Bunion - Chevron

INDICATIONS: Patient presents for pain in the left foot due to persistent bunion deformity.  Pt has failed conservative care and desires to have surgical correction at this time.  The nature of deformity/problem, anticipated procedure, post-operative recovery/convalescence, risks/complications, including but not limited to numbness, tingling, over/under correction, problems healing of soft tissue or bone, persistent pain and disability, have been explained to the patient in detail. All questions have been answered to the patient's satisfaction. No promises or guarantees have been given as to the outcome of the procedure.

PROCEDURE:  The patient was brought to the operating room and placed on the operating table in a supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.

A well padded ankle tourniquet was then applied to the ankle and set at 250 mmHg.

The left foot was then prepped, scrubbed, and draped in normal sterile technique. The left ankle tourniquet was inflated. Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 4-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe. The incision was deepened through subcutaneous tissues. All neuromuscular structures as they were encountered were carefully retracted and protected through the duration of the case. The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint.  Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal. The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion. A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint. The medial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw. The same saw was used to perform an chevron-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal.  The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal. Provisional fixation was achieved with a smooth wire that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction. The same wire was also used as guide wire for the insertion of a partially threaded screws from the 3.0mm Stryker system upon insertion of the screw, which was accomplished using AO technique. The wire was removed. Fixation on the table was found to be excellent. Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical. The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw. The area was copiously flushed with saline. The periosteal and capsular tissues were approximated with 2-0 and Vicryl suture material, 3-0 and 4-0 Monocryl was used to approximate the subcutaneous tissues. The incision site was reinforced with Steri-Strips. At this time, the patient's left ankle tourniquet was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with, copious amounts of fluff and Kling, stockinette, and a Cuban bandage. The patient's left foot was then placed in a surgical shoe.

The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medication and instructions on how to control her postoperative course. The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. _________ in one week's time for their first postoperative appointment.

Brohstrom

INDICATIONS: Patient presents for pain in the ankle due to persistent pain and instability.  Pt has failed conservative care and desires to have surgical correction at this time.  The nature of deformity/problem, anticipated procedure, post-operative recovery/convalescence, risks/complications, including but not limited to numbness, tingling, over/under correction, problems healing of soft tissue or bone, persistent pain and disability, have been explained to the patient in detail. All questions have been answered to the patient's satisfaction. No promises or guarantees have been given as to the outcome of the procedure.

PROCEDURE:  Under mild sedation, the patient was brought to the operating room and placed in the supine position.  General anesthesia was achieved.

The leg was then scrubbed, prepped and draped in the usual aseptic manner.  It was elevated and exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.  Attention was directed to the patient's lateral ankle where a curvilinear incision was made along the anterior portion of the fibula, extending down to the tip of the distal fibula and distal to the tip of the fibula.  This was made to the epidermis and dermis down to the subcutaneous tissue.  Any bleeders were cauterized as necessary. The subcutaneous tissue was then dissected with blunt dissection to expose the extensor retinaculum. There was laxity in the posterior portion at the border close to the fibula.  An incision was made in the ligament structure approx 0.5cm from the insertion on the fibula, to allow for later closure.  The extensor retinaculum was then retracted inferior/distally.  We extended our incision deeper down to the level of the ankle joint capsule.  There was noted to be a partial tear with some synovial tissue and coloration to the area.  We made an incision through the capsule along the margin of the lateral gutter down to the distal portion of the fibula.  It was noted that the patient's synovial tissue billowed to the area and that the intracapsular portion of the ligament appeared to be thickened and dystrophic and invaginated to the lateral gutter.  This correlated directly to where the patient's pain had been located.  We debrided the dystrophic tissue down to healthy margins and flushed the wound copiously with normal sterile saline.  The ankle joint was explored and no signs of osteochondral lesion could be noted and the synovial tissue debrided out and we reflushed again with normal sterile saline.  We then reapproximated the capsule and ligament with 2-0 Ethibond and figure-of-eight stitch technique with excellent reapproximation noted.  There was not noted to be any further invagination to the lateral gutter.  This was performed along the entire course of the ankle joint capsule.  We then plicated the extensor retinaculum up over the repair to reinforce the stabilization.  Subcutaneous tissue was then repaired with 3-0 Vicryl and the skin was closed with skin staples.  A local periligamental block was given with 0.5% Marcaine plain.  The area was then dressed with Adaptic, 4 x 4, Kling, Kerlix, ABD and then Ace wrap.  We then applied a modified Jones compression type cast with the patient's foot held in a dorsiflexed and mildly everted position.  Before the cast was applied, the ankle joint was tested and noted to be very secure and stable.  No anterior drawer on inversion stress was noted whatsoever.  Tourniquet was deflated and prompt return of good response was noted to all digits of the patient's right foot before the cast was applied.  The patient tolerated the procedure well and was transferred to the recovery room with vital signs stable.  Neurovascular status returned promptly following release of the tourniquet.

The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medication and instructions on how to control her postoperative course. The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. _________ in one week's time for their first postoperative appointment.

Peroneal tendon repair with groove deepening

INDICATIONS: Patient presents for pain in the ankle due to persistent pain and instability.  Pt has failed conservative care and desires to have surgical correction at this time.  The nature of deformity/problem, anticipated procedure, post-operative recovery/convalescence, risks/complications, including but not limited to numbness, tingling, over/under correction, problems healing of soft tissue or bone, persistent pain and disability, have been explained to the patient in detail. All questions have been answered to the patient's satisfaction. No promises or guarantees have been given as to the outcome of the procedure.

PROCEDURE:  Under mild sedation, the patient was brought to the operating room and placed in the supine position.  General anesthesia was achieved.

A curvilinear incision was created over the peroneals from just inferior to the tip of the fibula up approximately 2-3 inches superiorly. Bleeders were clamped and ligated. Sharp and blunt dissection was used to gain access to the superior peroneal retinaculum and to the peroneal tendons. The retinaculum was transected with Metzenbaum scissors. Further incisions exposed the peroneal tendons. The peroneus longus appeared to be in good condition without any flattening or signs of tearing. The broadening was debrided with the Metzenbaum scissors, and the tendon was tubularized and held with a running suture of 2-0 Ethibond. The tendon was torn from approximately 1 inch exposed, and a 1/8th drill bit was inserted behind the peroneal retinaculum, creating space within the fibular canal. The tamp was used to deepen the groove in the fibula. The tendons were placed back in to place, and the peroneal brevis tendon was wrapped with a 4x4 cm EpiFlx placental graft. This was secured with a 3-0 Vicryl.

Next, the area was flushed with normal saline, and the superior peroneal retinaculum was repaired with 2-0 Ethibond. Ther area was once again flushed with normal saline and closed in layered fashion with 3-0 Vicryl for subcutaneous tissues, and the skin was closed in a subcuticular manner...

The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medication and instructions on how to control her postoperative course. The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. _________ in one week's time for their first postoperative appointment.

CPT: 27658 - Repair flexor retinaculum, 27676 - Repair, dislocating peroneal tendon with fibular osteotomy (groove deepening)