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: 3-4 Week Postoperative Visit wound check diagnose and management of early complications place in walking cast until radiographic signs of healing present 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 standing radiographs of the foot 4 Perform operative consent describe complications of surgery including wound dehiscence pressure sores rocker bottom foot deformity wound complications nonunion
E Preoperative Plan 1 Examine subtalar motion under anesthesia 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 oscillating saw 1/4 inch and 1/2 inch osteotomes 1.6 mm and 2.0 mm smooth steinmann pins Chandler retractors Hohman retractors 2 Room setup and equipment standard OR table 3 Patient positioning supine place a bump under the ipsilateral hip for internal rotation of the foot G Plantar Release 1 Make the skin incision make a longitudinal incision medially of the plantar fascia 2 Perform dissection use sharp knife dissection through the skin and the subcutaneous fat 3 Expose the deep fascia identify and release the abductor hallucis off of the deep fascia expose the fascia that is deep to the abductor hallucis 4 Identify the neurovascular structures identify the posterior tibial nerve and artery proximally follow distally by releasing the overlying fascia 5 Expose the plantar fascia expose the plantar fascia where it attaches to the medial tubercle of the calcaneus 6 Release the tendons use Mayo scissors to release the flexor digitorum brevis, quadratus plantae and the abductor digiti quinti muscles at the their proximal origins 7 Loosely close the wound close the wound loosely with interrupted sutures to allow drainage of blood for prevention of hematoma H Proximal Dorsal Based Oblique Closing Wedge Osteotomy (Medial Column Osteotomy) 1 Make the skin incision make a longitudinal incision over the proximal metatarsal be careful to protect and identify the dorsal digital nerve 2 Perform subperiosteal dissection of the proximal metatarsal be sure to leave the plantar periosteum and soft tissue intact 3 Place pins place 2 small diameter Steinmann pins with a drill at the site of the bone cuts these pins should converge at the plantar apex the apex of the cut should be very proximal and plantar 4 Perform the osteotomy use a small oscillating saw to make the cuts use the wires as guides for the cuts 5 Remove the cut bone use a small osteotome and rongeur to remove some of the bone at the apex leave a bony and soft tissue hinge intact so that this is an incomplete closing wedge osteotomy 6 Reduce the osteotomy slowly close the ends together while maintaining the bone hinge 7 Apply fixation secure the osteotomy with a wire, screw or dorsal plate 8 Close the wound close the wound with loose interrupted sutures I Interphalangeal Joint Fusion (Modified Jones Procedure) 1 Make a transverse incision make a transverse incision over the interphalangeal joint of the great toe 2 Expose the articular surface carry the incision down to the extensor hallucis tendon transect the tendon at the level of the IP joint transversely incise the joint capsule continue with a no. 15 blade to expose the articular distal aspect of the proximal phlanx 3 Remove the articular surface use a rongeur to remove the articular cartilage and a small amount of subchondral bone on both sides of the IP joint 4 Place a guidewire place a guidewire in a retrograde fashion through the center of the distal phalax so that it exits distally just plantar to the nail 5 Reduce the joint reduce the joint in a neutral position 6 Place fixation insert the screw provide compression at the IP joint the proper length will place the tip of the screw into the proximal aspect of the proximal phalanx 7 Close the wound close the wound with loose interrupted sutures J Transfer of the EHL Tendon to the Metatarsal Neck (Modified Jones Procedure) 1 Make the skin incision make a longitudinal incision over the distal first metatarsal 2 Expose the EHL identify and isolate the extensor hallucis tendon this should be done until its cut end can be pulled into the incision 3 Prepare the EHL place a 0 whipstitch suture into the distal tendon 4 Expose the distal metatarsal subperiosteally expose the distal metatarsal 5 Prepare the metatarsal neck make a transverse drill hole in the metatarsal neck the drill diameter should be the same diameter as the extensor hallucis tendon 6 Pass the tendon pass the tendon with the assistance of wire or suture passer 7 Secure the tendon after the appropriate osteotomy is reduced and final fixation has been placed, secure the EHL to itself 8 Close the wound close the wound with loose interrupted sutures K Midfoot Osteotomy 1 Make the skin incision make a long dorsomedial skin incision at the apex of the deformity 2 Place the retractors place hohmann retractors dorsally and plantarly to expose the entire midfoot 3 Place Steinmann pins insert smooth Steinmann pins to define the proximal and distal aspects of the osteotomy 4 Perform the osteotomy make the osteotomy with an oscillating saw complete the osteotomy with rongeurs remove a dorsal based wedge 5 Reduce the osteotomy 6 Place fixation place two threaded Steinman pins for fixation 7 Close the wound close the incision with loose interrupted sutures L Calcaneal Osteotomy 1 Make a lateral oblique skin incision make a lateral oblique incision just posterior to the peroneal tendons 2 Identify the fibulocalcaneal ligament section this ligament along with the periosteum 3 Use an oscillating saw to perform osteotomy create a laterally based wedge on the calcaneus this should be immediately posterior to the peroneus longus tendon 4 Close the wedge 5 Perform fixation fixation of the wedge can be performed with a Steinmann pin or cannulated 7.3 mm screw introduce the screw percutaneously in the trajectory that is perpendicular to the osteotomy N Immobilization 1 Place in a non weightbearing cast leave in place for 4 weeks
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated IV fluids pain control physical therapy wound management remove dressings POD2 2 Discharges patient appropriately pain control schedule follow up in 2 weeks wound care R Complex Patient Care 1 Develops unique, complex post-operative management plans