Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Bunionectomy with Osteotomy Sample Report


PREOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity on the right lower extremity.

POSTOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity on the right lower extremity.

OPERATION PERFORMED:  Bunionectomy with osteotomy and internal fixation of the right foot.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with IV sedation.


SPECIMENS:  No pathologic samples were retained.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who presented several months ago complaining of pain associated with a bunion on the right foot.

She had undergone conservative treatment consisting of alteration in her shoe gear, orthotic devices, padding, etc., which had been ineffective in reducing symptoms, and due to the level of discomfort and limitations associated with it, the patient has opted for surgical correction.

The patient has been advised as to all possible risks and benefits of such procedure and agrees to it at this time by signing an informed consent.

DESCRIPTION OF OPERATION:  The patient was brought to the OR and placed on the operating table in the supine position.  After proper IV sedation was initiated by the anesthesiologist, local anesthesia was accomplished using approximately 8 mL of 0.5% Marcaine in the form of a modified forefoot block to the right lower extremity.  The patient was then aseptically prepped and draped in the usual fashion and a pneumatic cuff placed around her right ankle for hemostasis purposes.

After checking anesthesia, the patient was noted to be insensate, and the foot and ankle were then exsanguinated using an Esmarch bandage and the pneumatic cuff elevated to a level of approximately 250 mmHg.  After again checking anesthesia, attention was addressed to the dorsomedial aspect of the patient's right foot where a dorsal curvilinear incision was placed overlying the first metatarsophalangeal joint, approximately 6 cm long.

This was placed and deepened using sharp and dull dissection, taking care to cauterize all appropriate small vessels and preserve any neurovascular structures as indicated to the level of capsular tissue and periosteum, which was incised similar to the operative incision.  All appropriate soft tissues were then freed from the distal aspect of the first metatarsal and the base of the proximal phalanx revealing a small dorsomedial prominence, which was resected using power equipment.

The patient then had a sequential lateral release performed in the usual fashion, including the lateral capsular ligaments and the adductor tendon.  The digit assumed a much more rectus position after that procedure was performed and the sesamoid complex relocated.  The patient then had an osteotomy performed in the usual fashion using a chevron technique and fixated using a 22 mm long 2.7 absorbable screw.

The patient then had the first metatarsophalangeal joint placed through vigorous range of motion, and it was noted to be stable.  The patient then had the remainder of the first metatarsal head remodeled so as to remove any sharp edges or excess bone.  The patient then had the wound copiously irrigated using normal saline solution.  The deep soft tissue structures were reapproximated using 3-0 and 4-0 Vicryl suture and final skin closure attained using 4-0 polypropylene suture in a running interlocking technique.

The patient then had the wound cleansed and dressed using iodine-soaked Adaptic gauze, Kling and Coban.  The pneumatic cuff was then deflated.  The patient tolerated the anesthesia and the procedure well, left the OR for recovery with all vital signs stable and vascularity intact in the entire right lower extremity.

The patient was instructed as to postoperative care for bandaging as well as weightbearing status, which is full weightbearing with the use of postoperative shoe.  The patient was also educated as to all signs and symptoms of infection and asked to contact the clinic if any of those signs or symptoms should manifest.  The patient will return to the clinic in five days for first wound check.