PREOPERATIVE DIAGNOSES:
1. Hallux abductovalgus, hammertoe, fourth toe on the right.
2. Neuroma, third interspace on the right foot.

POSTOPERATIVE DIAGNOSES:
1. Hallux abductovalgus, hammertoe, fourth toe on the right.
2. Neuroma, third interspace on the right foot.

OPERATION PERFORMED: Simple bunionectomy of the first metatarsal head on the right foot; arthroplasty of the fourth toe, right foot.

SURGEON: John Doe, DPM

DESCRIPTION OF OPERATION: The patient was brought to the operative room and placed on the operating room table in the supine position for simple bunionectomy of the first metatarsal head on the right foot and arthroplasty of the fourth toe, right foot.

Ancef 1 g was given IV piggyback in the preoperative holding area. A pneumatic tourniquet was placed on the right ankle and local block was done by the surgeon, 16 mL of 50:50 mix of 0.5% Marcaine plain and 2% lidocaine plain. The right foot was prepped and draped in the usual aseptic manner. An Esmarch bandage was used to exsanguinate the right foot. Pneumatic tourniquet was insufflated to 250 mmHg. The Esmarch bandage was removed.

Attention was directed to the dorsomedial aspect of the first metatarsal for simple bunionectomy. A linear longitudinal, approximately 4 cm in length incision was made. It was deepened via sharp and blunt dissection, taking care to retract all vital structures and ligate any bleeding vessels. At this time, a linear longitudinal incision was made into the capsule and periosteum at the first metatarsal joint and head.

The capsule and periosteum was reflected taking care to retract all vital structures and ligate any bleeding vessels. It was noted that there was an enlarged medial eminence with osteophytic formation medially and dorsally at the first metatarsal head. The cartilage was intact. The medial eminence was excised using power equipment, and at this time, it was found the bone was extremely soft.

I was able to compress the bone easily with forceps. It was determined at this time that the bone was too soft for any kind of osteotomy, for the bone to be able to hold any kind of an implant. The dorsal aspect of the first metatarsal head was excised using power equipment and hence was directed to the lateral interspace where the fibular sesamoid was released from all of its attachments, except for those most plantar medial to allow for the first metatarsal head to sit over the sesamoids in a better position.

At this time, the area was flushed with copious amounts of sterile saline and then gentamicin, GU irrigant. The capsule and periosteum reapproximated attempting to tighten the medial capsule to allow for the hallux to sit in a more straight position over the first metatarsal head. This was done as best as possible without having performed an osteotomy.

The subcutaneous structures were reapproximated using 3-0 Vicryl. The skin was reapproximated using 5-0 nylon simple interrupted in horizontal mattress-type suture. The alignment was adequate at best due to the inability to attempt an osteotomy or implant to totally correct the position of the first metatarsal. Attention was directed to the fourth digit where a longitudinal incision was made and a semi-elliptical incision with the ellipse excised in toto.

The incision was deepened via sharp and blunt dissection taking care to retract all vital structures and ligate any bleeding vessels. A transverse incision was made into the proximal interphalangeal joint. The proximal head of the fourth digit was excised in toto using power equipment. The region was flushed with gentamicin, GU irrigant. The capsule was tightened and reapproximated to offer more corrected position of the fourth toe.

Skin was reapproximated using 5-0 nylon simple interrupted suture. At this time, 1 mL of dexamethasone phosphate was infiltrated into the third interspace on the right foot. Bacitracin ointment was applied and 1 mL dexamethasone phosphate was infiltrated around the first metatarsal area with 5 mL of 0.5% Marcaine plain. Adaptic was then placed over the incisions and a sterile gauze compression dressing was applied with Coban wrap.

The tourniquet was released and it was 50 minutes on tourniquet time. There was instantaneous return of blood flow to all digits on the right foot. The patient tolerated simple bunionectomy of the first metatarsal head, other procedures, and anesthesia well without complications, with vital signs stable and capillary refill time less than 2 seconds to all the digits on the right foot.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Status post navicular body fracture with marginal osteophytes, right foot.

