Extensor Hallucis Longus Tendon Repair Sample Report

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Traumatic laceration of the extensor hallucis longus tendon, left foot.

POSTOPERATIVE DIAGNOSIS: Traumatic laceration of the extensor hallucis longus tendon, left foot.

OPERATION PERFORMED: Open repair of extensor hallucis longus tendon, left foot.

SURGEON: John Doe, MD

ANESTHESIA: Local.

HEMOSTASIS: Electrocautery.

ESTIMATED BLOOD LOSS: Minimal.

DESCRIPTION OF OPERATION: The patient was placed on the operating table in the supine position. The left lower extremity was scrubbed and draped sterilely, and 10 mL of 0.5% Marcaine plain was injected for local anesthesia to the left foot.

A 5 cm linear longitudinal incision was created directly over the palpable defect of the extensor hallucis longus tendon and slightly distal and proximal to where the tendon was palpated. The defect was several centimeters proximal to the first metatarsal head. Dissection was continued into the subcutaneous layer utilizing blunt and sharp dissection, with care being taken to identify and retract all vital neurovascular structures. All bleeders were cauterized as necessary.

At this time, the tendon was identified, and an approximately 4 cm gap was noted between the tendon ends. The proximal portion of the tendon was pulled distally and noted to be able to extend toward the distal end of the tendon without excessive tension. Utilizing 4-0 PDS, a Bunnell-type suture technique was utilized to reattach the tendon ends. Simple interrupted sutures were also used to reinforce the tendon reapproximation. It must be noted that throughout the procedure the wound had been flushed with normal saline. The tendon sheath was closed utilizing 4-0 Vicryl. The subcutaneous layer was reapproximated utilizing 4-0 Vicryl and the skin was closed utilizing a horizontal mattress suture technique with 5-0 nylon.

Upon completion of the procedure, a total of 1 mL of Decadron phosphate and 3 mL 0.5% Marcaine plain were injected at the proximal aspect of the foot, away from the tendon repair. The incision was dressed with Adaptic and covered with a sterile compressive dressing consisting of gauze, Kling, Kerlix, cast padding and a posterior splint. The patient tolerated the procedure and anesthesia well and was transferred to the recovery room in apparent satisfactory condition with vital signs stable and vascular status intact.

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