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Posterior Tibial Tendon Repair Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left foot and ankle posterior tibial tendon tear with arch collapse and calcaneal valgus.

POSTOPERATIVE DIAGNOSIS:  Left foot and ankle posterior tibial tendon tear with arch collapse and calcaneal valgus.

OPERATION PERFORMED:
1.  Left foot posterior tibial tendon repair and advancement with flexor digitorum longus tendon transfer.
2.  Left calcaneal medial slide osteotomy.
3.  Left midfoot arthrodesis at the first metatarsal cuneiform joint.

SURGEON:  John Doe, DPM

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

HEMOSTASIS:  Left thigh tourniquet at 300 mmHg for 120 minutes.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Minimal.

SPONGE AND NEEDLE COUNT:  Correct.

DESCRIPTION OF OPERATION:  Under mild sedation, the patient was brought in and placed on the operating table in the supine position. Following general anesthesia and 600 mg of clindamycin, 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. The left thigh tourniquet was inflated to 300 mmHg. Attention was then directed to the medial aspect of the left ankle where a 5 cm incision was made along the posterior tibial tendon. The incision was then deepened down to the tendon. The tendon sheath was incised. There was moderate synovial fluid expressed as well as synovitis. There was a 1.5 cm linear tear of the posterior tibial tendon by the medial malleolus with moderate to severe attenuation of the tendon. The tendon was debrided and repaired at the linear partial tear with #5 nylon. It was then released from the base of the navicular. There was also a small accessory navicular bone that was removed from the tendon. The plantar medial aspect of the navicular was then resected utilizing the oscillating bone saw. The tendon sheath was developed for the flexor digitorum longus tendon. It was also noted that besides the posterior tibial tendon being severely attenuated, also the spring ligament had a partial tear and attenuation of the spring ligament at the talonavicular joint. The flexor digitorum longus tendon was identified and then followed back as far proximal as possible to the medial malleolus and then was released distally proximal to the master knot of Henry of the flexor hallucis longus tendon. A drill hole and tapping was done for the 5.5 Bio-Corkscrew screw, and the incision was then packed temporarily.

Attention was then directed to the first metatarsal cuneiform joint. It was noted to have severe laxity and hypermobility of the first ray. A 3 cm incision was made over the dorsomedial aspect of the first metatarsal cuneiform joint. The incision was then deepened down to the level of the joint. The articular cartilage and subcondylar bone was then resected utilizing oscillating bone saw and bone curettes. The bone was then fenestrated with 0.062 inch K wire and then irrigated. Attention was then directed to the lateral heel where a 4 cm linear incision was made just posterior to the peroneal tendons. Incision was then deepened down to the subcutaneous tissue. The sural nerve and lesser saphenous vein were identified and retracted anteriorly. A linear incision was made at the periosteum and then a linear osteotomy performed of the calcaneus. The ostium was then shifted medially approximately 8 mm and then fixated with two Acutrak Plus screws, 60 mm and 45 mm in length. Good alignment and good compression was noted clinically and radiographically. The incision was irrigated with copious amounts of normal saline and gentamicin. The rough edges of the osteotomy were then smoothed, and the incision was closed with 4-0 Vicryl and 4-0 nylon. Attention was then directed to the first metatarsal cuneiform joint arthrodesis and temporarily fixated with a 0.062 inch K wire and then a 4 hole Lapidus plate and Arthrex set, two locking screws proximally, one distally, and a cancellous screw in the central portion, and also the temporary guide was removed and then a 4.0 cancellous screw was then placed from the first metatarsal into the medial cuneiform from dorsal distal to plantar proximal. Good alignment and fixation noted clinically and radiographically with good stability of the arch and decreased hallux valgus and bunion. The incision was then flushed and closed with 4-0 Vicryl and 4-0 nylon. Attention was then directed to the posterior tibial tendon where a 5.5 Bio-Corkscrew anchor was then placed in the plantar medial aspect of the navicular. The posterior tibial tendon and flexor digitorum longus tendon were then advanced and attached to the anchor and then reinforced with a modified Krackow stitch. The distal ends of the tendon were also reinforced with #2 FiberWire. The spring ligament had to also be repaired with #2 FiberWire.

The incision was then flushed and closed with 3-0 Vicryl for the tendon sheath and 4-0 Vicryl and 4-0 nylon for the skin. The foot was then injected with an additional 10 mL of 0.5% Marcaine with epinephrine and bandaged with Betadine-soaked Adaptic, Betadine-soaked 4 x 4's, fluffs, Kling, cast padding, and short leg 3-way splint. The left thigh tourniquet was deflated at approximately 120 minutes with prompt hyperemic response to all digits of the left foot. The patient left the OR for the PACU with vital signs stable. The patient is to remain toe-touch weightbearing and follow up in one week and was placed in a short leg cast.