POSTOPERATIVE DIAGNOSIS:  Status post navicular body fracture with marginal osteophytes, right foot.

PROCEDURE PERFORMED:  Resection of osteophytes, dorsal surface of right navicular, with application of posterior mold.

SURGEON:  John Doe, DPM

ASSISTANT:  None.

SEDATION:  IV sedation local.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed up on the operating room table in the supine position. The correct site of surgery was identified, following which an intravenous sedative was administered. The proximal nerve block anesthetic was administered to the right foot and ankle utilizing a 0.5% Marcaine solution without epinephrine.

Next, the right leg and foot were prepared and draped in the usual aseptic manner. An Esmarch bandage was applied to her right forefoot and secured at the level of the right ankle; exsanguination and tourniquet ischemia. The following operations are performed.

Attention was directed to the dorsal and medial aspect of the right foot. An approximate 3.5 to 5 cm Z-type incision was made overlying the dorsal surface of the navicular. The incision was deepened through subcutaneous tissue. Small bleeding points were controlled with the monopolar Bovie. The subcutaneous tissues were then divided carefully to avoid any injury to the overlying neurovascular structures. The deep fascia was incised and retracted medially and laterally. The extensor tendons overlying the area were then elevated and retracted medially and laterally respectively.

Next, deep periosteal incision was made over the body of the navicular at which point severe dorsal osteophytes were identified, particularly at the more distal pole of the navicular. These were debrided with reciprocating power saw and bone rongeur. Sharp pieces of bone were then rasped and rongeured smoothly.

Inspection of the distal second cuneiform-navicular joint was inspected as well as talonavicular joint, and no overt arthritic changes were noted. A small quantity of bone wax was then applied to the cut surfaces of bone.

The deep fascia and periosteum were then reapproximated with interrupted sutures of 2-0 Vicryl, and the subcutaneous tissues were reapproximated with interrupted sutures of 5-0 Vicryl. The skin margins were reapproximated with several interrupted simple and vertical mattress sutures of 5-0 nylon. A small quantity of dexamethasone phosphate was instilled into the navicular cuneiform, into the navicular joints. The Esmarch bandage was released from the level of the right ankle. Circulation was promptly restored to within normal limits to the entire operated right foot and ankle, and hemostasis was considered satisfactory.

A primary sterile Xeroform dressing was applied to the skin incisions followed by several layers of fluff sterile gauze. A well-padded neutral position posterior mold was applied to the right lower extremity.

At the termination of the surgical procedure, the patient was then transported to the postanesthesia care unit in stable condition, and it was determined that she had tolerated the intravenous sedative, proximal nerve block anesthetic, and surgical procedures well.

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PREOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus deformity, first metatarsal and metatarsophalangeal joint, left foot.
2.  Retained foreign body, first metatarsal, right foot.

POSTOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus deformity, first metatarsal and metatarsophalangeal joint, left foot.
2.  Retained foreign body, first metatarsal, right foot.

OPERATION PERFORMED:
1.  Austin bunionectomy with screw fixation, left foot.
2.  Removal of deep retained foreign body, first metatarsal, right foot.

SURGEON:  John Doe, MD

ANESTHESIA:  Local monitored anesthesia care.

GROSS FINDINGS:  Pain and functional debility of the right foot when wearing shoe gear secondary to prominence of retained foreign body in the bone of the first metatarsal, right foot, pushing into the soft tissues dorsally. Also, painful hallux abductovalgus deformity in the left foot. Conservative attempts at dealing with symptoms and signs failed, and the patient elected surgical intervention to improve chances of improved function and to lessen discomfort.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the operating table in the supine position. An ankle pneumatic tourniquet was applied to both ankles. The patient was given local anesthesia in the form of a Mayo block of both feet. The patient was then prepped and draped in the usual sterile manner on both lower extremities. The left lower extremity was elevated and exsanguinated with an Esmarch bandage, and the ankle tourniquet of the left lower extremity elevated to a pressure of 250 mmHg.

