A Intermediate Evaluation and Management 1 Obtains focused history and physical history symptoms physical exam recognizes factors that could predict complications or poor outcome 2 Orders and interprets required diagnostic studies radiographs 3 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 4 Postop: 3 Week Postoperative Visit diagnose and management of early complications place the child in a foot abduction orthosis after correction this consists of two shoes that are attached to a bar that maintains the foot in external rotation keep the feet at shoulder width the shoes are placed in the degree of external rotation that was achieved in the last cast if this is unilateral correction, the unaffected foot is placed into 35 degrees of external rotation return to the clinic at intervals of 1 month, 3 months 6 months and 12 months from final cast removal maintain patient in FAO full time x3 months, followed by nighttime/naptime until 3 years old B Advanced Evaluation and Management 1 Modifies post-operative plan based on response to treatment patient fails to improve post-operatively C Preoperative H & P 1 Obtains history and performs basic physical exam check range of motion 2 Screen medical studies to identify and contraindications for surgery 3 Orders appropriate initial imaging and laboratory studies 4 Perform operative consent describe complications of surgery including residual deformity recurrence
E Preoperative Plan 1 Radiographic templating 2 Execute a surgical walkthrough describe 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 casting materials #6900 beaver plade 2 Room setup and equipment OR table 3 Patient positioning supine G Cavus Deformity Correction 1 Supinate the pronated foot 2 Elevate the first metatarsal 3 Place a well molded plaster cast with the forefoot supinated and a mold under the first metatarsal this will maintain all the metatarsal heads in a row H Forefoot Adductus and Hindroot Varus Correction 1 Manipulate the forefoot abduct the forefoot against counterpressure on the head of the talus make sure the counterpressure is not on the fibula or the calcaneocuboid joint this will correct the metatarsus adductus by reduction of the metatarsals and the navicular on the head of the talus and the cuboid on the calcaneus with further casting the calcaneus will begin to evert and abduct under the talus the hindfoot will then begin to convert from varus to neutral or valgus it is critical to perform abduction with the foot in with the forefoot in supination and the foot in equinus so that the calcaneus can evert and abduct underneath the talus 2 Perform serial maniulations and casting perform weekly manipulations and castings with the forefoot in supination and with the foot in equinus until full correction of forefoot adduction and hindfoot varus is obtained I Equinus Correction 1 Prepare for the tenotomy prepare the area with Betadine prep if performing in the office, place topical anesthetic to the area of the tenotomy 45 minutes before the procedure 2 Position the extremity have an assistant hold the knee position the foot to avoid excessive dorsiflexion be aware of the location of the medial neurovascular bundle and remember the elevated calcaneal pitch 3 Perform a heel cord tenotomy perform the tenotomy about 1.5 cm above the palpable tuberosity of the calcaneus insert a #6900 beaver blade or # 11 blade medial to the tendon edge rotate the blade laterally so that is lies partially anterior to the Achilles tendon use a the contralateral finger to push the Achilles tendon against the blade to complete the tenotomy 4 Confirm that complete tenotomy has been performed complete tenotomy is confirmed when there is an audible pop and there is an increase in dorsiflexion of approximately 20 degrees J Casting of the Tenotomy 1 Prepare the surgical site for casting 2 Place the cast place a well molded plaster cast over a sterile cotton roll over the tenotomy site apply the cast with maximum dorsiflexion and abduction of the foot place mold over talar head for counter pressure
O Perioperative Inpatient Management 1 Discharges patient appropriately pain control schedule follow 3 weeks wound care R Complex Patient Care 1 Develops unique, complex post-operative management plans