Hector Cervantes DPM - OCH
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<BODY> ASSISTANT: ANESTHESIOLOGIST: DATE OF BIRTH: T WARREN SCHWEITZER, MD 09/15/1960 PROCEDURE PERFORMED: 1. Osteotomy with bunionectomy with screw fixation, right foot. 2. Akin osteotomy, proximal phalanx, right foot. PREOPERATIVE DIAGNOSES: 1. Chronic painful hallux valgus (HV) with bunion deformity, right foot. 2. Hallux valgus, right foot. POSTOPERATIVE DIAGNOSES: 1. Chronic painful hallux valgus (HV) with bunion deformity, right foot. 2. Hallux valgus, right foot. ANESTHESIA: MAC with local with 20 mL of 1:1 mixture of 2% Xylocaine plain and 0.5% Marcaine plain in a __________ block fashion. HEMOSTASIS: Right ankle tourniquet to 250 mmHg pressure. ESTIMATED BLOOD LOSS: Minimal, less than 10 cc. MATERIAL USED: 2-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, 2.7 cortical Synthes screw, 28-gauge monofilament wire. INJECTABLES: 20 mL of 0.5% Marcaine plain with 2 mL of dexamethasone phosphate. COMPLICATION: None. INDICATION FOR SURGERY: The patient was met in the preoperative area and all her questions were answered. The risks, complications, alternatives, and options were reviewed again with the patient and the patient was willing to proceed with the planned procedures. There were no guarantees given or implied at any time. With this understanding, would like to proceed with the planned procedures. DESCRIPTION OF PROCEDURE: The patient was brought into the operating room and placed on the operating room table in supine position. Following IV sedation, local anesthesia was obtained about the patient's right foot with 20 mL of a 1:1 mixture of 2% Xylocaine plain and 0.5% Marcaine plain in a __________ block fashion. The right foot and ankle were then prepped, scrubbed, and draped in the usual aseptic manner. Next, 1 g of Ancef was given through the IV by the anesthesiologist. Next, an Esmarch bandage was utilized to exsanguinate the patient's right foot. A pneumatic ankle tourniquet was inflated to 250 mmHg pressure. Attention was directed to the dorsal aspect of the 1st MPJ of the right foot. An approximately 6 mm linear longitudinal incision was made medial and parallel to the tendon of the extensor hallucis longus. The incision was deepened through the subcutaneous tissue using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were cauterized as necessary. At this time a linear longitudinal-type capsulotomy was performed over the dorsal aspect of the 1st metatarsophalangeal joint of the right foot. The periosteum and capsular structures were then carefully dissected free of the osseous attachments and reflected medially and laterally, thus exposing the head of the 1st metatarsal in the operative field. Next, utilizing the MicroAire oscillating bone saw, the dorsal and medial prominences were resected. Attention was directed to the 1st interspace through the original skin incision, where the tendon of the flexor hallucis brevis was eventually identified and tenotomized. This incision was continued deep using blunt and sharp dissection to the level of the fibular sesamoid, which was freed of the soft tissue attachments. Next, the lateral capsule was also released by sharp and blunt dissection. At this time, the hip was externally rotated and the knee was flexed to bring the medial surface of the right foot superior to allow better access for the medial aspects of the metatarsal head for osteotomy cut. Attention was then directed to the medial aspect of the 1st metatarsal head, where a through-and-through Vtype osteotomy was created in the metaphyseal region of this bone utilizing the MicroAire bone saw. The apex of this osteotomy was placed distally. Upon completion of the osteotomy, the capital fragment was distracted out of its sheath laterally to a more correct position and impacted upon the 1st metatarsal shaft. At this time, a 0.045-inch K-wire was driven from distal to proximal across osteotomy site to serve as a temporary fixation. The dorsomedial aspect of the metatarsal head was noted to have cartilage erosion; therefore, drilling of the head of the 1st metatarsal was accomplished to promote fibrocartilage growth. Following a standard AO __________ Wilson technique, a 2.7 cortical screw was inserted and placed across the osteotomy site with excellent compression of it. At this time, the remaining 0.045-inch K-wire was removed. Attention was then directed to the remaining medial bone shelf, which was resected utilizing the oscillating bone saw. The correction osteotomy was assessed and found that the right hallux was noted to be laterally displaced. Attention was directed to the shaft of the distal and proximal phalanx of the right hallux, where periosteal structures were then carefully dissected free of the __________ attachments and reflected medially and laterally, thus exposing the shaft of the distal and proximal phalanx. Next, utilizing the MicroAire oscillating bone saw, a transverse osteotomy was made at the base of the proximal phalanx but left the lateral cortex intact. Utilizing the reciprocating technique, a wedge of rectangular shape of bone was resected at the base of the proximal phalanx. Next, the right hallux was noted to be in a more correct alignment after resection of the bone at the base of the proximal phalanx. Next, a 1.5 mm drill bit was utilized to make a hole out of the distal and proximal phalanx and this was shaped to prepare for a 20-gauge monofilament wire. The wire was put through the holes in the distal and proximal phalanx. Next, the osteotomy was noted to be in a good compression. At this moment, the correction osteotomy was reassessed and the hallux was in good anatomical position and alignment. The wound was copiously lavaged with antibiotic solution. Again, the correction of the deformity was assessed at this time and noted to be excellent. The periosteum and capsular structures were then reapproximated and coapted utilizing 3-0 Vicryl. The subcuticular tissues were then reapproximated and coapted utilizing 4-0 Vicryl, and the skin was reapproximated and coapted utilizing 5-0 Prolene in a continuous running interlocking suture technique. Upon completion of the procedure of the right foot, a total of 20 mL of 0.5% Marcaine plain and 2 mL of dexamethasone phosphate was injected into the surgical site. The incision was then dressed with Betadine-soaked Adaptic, covered with a sterile compression dressing consisting of 4 x 4's, Kling, and Ace wrap. The right pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to the digits of the right foot. The patient tolerated the procedure and anesthesia well. The patient was then transferred to the recovery room with vital signs stable and neurovascular status intact to the digits of the right foot. Following a period of postoperative monitoring, the patient was discharged to home with postoperative instructions as follows: 1. Keep the dressings clean and intact as well as surgical shoe, and wear the postop shoe at all the times. 2. The patient should ice and elevate the right lower extremity. 3. The patient should take all prescribed medications for inflammation and pain. 4. Postoperative followup with Dr. Cervantes' clinic in 2-3 days. The patient was given a phone number to call the office if any questions, problems, or concerns arise prior to her coming to the office. </BODY>
