POSTOPERATIVE DIAGNOSES:
1. Left foot hallux abductovalgus deformity.
2. Left fifth digit adductovarus hammertoe deformity.
3. Left first metatarsophalangeal joint gouty tophi.
PROCEDURES:
1. Left foot Austin bunionectomy with screw fixation and
medial capsulorrhaphy.
2. Left fifth digit skin plasty for adductovarus deformity
correction.
3. Left first metatarsophalangeal joint excision of gouty
tophi.
PATHOLOGY: Left first MPJ gouty tophi.
ANESTHESIA: MAC sedation with IV anesthetic of 1% lidocaine
plain, 20 mL.
MATERIALS: Stryker 3.0 headed screw, 2-0 Vicryl, 3-0 Vicryl, and
4-0 nylon.
INJECTABLES: 1 mL of dexamethasone given postoperatively as
well as 10 mL of 0.5% Marcaine plain.
TECHNIQUE: The patient presented to the preoperative holding area having been n.p.o. past midnight. All preoperative studies were reviewed and discussed with the patient as well as the risks and benefits. The patient wished to proceed with the proposed procedure. The left lower extremity was marked with indelible ink. The patient received preoperative IV antibiotic of 2 g Ancef.
The patient was then transported to the operating room and placed on the operating room table in supine position. Following this, a time-out was then called between myself, anesthesiologist, surgical nurse, and surgical tech about the procedure to be performed as well as the location of the procedure. All were in agreement. Following IV sedation, the left pneumatic ankle tourniquet was then placed to a well padded area above the ankle joint. A Mayo block was then performed over the left first ray as well as reverse Mayo block for the fifth digit. The foot was then scrubbed, prepped and draped in the usual aseptic manner.
Attention was then directed to the left foot hallux abductovalgus deformity. An incision was made medial to the extensor hallucis longus tendon, contouring this to the deformity itself. The incision was then brought through skin into the subcutaneous tissue. Care was taken to retract any neurovascular structures. Upon doing so, a linear capsulotomy was then performed over the left first metatarsophalangeal joint. The head was then fully exposed and noted to have 1 x 1 cm gouty tophi medial to the metatarsophalangeal joint. This was resected in total and separate from the surrounding bone and soft tissue. The specimen was then passed from the operative field and sent to Pathology for further analysis. Attention was then directed back to the incision site within the left first interspace. The adductor conjoined tendon was then released. Attention was then directed
back to the left metatarsal head. The medial eminence was then slightly dissected to create a flat surface. After this, an Austin bunionectomy was then performed with a sagittal saw with a through-and-through cut through the head of the metatarsal with dorsal arm slightly longer. The capital fragment was then shifted laterally and temporarily fixated with a K-wire from the Stryker screw set. Under fluoroscopic guidance it was noted to be in excellent alignment. A Stryker 3.0 screw was then placed through the cannulated wire into the area under Stryker manufacturer guidelines. Noted in excellent compression and alignment well stable. K-wire was then removed. Further medial eminence was then resected as such to create a smooth surface as well as a barrel bur to smooth out any rough edges. The capsulotomy was then sutured closed with 2-0 Vicryl, but upon doing so it was decided to do a medial capsulorrhaphy to help bring the hallux in a more corrected position, thus a wedge capsulorrhaphy was then removed from the medial side of the left first metatarsophalangeal joint and was sutured/tightened closed, noting the hallux in a more corrective alignment. The rest of the capsule was then closed with 2-0 Vicryl. A wet sponge was then placed in the area.
Attention was then directed to the left fifth digit, where an adductovarus hammertoe deformity was noted. Upon mapping out the skin edges, a semi-elliptical incision was made about the proximal interphalangeal joint. By doing so, a wedge of skin was removed, and by holding the 2 skin edges together it was noted to bring the toe itself in a more corrective rectus position. Thus the area was sutured closed with 4-0 nylon.
All areas were then reevaluated under fluoroscopic guidance and noted to be in excellent alignment. Attention was then directed back to the left first metatarsophalangeal joint of the hallux abductovalgus deformity. A running subcuticular stitch with 3-0 Vicryl was then performed. Mastisol was placed about the area. Steri-Strips were then placed around the skin edges to help keep closure. One mL of dexamethasone as well as 10 mL of 0.5% Marcaine plain was then injected about the region. Areas were then dressed with Betadine-soaked Adaptic, 4 x 4’s, gauze and Kling. Tourniquet was then deflated and immediate hyperemia returned to all digits of the left foot. The left foot was then placed in a slipper cast for added protection. The patient was then transferred to the postoperative holding area with vital
signs intact as well as vascular structures intact to the left foot.