At this time, a dorsomedial incision of approximately 6 cm was made over the first metatarsal and metatarsophalangeal joint of the left foot. Subcutaneous neurovascular layer was sharply and bluntly dissected, with care being taken to protect all nerves, retracting, ligating, cauterizing all vessels as appropriate.

The periosteum and capsule were then visualized and incised in line with the original skin incision and augmented with an inverted-L capsulorrhaphy. The periosteum and capsule were then reflected medially and laterally from the metatarsal and its head. The hypertrophic bone of the first metatarsal, dorsal medial eminence, was resected with a sagittal saw and two transverse plain V osteotomies were then fashioned utilizing standard 0.45 guidewire technique.

The osteotomies were performed and the dorsal distal fragment mobilized laterally to the precise position to resolve the intermetatarsal angle of abnormality and proximal articular set angle. These were held in fixation with two 14 mm x 2.4 mm Osteomed cortical screws, placed in the standard Osteomed technique. The redundant bone was then removed with a sagittal saw and smoothed with a rotary bur and the wound flushed with copious sterile saline solution.

The periosteum and capsule were then sutured with 4-0 Vicryl in the subcutaneous layer, 4-0 Vicryl in the skin with a running intracuticular stitch of 5-0 Prolene augmented with regular staples. The left foot was then reanesthetized with 0.5% Marcaine plain, and wound was dressed with Silvadene-impregnated Owens silk, sterile 4 x 4s, Kerlix, Kling, and Ace wrap for retention. The left ankle tourniquet was deflated after a total time of approximately 70 minutes.

The right lower extremity was then elevated and exsanguinated with an Esmarch bandage and ankle tourniquet elevated to the pressure 250 mmHg. An incision was made in the skin, approximately 2 cm in length, over the prominent foreign body. Subcuticular neurovascular layer was dissected in the same manner previously described and the periosteum incised. The head of the screw was evident and was removed with a Synthes screwdriver that fit the 4.0 cancellous bone screw. The foreign body was removed intact.

The wound was flushed with copious sterile saline solution and the periosteum and subcutaneous layers sutured with 4-0 Vicryl and the skin with simple interrupted sutures of 5-0 Prolene. The wound was dressed in the same manner as previously described for the left lower extremity, and the tourniquet was deflated after a total time of 8 minutes.

The patient tolerated the surgeries on both lower extremities well and left the operating room for the recovery room with stable vital signs and vascular status intact to both lower extremities and digits.

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PREOPERATIVE DIAGNOSIS: Soft tissue mass, left heel, possible ganglion cyst.

POSTOPERATIVE DIAGNOSIS: Soft tissue mass, left heel, possible ganglion cyst.

PROCEDURE PERFORMED: Excision of soft tissue mass, 2 x 2 cm lesion, left heel, under local monitored anesthesia care.

SURGEON: John Doe, MD

SEDATION: LMAC.

INDICATIONS FOR OPERATION: This is a healthy (XX)-year-old female who presented with a continuing painful enlarging mass in her left heel. Radiographs and MRI demonstrate possible fluid-filled area consistent with ganglion cyst. Two in-office aspirations have not provided any relief, and we discussed in detail with the patient a more sophisticated, aggressive excision of this lesion and sending it to Pathology for both gross and microscopic examination. We discussed in detail with the patient risks, complications, outcomes, and expectations involved. The patient understood and signed the consent form.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in the supine position and transferred to the operating table in the same supine position. Her left foot was dressed and draped in appropriate aseptic technique, and approximately 22 mL of 0.5% Marcaine plain was used to anesthetize her left lower extremity. An ankle tourniquet set at 250 mmHg was placed on her left ankle and inflated, and the patient also received 1 gram Ancef IV piggyback prior to the procedure for antibiotic prophylaxis.

