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Middle Facet Coalition Excision Open Plantar Fasciotomy Sample


1.  Left foot middle facet subtalar joint coalition.
2.  Left foot plantar fasciitis.

1.  Left foot middle facet subtalar joint coalition.
2.  Left foot plantar fasciitis.

1.  Left foot excision of middle facet coalition with subtalar joint arthroereisis and insertion of GraftJacket spacer.
2.  Left foot open plantar fasciotomy.






DESCRIPTION OF OPERATION:  Under mild IV sedation, the patient was brought back into the operating room and placed on the operating table in a supine position. General anesthesia was then obtained. Thigh tourniquet was then placed on the patient's left thigh. Approximately 10 mL of 1:1 mixture of 2% lidocaine plain and 0.5% Marcaine plain was then injected in an ankle block fashion. The left lower extremity was then scrubbed, prepped and draped in the usual aseptic manner. The lower extremity was then elevated and exsanguinated utilizing an Esmarch bandage. The tourniquet was then inflated. Attention was then directed to the medial aspect of the patient's foot where a lazy-S type of incision was made, traversing along the course of the posterior tibial tendon, starting just proximal to the fibula and extending distal to the area of the navicular tuberosity. The incision was deepened down through superficial and deep structures. Care was taken to identify and retract all vital neural and vascular structures. All bleeders were cauterized and ligated as necessary. Layer by layer, dissection was carried down. The appropriate area of tibial tendon was identified and retracted. Next, the flexor digitorum longus tendon was also identified and retracted. The neurovascular bundle was identified and retracted. The flexor hallucis longus tendon was identified. However, due to its deep nature, it did not need to be mobilized. The individual layers were tagged appropriately for closure at the end of the case. At this time, the dissection was overlying the medial aspect of the sustentaculum tali. Therefore, a periosteal capsular incision was made overlying the sustentaculum tali, starting from distal, extending proximal, overlying the posterior facet. A combination of sharp and blunt dissection was utilized to reflect all soft tissues superiorly and inferiorly off of this bony area. Posterior facet was then exposed. It was followed distally to where the middle facet would be. At this time, a complete bony fusion of the middle facet was noted. There was no joint space appreciated whatsoever. The patient's subtalar joint was put through range of motion and no supination was noted. However, the patient was still able to excessively pronate. The 0.045-inch K-wires were driven from lateral to medial through the sinus tarsi out the area where the middle facet would be, utilizing intraoperative fluoroscopy to confirm proper dissection placement and the presence of this bony coalition. A combination of an osteotome, rotating bur, bone curettes and sagittal saw were utilized to carve out the bony wedge just superior to the true sustentaculum tali and inferior to the body of the talus to re-create the position of the middle facet. Systematically, this bony wedge was carved out to be confluent with the anterior facet and the sinus tarsi as was located by following the posterior facet. Once the bony block was completely excised, the subtalar joint was put through range of motion. At this point, it was noted that there was an additional several degrees of supination and mobilization of the subtalar joint due to the resection of the calcaneal talar middle facet bridge. Intraoperative fluoroscopy confirmed proper bony resection in multiple planes. At this time, the tourniquet was deflated for 10 minutes and then reinflated to allow for reperfusion of the left limb. After the tourniquet was reinflated, an incision was made overlying the lateral aspect of the foot overlying the sinus tarsi. Dissection was carried down into the sinus tarsi where utilizing a guidewire, the HyProCure subtalar joint arthroereisis implant was inserted. Intraoperative fluoroscopy would confirm proper placement up against the talus into the sinus tarsi of this HyProCure device. Once the HyProCure was placed, the excessive pronation was noted to be limited, as the patient was now able to pronate to approximately 4 degrees. The patient still had the additional supination that was created by the resection of the bar. All the areas were then copiously flushed with normal sterile saline. At this time, attention was redirected into the void that was created with resection of the subtalar joint bar. There was bony bleeding noted in that area and a significant void. Decision at this time was made to insert a rolled-up GraftJacket into that area to act as a matrix for fibrous growth and for prevention of bony ingrowth in the area. Also, this was to act as a void filler. The GraftJacket was then rolled up onto itself with the avascular side outward. It was then sewn in place utilizing 4-0 Vicryl. The GraftJacket was then placed inside this area as a filler. Again, the area was copiously flushed with normal sterile saline. Closure was obtained medially in a layered fashion utilizing a combination of 3-0 Vicryl and 4-0 Vicryl. Skin was then reapproximated utilizing 4-0 Prolene in a running locking suture fashion. The lateral incision over the sinus tarsi was closed deep utilizing 4-0 Vicryl and skin was reapproximated utilizing 4-0 Prolene in a horizontal interrupted suture fashion. Next, attention was then directed to the plantar medal aspect of the patient's right heel where the plantar medial tuberosity was palpated. A small stab incision was made overlying this area. Dissection was carried down to free up the plantar fascia both plantarly and superiorly. The plantar fascia was then isolated and incised, utilizing a #15 blade. Excellent release of the plantar fascia was noted upon palpating the arch of the foot. The area was copiously flushed with normal sterile saline and skin was reapproximated utilizing 4-0 Prolene in a simple interrupted suture fashion. All incisional areas were then dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4's, Kling, Kerlix, EBIce cooler, additional cast padding, Ace bandage, posterior splint and additional Ace bandage. The tourniquet was deflated and a prompt hyperemic response was noted to the left lower extremity. The patient was then sent to the recovery room.