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Bunionectomy and Akin Osteotomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus, left foot.
2.  Hammer digit syndrome, second, left foot.

POSTOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus, left foot.
2.  Hammer digit syndrome, second, left foot.

OPERATIONS PERFORMED:
1.  Bunionectomy with a first metatarsal osteotomy and screw fixation of the left.
2.  Akin osteotomy of the proximal phalanx of the hallux with screw fixation of the left.
3.  Arthroplasty of the second proximal interphalangeal joint of the left.
4.  Tenotomy of the extensor digitorum longus tendon and capsulotomy of the second metatarsophalangeal joint of the left with K-wire fixation of the second digit, left foot.

SURGEON:  John Doe, MD

HEMOSTASIS:  Esmarch bandage for approximately 90 minutes.

MATERIALS USED:
1.  Two 2.7 mm diameter screws in the first metatarsal; one 18 mm in length and one 20 mm in length.
2.  A 2 mm Synthes screw in the proximal phalanx of the hallux, 24 mm in length, and 0.045 inch K-wire in the second digit, left foot.
3.  Also used 2-0, 3-0, 4-0, 5-0 Vicryl and 5-0 nylon.

INJECTABLES:  Preoperatively, 20 mL of 0.5% Marcaine plain and postoperatively 3 mL of dexamethasone phosphate.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room in the supine position with IV intact for intravenous sedation. He was given 1 g of Ancef IV piggyback for prophylactic antibiotic. He was transferred from the cart to the operating room table and administered IV sedation via the anesthesia department. Under aseptic conditions, preoperative injection was then given. After proper surgical scrub, he was prepped and draped. The left foot was exsanguinated using a Martin bandage tourniquet. Attention was then directed to the large dorsomedial prominence at the hallux and the first metatarsal. A 7 cm linear skin incision was made over the proximal phalanx of the hallux onto the first metatarsal. Dissection was carried down through the superficial tissue under loupe magnification making sure to avoid any neurovascular structures and coagulating any other bleeding venous structures. Dissection was carried down through the deep tissue where a thickened capsule was noted over the first metatarsophalangeal joint and much xanthochromic thickened joint fluid was noted to be within that joint itself. Upon inspection of the cartilage at the joint, it was laterally deviated and mildly eroded on the medial surface. The large first metatarsal prominence was delivered into the area under dissection. The prominence was partially transected with a sagittal saw and dissection was carried down laterally into the first interspace to free up the lateral sesamoid. The sesamoidal metatarsal, sesamoid phalangeal ligaments were all transected, as well as the abductor hallucis tendon. This allowed for more hallux range of motion but it still appeared to be in a lateral deviated position.

Therefore, a first metatarsal osteotomy was performed. The Z or scarf osteotomy was done utilizing the sagittal saw. Capital fragment was freed and shifted laterally. Metatarsal fragment was transfixed to the metatarsal shaft itself with a 0.062 inch K-wire for temporary fixation. Bone clamp was used to fixate the most proximal piece and two 2.7 mm screws were then applied according to the AO technique. Temporary fixation of the K-wire was taken out and the bone was smoothed off utilizing the sagittal saw and a rotating bur. Noting that there was still some lateral deviation to the hallux, an Akin osteotomy was performed on the proximal phalanx, keeping the most lateral proximal apex intact as the secondary point of fixation. The triangular wedge was removed from the Akin osteotomy and the digit attained a more rectus position. A 2 mm Synthes screw was used, 24 mm in length, to transfix into the osteotomy according to AO technique. There was rigid fixation noted at each side. The area was copiously irrigated with Neosporin solution. The wedge was taken out of the dorsal capsule since there was excess capsule and closed with 2-0 Vicryl. The digit attained a more rectus position and, therefore, the subcutaneous tissue was closed with 3-0 Vicryl. Skin was closed with 4-0 retention sutures and 5-0 Vicryl running intracuticular, bolstered by Steri-Strips.

Attention was then directed to the second digit where two semi-elliptical skin incisions were made over the contracted proximal interphalangeal joint, 2 cm in length. The skin wedge was removed. Dissection was carried down to the capsule, proximal interphalangeal joint, which was entered. Dissection of periosteum and capsule of the proximal phalanx was done, exposing proximal phalanx into the site. The enlarged head of the proximal phalanx had erosion of cartilage where it had been articulating with the middle phalanx in the contracted position. Therefore, an arthroplasty was performed at the surgical neck of the second digit. This allowed the digit to become more rectus but still had a dorsiflexed position at the metatarsophalangeal joint. Therefore, an incision was made at the second metatarsophalangeal joint performing an extensor tenotomy, as well as a capsulotomy of the second metatarsophalangeal joint. The digit obtained a more rectus position but still would contract at the proximal interphalangeal joint. Therefore, 0.045 inch K-wire was used, retrograded into the proximal phalanx from distally to keep the second digit rectus. The extensor digitorum longus tendon was used as an interpositional graft at the proximal interphalangeal joint.

The site was copiously irrigated and closed with 4-0 Vicryl and 5-0 nylon. The capsulotomy, tenotomy site was also closed with 5-0 nylon. The site was infiltrated with dexamethasone phosphate and Betadine-soaked Adaptic, as well as a dry sterile dressing was then applied. Tourniquet was removed and immediate warmth and perfusion was noted to return to all the digits 1 through 5 on the left foot. A pin cap was placed over the 0.045 inch K-wire. The patient was transferred from the operating table to the cart into postanesthesia recovery unit. The patient tolerated the procedure well, as well as the anesthesia, and left the operating room with his vital signs stable and vascular status intact.