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Metatarsal Cheilectomy / Decompressive Osteotomy Sample


PREOPERATIVE DIAGNOSIS:  Left hallux rigidus.

POSTOPERATIVE DIAGNOSIS:  Left hallux rigidus.

1.  First metatarsal cheilectomy, left
2.  First metatarsal decompressive osteotomy, left foot.

SURGEON:  John Doe, DPM 


HEMOSTASIS:  Pneumatic ankle tourniquet at 250 mmHg.



DESCRIPTION OF OPERATION:  The patient was taken to the OR and placed supine on the operating room table. After 1 gram IV Ancef and adequate IV sedation, a total of 20 mL of 0.5% Marcaine plain was injected about the first ray to achieve local anesthesia. A well-padded pneumatic ankle tourniquet was placed about the left lower extremity. The foot was then prepped and draped in the usual sterile manner. An Esmarch bandage was utilized to exsanguinate the patient's left foot and the ankle tourniquet was inflated to 250 mmHg.

Attention was then directed to the dorsomedial aspect of the first ray, where a linear longitudinal incision was made. The incision was deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were ligated and cauterized as necessary. At this time, a linear longitudinal capsular and periosteal incision was made at the first metatarsophalangeal joint. The capsule was reflected from the medial and dorsomedial aspect of the first metatarsal head. The joint was then inspected for any cartilaginous defects, which were not found. At this time, a sagittal saw was utilized to resect the prominent dorsal eminence on the first metatarsal head. At this time, the motion of the hallux was still restricted, so we decided to do an osteotomy of the first metatarsal. A through-and-through modified Watermann-Green type osteotomy was performed in the distal metaphyseal region of the first metatarsal. An approximately 1 to 2 mm slice of bone was resected from the dorsal aspect of the osteotomy to allow for some plantarflexion and shortening of the first metatarsal. The capital fragment was impacted onto the first metatarsal and a Synthes 3.0 mm headless compression screw was then inserted across the osteotomy site with excellent compression noted.

At this time, the wound was irrigated with copious amounts of sterile normal saline. The screw position was checked under fluoroscopy. The motion of the great toe was deemed adequate. The capsular structures were closed with 2-0 Vicryl suture, the subcutaneous tissues were closed with 4-0 Vicryl suture and skin with 4-0 nylon in horizontal mattress fashion. Upon completion of the procedure, the incision was dressed with Xeroform gauge and a sterile compressive dressing was applied to the left foot. The pneumatic ankle tourniquet was deflated and a prompt hyperemic response was noted to all digits of the left foot. The foot was well padded and a forefoot slipper cast was applied. The patient tolerated the procedure and anesthesia well and was transported to PACU with vital signs stable. The patient will be discharged after a brief postoperative stay with written and oral postoperative instructions.