A Basic Preoperative Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam concomitant and associated orthopaedic injuries check neurovascular status 2 Appropriately orders and interprets advanced imaging studies/lab studies radiographs weigthbearing ankle series AP mortise lateral CT scan determines the degree of arthritis in the subtalar joint and anatomy of the ankle MRI used to check for osteonecrosis of the talus 3 Prescribes and manages non-operative treatment activity modification guides trial of medical managment NSAIDS intraarticular steroid injections UCBL brace 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check remove cast remove sutures place in weightbearing short fiberglass cast diagnose and management of early complications<br /> wound healing infection DVT postop: 4-6 week postoperative visit obtain radiographs remove cast place in walking orthosis diagnosis and management of late complications<br /> postop:12 week postoperative Visit obtain radiographs to check for union start range of motion exercises B Advanced Evaluation and Management 1 Provides patient specific non-operative treatment diagnostic injections 2 Modifies and adjusts post-operative treatment plan as needed C Preoperative H & P 1 Obtain history and perform basic physical exam complete neurovascular exam of extremity. identify medical co-morbidities that might impact surgical treatment diabetes, smoking and previous surgery all effect wound healing 2 Order basic imaging studies order weight-bearing triplanar films of the ankle 3 Perform operative consent describe complications of surgery including infection nonunion neurovascular injury wound healing problems
E Preoperative Plan 1 Radiographic templating Use radiographs and CT scan to map out placement of implants 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation microsagittal saw osteotomes curets 7.3 mm cannulated screws 4.0 or 4.5 mm cannulated screws plating systems (optional) 2 Room setup and equipment standard OR table 3 Patient positioning supine with foot at the edge of the table place sandbag under the ipsilateral hip to internally rotate the foot G Superficial Dissection 1 Mark out the anatomy and the incision start incision 10 proximal to the tip of the fibula extend incision distally down the shaft of the fibula to the base of the fourth metatarsal internervous plane is between the peroneal muscles and the extensors 2 Incise retinaculum incise the superior peroneal retinaculum posteriorly mobilize the peroneal tendons protect the sural and SPN make sure to maintain full thickness skin flaps 3 Remove periosteum use osteotomes to strip the periosteum of the fiibula anteriorly H Deep Dissection 1 Extend the incision medially expose the distal tibia, tibiotalar articulation posterior facet of the subtalar joint and the sinus tarsi 2 Strip the periosteum off the fibula use an osteotome to strip the anterior fibula and strip the posterior fibula slightly I Joint Preparation 1 Expose the anterior joint use a periosteal elevator to strip the <span class="pi3bx6" id="pi3bx6_12">soft tissue</span> from the distal end of the tibia and the talar neck to the medial malleolus 2 Perform fibular osteotomy use an <span class="pi3bx6" id="pi3bx6_5">oscillating saw</span> to create a fibular osteotomy approximately 4 to 6 cm proximal to the tip of the lateral malleolus debride the syndesmosis cartilage soft tissue and cortical bone 3 Harvest fibular bone graft make a sagittal cut of the fibula to resect the medial fibular fragment morselize and use for <span class="pi3bx6" id="pi3bx6_6">autologous bone</span> graft 4 Remove ankle capsule use sharp dissection through the lateral incision to elevate the scarred ankle capsule and strip soft tissue attachments from the joint both anteriorly and posteriorly place retractors to expose the ankle mortise and protect soft tissues while the bone cuts are made manually denude the tibiotalar joint of cartilage and subchondral bone with curettes and or osteotomes J Arthrodesis Preparation 1 Place foot in proper alignment for arthrodesis place talus in position so that the forefoot is in 5 to 10 degrees of external rotation place hindfoot into 5 degrees of valgus and 0 degrees of dorsiflexion make a cut through the dome of the talus that is parallel to the distal tibia cut resect 3 to 5 mm of bone bring the joint together and check the alignment 2 Expose the medial malleolus make a 6 cm longitudinal incision along the anterior third of the medial malleolus dissect through the subcutaneous tissue make sure to maintain full thickness flaps remove the ankle capsule and periosteum remove any residual cartilage and sclerotic bone 3 Create vascular channels drill joint surface until bleeding bone is obtained obtain the desired alignment K Fixation 1 Place guidepins secure joint by placing to guidepins for large partially threaded cannulated screws start at the base of the talar neck and direct guidepin proximally in the posteromedial direction and lateral to the anterior process start the second guidepin just above the posterior facet and anterior to the lateral process in the postermedial direction parallel to the first guidepin make sure not to violate the subtalar joint with the guidepins 2 Check alignment use fluouroscopy to check the alignment and placement of the guidepins 3 Place cannulated screws remove guidepins 4 Use fluoroscopy to check reduction and screw placement L Treat Intraoperative and Immediate Postoperative Complications 1 Step 1 of treating intraoperative complications 2 Step 2 of treating intraoperative complications N Wound Closure 1 Irrigation and hemostasis ensure hemostasis using cautery 2 Superficial closure use 3-0 nylon horizontal mattress sutures for skin 3 Deep closure use 2-0 vicryl for the subcutaneous layer 4 Dressing and immediate mobilization place in well padded non-weightbearing short leg plaster cast split in postop to allow for swelling
O Peroperative Inpatient Management 1 Write comprehensive admission orders pain meds IV fluids DVT prophylaxis advance diet as tolerated check appropriate labs foley out when ambulating wound care physical therapy non-weightbearing strict elevation check postoperative films 2 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks R Complex Patient Care 1 Treat complex complications