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Ankle Tarsal Tunnel Release Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left ankle tarsal tunnel syndrome.

POSTOPERATIVE DIAGNOSIS:
Left ankle tarsal tunnel syndrome.

OPERATION PERFORMED:
Left ankle tarsal tunnel release.

SURGEON:  John Doe, DPM

ANESTHESIA:  General anesthesia with local of 20 mL 0.5% Marcaine with epinephrine.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

INJECTABLES:  Five mL of 0.5% Marcaine with epinephrine, 1 mL of Decadron.

DESCRIPTION OF OPERATION:  Under mild sedation, the patient was brought to the operating room and placed on the operating table in the supine position. Following general anesthesia and 1 gram of Kefzol, approximately 20 mL of 0.5% Marcaine with epinephrine was injected about the left ankle. The foot was then scrubbed, prepped and draped in the usual aseptic manner. The left leg was then elevated and exsanguinated and the left high leg tourniquet was inflated to 300 mmHg.

Attention was directed to the medial aspect of the left ankle, the tarsal tunnel area, where a 4 cm incision was made along the course, just posterior inferior to the posterior tibial tendon. The incision was then deepened down to flexor retinaculum, which was incised. The compartment of the tibial nerve and tibial artery and venae comitantes were identified. The tibial nerve was identified, noted to have moderate fibrosis and fatty tissue on the tendon, but no signs of ganglion cysts or other foreign body. The scar tissue and fatty tissue was debrided from the nerve. The incisions followed inferiorly down to the porta pedis, which was opened in order to decompress the nerve. The flexor digitorum longus tendon was also identified and opened the tendon sheath. No signs of pathology or synovitis were noted.

The incision was then flushed with copious amounts of saline and Kantrex. The skin was closed with 4-0 Vicryl and 4-0 nylon. The incision was then injected with 5 mL of 0.5% Marcaine with epinephrine, 1 mL of Decadron and bandaged with Betadine-soaked Adaptic, Betadine-soaked 4 x 4's, fluffs, Kling, cast padding and short leg splint. The left high leg tourniquet was deflated at approximately 20 minutes with prompt hyperemic response to the left foot. The patient left the OR for the PACU with vital signs stable. The patient is to remain partial weightbearing with crutches.