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Dr. Dennis Yenn's Major Surgeries - Op Report -
Chevron Osteotomy for Austin Bunionectomy w/ screw fixation
For educational purposes only, residents' use.
OPERATIVE REPORT (sample)
DATE OF SURGERY: 00/00/01
PRE-OPERATIVE DIAGNOSIS:
1. Hallux abducto valgus and bunion deformity, right foot
POST- OPERATIVE DIAGNOSIS:
1. Hallux abducto valgus and bunion deformity, right foot
PROCEDURE: Austin bunionectomy with fixation (screw or tapered orthosorb), right foot
SURGEON: Dr. Dennis Yenn, DPM
PROCTOR: Dr. John Doe, DPM
RESIDENT(S): Dr. Your name, DPM (PGY2)
ANESTHSIOLOGIST: Dr. John Doe 2, MD
ANESTHESIA: Local with IV sedation
INDICATIONS FOR SURGERY, and HPI: see Podiatric H&P
FINDINGS:
1) Degenerative cartilage on the head of the metatarsal and base of the proximal phalanx of the great toe.
2) Associated hyperkeratotic tissue, plantar medial aspect of the hallux at the interphalangeal joint area.
3) Soft osteoporetic bone.
4) Intra-operatively, large Proximal Articular Set Angle (PASA) at 1st MPJ.
5) Medial prominence and/or dorsal spur on met head.
6) Hallux limitus and impingement.
PROCEDURE IN DETAIL: Under mild sedation, the patient was bought into the operating room and assisted on to the operating table in a supine (or prone) position. A pneumatic ankle tourniquet was then placed about the patient’s right ankle. Following IV sedation, local anesthesic block was administered to the right foot appropriately a 1:1 mixture of 2% lidocaine plain and 1/2 % marcaine plain. The foot was then scrubbed, prepped, and draped in the usual aseptic manner. An esmarch bandage was then utilized to exsanguinate the patient’s right foot, and the pneumatic ankle tourniquet was inflated to 250 mm Hg.
Attention was then directed to the dorsal-medial aspect of the 1st metatarsal head R foot where a linear longitudinal incision was carried out just medial and parallel to the tendon of the extensor hallucis longus and involved the contour of the deformity. The incision was then deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neural and vascular structures. All bleeders were ligated and cauterized as necessary.
At this time, a capsulotomy was performed over the 1st MPJ. The periosteal and capsular structures were then carefully reflected gaining entrance. Noted is the existence of a large PASA angle as well as yellow degenerative cartilage on the met head. Then the medial eminence which was then resected with an oscillating saggital saw, and then passed from the operative site. This also provides a flat medial shelf for the anticipated Austin cuts. Cystic and osteoporetic changes are noted on the head of the metatarsal. A K-wire was then used to fenestrate the met head. (The dorsal spur was then resected with bone forceps.) The extensor hallucis brevis tendon was then identified and cut, relieving some of the deforming force.
Attention was then directed to the 1st interspace where Metzenbauem scissors provided blunt dissection to identify the conjoint tendon of the adductor hallucis muscle and then detached at it’s attachment at the fibular sesmoid. (The fibular sesmoid was noted to be hyperplastic and strongly adhered to the plantar structures which then a periosteal elevator was used to free this structure successfully and negating the need to remove the fibular sesmoid.) Then the deep intermetatarsal ligament was also transected, and then a capsulotomy was then performed in the interspace to complete the lateral release. The great toe was then abducted, and the soft tissue reduction was noted to be excellent.
Attention was then directed back to the medial aspect of the 1st met head where a K-wire was inserted directly in the center of the met head entering from medial to lateral. The oscillating sagital saw then used to successfully perform complete thru and thru Chevron “V” type Austin osteotomy, with the K-wire serving as the guide and apex to the cuts, and the angle of the “V” approximately 60 degrees. A small dorsal wedge was then resected to achieve slight plantar-flexion of the met head as well as correction of the PASA. The K-wire was then removed, and the capital fragment distracted and moved into a more laterally corrected position, and then impacted into the shaft of the metatarsal.
