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Tibial Sesamoid Excision Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Chronic sesamoiditis of the left foot with elongated first metatarsal and contracted left hallux.

POSTOPERATIVE DIAGNOSIS:  Chronic sesamoiditis of the left foot with elongated first metatarsal and contracted left hallux with degenerative changes of the sesamoid apparatus of the left foot.

OPERATION PERFORMED:
1.  Excision of the tibial sesamoid and excision of the fibular sesamoid of the left foot.
2.  Fusion of the left hallux interphalangeal joint.

ANESTHESIA:  MAC, preoperative block consisted of 10 mL of 0.5% Marcaine with epinephrine.

COMPLICATIONS:  None.

TOTAL TOURNIQUET TIME:  50 minutes.

OPERATIVE FINDINGS:  Intraoperatively, the patient did have hypertrophy of the synovium on the plantar aspect of the first metatarsophalangeal joint with the inflammatory changes and erosions of the articular surface of the tibial and fibular sesamoids.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position on the operating table.  Anesthesiologist administered intravenous sedative agents.  A local field block was performed.  The foot and leg were prepped and draped in normal sterile technique.  Esmarch bandage used to exsanguinate the foot, and ankle tourniquet was inflated to 250 mmHg.

A plantar medial longitudinal incision was made and centered over the first metatarsophalangeal joint of the left foot.  Dissection was carefully carried down through superficial and deep fascial layer.  At this time, the capsule was identified and divided longitudinally.  The tibial sesamoid was identified and resected in toto.

There was thinning of the articular surface with chronic inflammatory changes of the surrounding soft tissues.  The flexor hallucis longus tendon was identified and gently retracted plantarly exposing the fibular sesamoid, which was also excised in toto.

The fibular sesamoid was a bipartite sesamoid with irregularities and degenerative changes.  Copious lavage was performed.  The capsular layer was closed with 3-0 Vicryl, the subcutaneous deep fascial layer was closed with 4-0 Vicryl, and the skin edges were approximated with 4-0 Prolene using a running subcuticular stitch.  Steri-Strips were applied.

A longitudinal incision was then made and centered over the interphalangeal joint of the left hallux.  Dissection was carefully carried down through superficial and deep fascial layer.  The extensor tendon was transected transversely at the level of the interphalangeal joint.  Distal articular surface of the first proximal phalanx was resected as well as the base of the distal phalanx.  The cut edges were flush.  Copious lavage was performed.

A guidepin for the 4.0 cannulated screw was then inserted through the distal aspect of the hallux and then retrograde back through the proximal phalanx.  The position was verified on fluoroscopy.  A 48 mm cannulated partially threaded screw was then inserted, and excellent compression was achieved.  The hallux now lay in a rectus position.  Copious lavage was performed.

The extensor tendon was repaired with 3-0 Vicryl, the subcutaneous layer was closed with 4-0 Vicryl, and the skin edges were approximated with 4-0 Prolene using a running subcuticular stitch.  Steri-Strips were applied.  A postoperative block was performed using 8 mL of 9:1 mixture of 0.5% Marcaine plain and dexamethasone phosphate.  Betadine-soaked Owens gauze and a bulky dry sterile dressing were applied holding the hallux in a rectus position.

The patient tolerated the procedure and anesthesia well and left the operating room for the recovery room weightbearing as tolerated with the Cam walker, and follow up with us next week for a wound check.