroscopy. Acumed bone harvesting device was then used to harvest a good quantity of cancellous bone through a single entry portal. Satisfactory bone was able to be obtained. Wound was irrigated with normal saline solution.
After re-irrigation of wounds, bone graft was packed into arthrodesis sites and particularly in the bony defect noted widely. A satisfactory quantity of bone was obtained. Multiple troughs were created at each arthrodesis site to aid in healing. FluoroScan confirmed good overall alignment and hardware placement.
Wounds were closed in layers using 2-0 Vicryl interrupted suture for capsule and deep fascia. The subcu was approximated using 3-0 Vicryl interrupted buried sutures. The skin was closed in all wounds using staples.
It should be noted that tourniquet was released prior to completion of wound closure with good reperfusion of the foot noted. The tourniquet was initially inflated for 120 minutes and then let down for 20 minutes prior to being reinflated for 53 minutes.
Sterile dressings were then applied followed by an extremely well-padded short-leg fiberglass cast with the foot and ankle in neutral alignment. Once the cast had hardened, it was split anteriorly removing 1 cm section. Anesthesia was reversed, and the patient was transferred to the recovery room in stable condition. Instrument and sponge counts were correct. No complications.
