A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam evaluate vascular status infection neuropathy trauma vascular exam need to assess associated injuries and comorbidities (diabetes) documental baseline neurovascular exam 2 Appropriately interprets basic imaging studies AP/Lat views of foot, ankle, and tibia/fibula MRI of the to look for integrity of soft tissue and infection 3 Appropriately orders and interprets advanced imaging studies CT and MRI w/ or w/o contrast) 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Postop: 2 week Postoperative Visit wound management diagnose and management of early complications<br /> wound healing infection DVT place a cast with the ankle in neutral position 6 Postop: 4 week Postoperative Visit place a walking cast with the ankle in neutral 7 Treat postoperative complications B Advanced Evaluation and Management 1 Provides complex non-operative treatment multiple co-morbidities non-compliant C Preoperative H & P 1 Perform basic medical and orthopaedic history and physical check neurovascular status to determine level of amputation 2 Order basic imaging studies weightbearing images AP/Lat views of foot, ankle, and tibia/fibula 3 Perform operative consent describe complications of surgery
E Preoperative Plan 1 Radiographic templating 2 Execute surgical workthrough describes the steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation basic orthopedic set 2 Room setup and equipment standard OR table fluoroscopy 3 Patient positioning place patient prone place a thigh tourniquet G Skin Incisions 1 Make the first cut make the first incision at the site of the rupture 2 Make the second cut second incision 5 cm proximal to the first incision make this incision over the medial half this minimizes the risk of injury to the sural nerve 3 Make the third cut third incision 5 cm distal to the rupture H Passage of the First Suture 1 Identify the tendon use a small curved hemostat to define the track of the tendon 2 Suture the proximal end of the tendon use a curved 90 mm cutting needle with number 1 nylon suture pass a the needle through middle incision through the tendon substance and have it exit through the proximal incision reintroduce the needle through the proximal incision make sure that separate entry point is used have the needle exit the middle incision 3 Suture the distal end of the tendon introduce the needle through the middle incision pass the needle through the distal stump of the tendon 4 Test the sutures apply traction to the suture ends to ensure that good hold of both tendons is present place an artery clip on the free ends of the suture I Passage of the Second Suture 1 Suture the proximal end of the tendon use a curved 90 mm cutting needle with number 1 nylon suture pass a the needle through middle incision through the tendon substance and have it exit through the proximal incision reintroduce the needle through the proximal incision make sure that separate entry point is used have the needle exit the middle incision 2 Suture the distal end of the tendon introduce the needle through the middle incision pass the needle through the distal stump of the tendon 3 Test the sutures apply traction to the suture ends to ensure that good hold of both tendons is present place an artery clip on the free ends of the suture J Suture Tying 1 Tie the sutures place the ankle in the plantar flexion tie the sutures with the ankle in plantar flexion K Wound Closure 1 Close the wound close the wound with nonabsorbale suture 2 Immobilize the ankle place a cast with the ankle in plantar flexion
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans