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Triple Arthrodesis / Achilles Tendon Lengthening Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right calcaneonavicular coalition.
2.  Equinus contracture.

POSTOPERATIVE DIAGNOSES:
1.  Right calcaneonavicular coalition.
2.  Equinus contracture.

OPERATIONS PERFORMED:
1.  Right triple arthrodesis.
2.  Right Achilles tendon lengthening.
3.  Excision of right calcaneonavicular tarsal coalition.
4.  Right distal tibial autograft.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and intravenous Ancef 1 gram was administered. After induction of general anesthetic, a tourniquet was placed over his right upper thigh. His right lower extremity was then prepped and draped in the usual sterile fashion. The foot was exsanguinated with Esmarch bandage and tourniquet was inflated to 275 mmHg. A longitudinal incision was made along the lateral aspect of the foot extending from the distal tip of the fibula towards the base of the fourth metatarsal. The skin was dissected sharply. Blunt dissection was carried down to the overlying extensor digitorum brevis muscle belly that was elevated and reflected distally. We exposed the dorsal aspect of the anterior calcaneus and then the calcaneocuboid joint. The joint was distracted using Caspar retractors and then the articular surface was debrided of cartilage.  A high-speed bur was used to remove overlying cortical bone and expose underlying cancellous bone. We used an osteotome to remove the portion of the prominent anterior process of the calcaneus. This was morcellized and used as bone graft later. We then carried our dissection deep into the wound and took down the calcaneonavicular coalition using a combination of rongeurs and osteotome as well as curette. When we had adequately mobilized the calcaneonavicular joint, we then evaluated the subtalar joint. It was fairly stiff and so I elected to proceed with exposure of the medial side of the joint.

We made a longitudinal incision just medial to the tibialis anterior tendon. Skin was dissected sharply. Blunt dissection was carried down to the talonavicular capsule and that was incised in line with skin incision. We exposed the articular surface, elevated the periosteum both medially and laterally to expose the dorsal half of the joint. Joint was distracted again using Caspar retractors and then articular surface was removed using combination of curettes and a periosteal elevator. We used rongeurs to remove remaining soft tissue. At this point, we were better able to mobilize the hindfoot and redirected our attention laterally. I placed a laminar spreader between the lateral process of the talus as well as the anterior process of the calcaneus and used it to distract the joint. We removed the articular cartilage from the subtalar joint using curettes and periosteal elevator. We used a high-speed bur to remove cortical bone. At this point, we were able to passively correct the position of the hindfoot. While correcting the valgus malalignment of the hindfoot, we provisionally fixed the subtalar joint using a screw that was placed through the dorsal neck of the talus and directed into the posterior tuberosity. We first placed the guidewire and checked its position under fluoroscopy and then secured it using a 6.5 mm cannulated screw.

Next, we corrected the rotation of the supination of the forefoot. There was a fair amount of tightness in the Achilles tendon, so we proceeded with lengthening of the Achilles tendon using #11 blade scalpel and percutaneously lengthening the tendon using the Hoke method. We then corrected supination of the forefoot and provisionally fixed the talonavicular joint using two guidewires and the 4.5 mm cannulated screws. We checked position of the guidewires under fluoroscopy. We drilled and then inserted two 56 mm partially threaded cancellous 4.5 mm cannulated screws and obtained good purchase with both screws. We checked positioning under fluoroscopy again. Finally, we secured our calcaneocuboid joint using crossed 3.5 mm cancellous screws that were placed after measuring, drilling, and tapping in the usual fashion. We made a small incision in the distal tibia along the distal anteromedial border of the tibia. The skin was dissected sharply. We made a window in the periosteum, and then using our Acumed bone graft harvesting device, we harvested some bone graft from the distal tibia. Using this and the previous morcellized bone graft, we packed this within the remainder of the subtalar joint after preparing the articular surface again using a high-speed bur. We made a trough in the dorsal aspect of the talonavicular joint and packed this with bone graft as well. We had good bony apposition of our calcaneocuboid joint.

The wounds were irrigated prior to placing the bone graft. We then closed the periosteum over the talonavicular joint using 2-0 Vicryl sutures. Periosteum of distal tibia was closed using 2-0 Vicryl suture as well. Extensor digitorum brevis muscle belly was reapproximated using 2-0 Vicryl suture. Subcutaneous tissues were closed using inverted 2-0 Vicryl sutures and the skin was closed using surgical staples. Xeroform sterile dressings followed by well-padded short leg posterior splint with the foot in slight plantarflexion were applied. The patient tolerated the procedure well and was transferred to the PACU in stable condition.  There were no intraoperative complications. Estimated blood loss was 50 mL. Tourniquet was elevated for 140 minutes and down for 30 minutes and up again for 33 minutes.