At this time a new K-wire was driven from proximal dorsal to plantar medial distal, crossing the osteotomy site and will serve as the guide for the insertion of a cannulated screw. Following the rules and principles of AO fixation, the following procedures were performed using Synthese's small fragment set: pre-drill, drill, countersink, depth gauge, measure, over drill, pre-tap, and tap was performed and after each measurement and 3 mm proximal to the osteotomy site. Next, the appropriate size of tapping cancellous screw w/ lag technique was then inserted with care not to hit temporary K-wire. Excellent compression was noted as evidenced by the expelling of liquid marrow at the osteotomy site. The distal end of the screw was verified for certain, as to not not proud the cartilage, and the K-wire then removed.
The remaining medial shelf was then transected and passed from the operative field. A power rasp smooths any rough edges. Copious lavage was completed with irrigation of normal saline all across areas of the operative site. A rolled up 4X4 was then placed between the 1st and 2nd toes to assist the correction and then the capsule tissues then reapproximated and coapted with absorbable 2-0 vicryl sutures and deep structures also closed with absorbable 3-0 vicryl sutures . The skin closed with non-absorbable 4-0 prolene sutures in a horizontal (or vertical) mattress fashion.
Deflation of the right tourniquet. Prompt hyperemia noted across all digits of the right foot. Local injected consisted 1/4 % marcaine plain, and then cortisone (kenalog-10). The surgical wound and foot dressed as follows: Xeroform, 4X4 gauges, kerlex, coban, and a post-op shoe.
CLOSING STATEMENT: The patient tolerated the procedure and anesthesia well, left the operating room along with the anesthesiologist in stable condition. Following a period of post-operative monitoring, the patient will be discharged home per PAR (Post Anesthesia Recovery) with instructions to elevate both feet above the heart, take appropriate pain medications PRN, keep dressing clean and dry, and to follow up with an appointment at Dr. Yenn’s clinical office.
PATHOLOGY SENT: bone R/L foot/feet
ESTIMATED BLOOD LOSS: Minimal
COMPLICATIONS: None
__________________
By Dr. Your Name, DPM
___________________
For Dr. Dennis Yenn, DPM
At the end of your dictation, please conclude with, “this ends the dictation report for patient’s name _______________. My name is Dr. your name dictating for Dr. Yenn. Please mail copies to all physicians listed in the beginning of the dictation including myself. Any questions please page me, Dr. Your Name at 555-555-5555. Thank you for you time.” Write down the report number for future reference.
Notes: be careful of numbers. For dictation purposes,
1) K-wires, say 0.062 (“zero point zero six two”), and not the way we commonly say it 6-2.
2) For 0.5% marcaine, say (“zero point five percent” or “half percent”).
3) For 2-0 Vicryl, say (“two hyphen zero”)
4) Dictate all doses and frequency, but DO NOT dictate amounts. Example: do NOT dictate “10 cc administered” or “tourniquet inflated to 275mmHg."
Importance of dictation:
1) serves as medical record keeping for future treatment(s)
2) serves as documented evidence for work done when billing or auditing.
3) legal defense for
a) amounts of medications administered
b) complications arisen with or without fault of OR.
Please fill out teaching form and have Dr. Yenn sign it before you leave (if your program requires it). Remember to give patients the Rx script for pain, and go over post-op instructions. The PAR should have a hardcopy of the handout titled, “Surgery Information for Patient.” Please stay at least 15 min after the patient has entered the PAR to make sure everything’s OK. Tell the patient if he/she has questions or concerns, call you (the resident). Then if necessary, the resident pages Dr. Yenn.
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click here for surgery info
Last update: 01/22/04, First update: 03/25/01.
home page: www.dyenn.com