An incision, approximately 3-4 cm long, was placed over her left heel, and this was carefully deepened to the level of the subcutaneous tissue. Immediately, we noticed the large soft tissue mass consistent with a neuroma-type tissue, and this was carefully excised using both sharp and blunt dissection. The mass itself measured 2 x 2 cm, and this was sent to Pathology for both gross and microscopic examination.

The surgical area was then thoroughly examined, and any further pathologic tissue was debrided. The area was thoroughly rinsed and irrigated with kanamycin-type solution. The deep tissue was then reapproximated using 3-0 Vicryl suture and the epidermal tissue reapproximated using 3-0 nylon suture in a horizontal mattress-type fashion.

A sterile compressive dressing was placed on the patient’s foot, and the tourniquet was let down. All digits, including the fifth digit, became pink and warm with good capillary refill times. The patient left the OR in good condition and will follow up with us in approximately 7-10 days.

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PREOPERATIVE DIAGNOSES:
1.  Hallux limitus/hallux rigidus.
2.  Severe degenerative joint disease, first metatarsophalangeal joint, right foot.

POSTOPERATIVE DIAGNOSES:
1.  Hallux limitus/hallux rigidus.
2.  Severe degenerative joint disease, first metatarsophalangeal joint, right foot.

OPERATIONS PERFORMED:
1.  Cheilectomy, right foot.
2.  First metatarsal osteotomy, modified Youngswick, right foot.
3.  Autogenous graft, right foot.
4.  Soft tissue interposition, first metatarsophalangeal joint, right foot.

SURGEON:  John Doe, DPM

ASSISTANT:  Jane Doe, DPM

ANESTHESIA:  MAC with local.

HEMOSTASIS:  Pneumatic ankle tourniquet.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  The patient was placed in supine position following IV sedation. A local anesthetic block was obtained utilizing 15 mL of 0.5% Marcaine plain in a Mayo block fashion. A pneumatic tourniquet was placed about the well-padded right ankle. The right lower extremity was scrubbed and draped. An Esmarch was utilized for exsanguination, and the pneumatic ankle tourniquet was inflated to 250 mmHg.

A 6 cm linear longitudinal incision was made medial and parallel to the tendon of the extensor hallucis longus and above the contour of the deformity. The incision was centered over the first metatarsal head and deepened through the subcutaneous tissues using blunt and sharp dissection. Care was taken to identify and retract all vital and neurovascular structures. All bleeders were cauterized as necessary. At this time, a linear capsulotomy was performed over the dorsal aspect of the first metatarsophalangeal joint. The periosteal and capsular structures were then carefully dissected free of the osseous attachments and reflected medially and laterally, thus exposing the head of the first metatarsal at the operative site.

Immediately, a large dorsal exostosis was noted on the first metatarsal head. Additionally, large loose joint mouse was noted within the dorsal aspect of the joint. This was dissected free and removed. A sagittal saw was utilized to resect the dorsal prominence, the medial and lateral prominences and from the first metatarsal head. A power rasp was utilized to smooth all bony prominences. A rongeur was utilized to resect the prominent base of the proximal phalanx to more of an anatomic size. A power rasp was also utilized to smooth all bony prominences.

Attention was directed to the first interspace via the original skin incision where the tendon of the extensor hallucis brevis was initially identified and tenectomized. The dissection was continued using blunt dissection down to the level of the fibular sesamoid, which was free of its soft attachments proximally, laterally and distally. The conjoined tendon at the adductor hallucis muscle was then identified and transected at its attachment to the base of the proximal phalanx of the hallux. At this time, the lateral contraction present on the hallux was noted to be reduced, and the sesamoid apparatus was noted to float into a more corrected medial position. Attention was directed to the medial aspect of the first metatarsal head where after placing an apical axis guidewire, a through and through V-type osteotomy was created in the metaphyseal region of this bone utilizing a sagittal bone saw to the apex of the osteotomy point distally.

Utilizing the bone, which was resected from the dorsal prominent exostosis previously and after carefully removing all cortical aspects of the bone with a rongeur and bone cutting forceps, a rectangular-shaped autogenous bone graft was inserted within the site of the plantar osteotomy in the first metatarsal head further plantar flexing the metatarsal head. At this time, two 0.062 inch K-wire was driven from dorsal, proximal to plantar distal across the osteotomy site to serve as internal fixation. The K-wires were then bent, cut, and turned against the shaft of the metatarsal. The power rasp was utilized to again remove all bony prominences. The wound was flushed with a copious amount of sterile normal saline.

An elliptical capsulotomy was performed at the medial aspect of the joint, and the capsule was pulled within the first metatarsophalangeal joint to serve as soft tissue interposition within the severely arthritic joint. It must be noted that the joint was completely devoid of cartilage, and subchondral drilling was not deemed an option. Subchondral cysts were noted as well as subchondral erosion. With the capsule interposed, a 3-0 Ethibond was utilized in a simple interrupted fashion to hold the capsule in its new proper position. The first metatarsophalangeal joint was placed through range of motion at this time, and the range of motion was noted to greatly increase. The range of motion at the start of the procedure approached 0 to 5 degrees and towards the end of procedure was noted to increase to approximately 40 to 50 degrees.

The wound was again flushed with normal saline solution. The periosteal and capsular structures were reapproximated and coaptated utilizing 3-0 Vicryl. The subcutaneous layer was reapproximated utilizing 4-0 Vicryl, and the skin was closed in a simple running subcuticular suture technique with 4-0 Monocryl. Benzoin and Steri-Strips were applied to reinforce the skin closure. Upon conclusion of the procedure, a mixture of 1 mL of Decadron phosphate and 9 mL of 0.5% Marcaine plain was also injected. The incision was dressed with Adaptic and covered with a sterile compressive dressing consisting of gauze, Kling, Kerlix, Coban, and Ace. The patient tolerated the procedure and anesthesia well. He was transferred to the recovery room in apparent satisfactory condition with vital signs stable and vascular status intact to the right foot.

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HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male. He has been a prior patient at this clinic a number of years ago, during which time he had a pair of functional orthotics. Since that time, the patient has gotten orthotics from another podiatrist but decided to return to our care. The patient was an active runner and several years ago slowed down his running program, and he wishes to start increasing his mileage again, and the goal is to complete a marathon next year. The patient presents wishing to have new orthotics made, as well as having right foot and right hip pain.

PAST MEDICAL HISTORY: Remarkable for a limb length difference that we diagnosed as well as pain on the plantar aspect of the second MPJ, left foot.

PRESENT MEDICAL HISTORY: Remarkable for high blood pressure; otherwise, the patient has no medical history or a present medical history that is related to his presenting problem.

PODIATRIC HISTORY: Significant for starting to begin a running program. He has a history of fracture of his left foot two times. He denies back pain, except when doing prolonged standing. His regular running shoe gears are the Beast Brooks shoe. He wears desert boots and Men’s Oxfords style dress shoes. The type of orthotics the patient is wearing is the semi-rigid orthotic with a PPT arch fill and forefoot varus correction, bilateral, and a first ray cutout of the left foot, metatarsal pad. There was no wear pattern discernible on his shoes.

PHYSICAL EXAMINATION:
VASCULAR: DP: 3/4 bilateral. PT: 3/4 bilateral. PULSES: Capillary filling time is 2-3 seconds. VARICOSITIES: Mild. EDEMA: None. The feet were both warm.
NEUROLOGIC: Negative Tinel’s, vibratory sense grossly intact, and deep tendon reflex was 2/5 bilateral.
DERMATOLOGIC: Revealed a callus on the medial aspect of the first metatarsal head, left foot.
MUSCULOSKELETAL: Revealed a HAV deformity with a moderate dorsomedial hyperostosis of the first metatarsal head of the left foot much greater than the right. Also, a decrease in the fat pad was noted at the forefoot bilateral. There was no pain on palpation of the plantar aspect of the second metatarsal, left, but there was on exam of the right, though there was no drawer sign. The toes of the left foot were noted to be contracted much greater than the right, and there was a moderate contracture of the second toe of the left foot. The patient was able to raise and invert his left foot though had trouble raising and inverting the heel of his right foot. The first MPJ range of motion was 20 degrees bilateral dorsal and 10 degrees plantar bilateral. The first ray was in a dorsiflexed position, bilateral, and normal range of motion. There was no crepitus on range of motion of the first MPJ. On stance, there was navicular sag of the right foot greater than the left, and there was a too-many-toe sign bilateral. Off weightbearing, there was a normal longitudinal arch, was extremely compressed weightbearing. Subtalar joint range of motion was limited on the left and normal on the right. The resting calcaneal stance position was 5 degrees valgus of the left and 10 degrees valgus of the right. Forefoot position was 4 degrees varus of the left and 6 degrees of the right. Neutral calcaneal stance was 10 degrees of the right with a calcaneal cuboid break and 3 degrees rearfoot varus of the left. Ankle dorsiflexion was -3 degrees left and 0 degrees right. Hip rotation was 50 degrees external and 10 degrees internal. Hamstring flexibility was 90 degrees and quadricep flexibility was 110 degrees. Leg length difference was noted to be equal though the malleoli to floor was 3 cm of the right and 4 cm on the left.

IMPRESSION:
1.  Mild capsulitis of the second metatarsophalangeal joint, right foot.
2.  Grade I posterior tibial dysfunction.
3.  Bunion deformity of the left foot.
4.  Leg length difference.

TREATMENT PLAN:  The treatment provided for the patient today was discussion of the above diagnoses, and we casted him for a pair of functional orthotics for running and a second pair for his dress Oxfords. He is to return to the office for the orthotics, and at that time, we will do a gait analysis to ensure that the orthotics are functioning properly.

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OBJECTIVE:  Vital Signs: Temperature 98.6 degrees, pulse 104, respirations 20, and blood pressure 200/96. Dorsalis pedis and posterior tibial pulses are nonpalpable bilaterally. Using Doppler ultrasound, the posterior tibial pulses are audible. However, the dorsalis pedis is not audible in the bilateral lower extremities. There is erythema noted to the right forefoot and is most pronounced in the digits 1 and 4. Proximal streaking is noted extending from the dorsal surface near the fourth interspace extending proximally over the foot and also is located at the lateral aspect of the fourth digit on the right foot. The ulcer measures approximately 1 cm x 1 cm in size; has a dark, dry fibrotic base with surrounding macerated borders. There is no drainage, no malodor appreciated. Skin is cool to the touch. Sensation is diminished in the bilateral lower extremities. Muscle strength is within normal limits.

LABORATORY DATA:  WBC 16.4, hemoglobin 14.2, hematocrit 41.6, and platelets 342,000. Sodium 136, potassium 4.2, chloride 102, CO2 of 24, BUN 18, creatinine 0.9, and glucose 280. Wound culture of the right fourth digital ulcer, 3+ gram-positive cocci, 1+ gram-positive rods. Blood cultures x2 pending at this time. Urine culture, 3+ bacteria.

RADIOLOGICAL DATA:  Three views of the right foot, no soft tissue emphysema, no fractures or dislocation. No evidence of osteomyelitis.

ASSESSMENT:
1.  Right foot ulcer with cellulitis/lymphangitis.
2.  Diabetes mellitus.
3.  Hypertension.
4.  Urinary tract infection.

PLAN:  At this time, continue IV antibiotics until further recommendations are made by Infectious Disease. We will order serial Dopplers, bilateral lower extremities. The patient has been advised to keep the right leg elevated when at rest and to minimize weightbearing as much as possible on the right leg. Further recommendations to follow.

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