1. Right foot cellulitis with abscess.
2. Chronic ulceration of the right hallux.
3. Osteomyelitis of the distal phalanx of the right hallux.
POSTOPERATIVE DIAGNOSIS:
1. Status post incision and drainage of the right foot.
2. Status post amputation of the distal phalanx of the
right hallux.
3. Status post bone biopsy of the proximal phalanx of the
right hallux.
4. Status post excision of chronic ulceration right hallux.
PROCEDURES PERFORMED:
1. Incision and drainage of the right foot.
2. Amputation of the distal phalanx of the right hallux.28825
3. Bone biopsy of the proximal phalanx of the right hallux. 20240
4. Excision of chronic ulceration right hallux.
OPERATIVE FINDINGS: Necrotic base of the distal phalanx of right foot.
INJECTABLES: 20 mL of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain.
HEMOSTASIS: None.
MATERIALS USED: 2-0 Prolene suture, antibiotic, bacitracin irrigated saline with pulse lavage.
COMPLICATIONS: None.
SPECIMENS:
Both aerobic and anaerobic cultures. Bone pathology specimens of distal phalanx and clearance fragment.
DESCRIPTION OF PROCEDURE: The patient was brought in the operating room and placed on the operating table in supine position. The patient’s right foot was marked in preoperative area. Timeout was performed at this time. Approximately 20 mL of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain
was injected in the patient’s right foot in a Mayo nerve block fashion. The right foot was then prepped, scrubbed and draped in typical aseptic technique.
INCISION AND DRAINAGE OF THE RIGHT FOOT: Attention was then directed to the dorsal medial aspect of the right hallux where necrotic changes were noted on the MRI prior to surgery. A fish mouth type of incision was created over the IPJ joint of the right hallux. The incision was deepened through subcutaneous tissue using sharp and blunt dissection techniques. Care was taken to identify and retract all neurovascular structures. All bleeders were cauterized as necessary. Upon dissection of the subcutaneous tissue, the interphalangeal joint of the right hallux was subsequently identified and incised utilizing 15 blade. Upon incision of
the IPJ joint the dorsal medial base of the distal phalanx noted to crumble and being necrotic in nature. The distal phalanx of the right hallux was then subsequently removed in total through the IPJ joint and sent to pathology for further identification.
AMPUTATION OF DISTAL PHALANX, RIGHT FOOT: The distal phalanx of the right hallux was subsequently removed utilizing a #15 blade and sent to pathology for further identification. The removal of the distal phalanx was through the IPJ joint of the right hallux. The base of the distal phalanx was noted to be necrotic and crumbling in nature.
BONE BIOPSY OF PROXIMAL PHALANX OF THE RIGHT HALLUX: Attention was then directed to the head of the proximal phalanx of the right hallux which appeared to be necrotic in nature, though hard in texture and mildly gray in appearance. A sagittal saw was then subsequently utilized in order to remove the head of
the proximal phalanx, which was sent to pathology for further identification. Next, a clearance fragment of the shaft of the proximal phalanx was subsequently resected utilizing a sagittal saw, which was noted to be healthy in texture and appearance, and sent to pathology for clearance fragment. All necrotic tissue was subsequently removed surrounding the proximal phalanx shaft and base. A small abscess was noted along the tendon extensor hallucis longus on the head of the
proximal phalanx before it was resected, and has subsequently excised utilizing a rongeur.
Excision of chronic ulceration right hallux. An ulceration that was noted on the plantar aspect of the right proximal phalanx head was subsequently excised utilizing a 3 to 1 elliptical incision, it was removed of all necrotic tissue.
The incision was then irrigated with copious amounts of both sterile saline, as well as bacitracin and impregnated saline as well. The wound and incision was thoroughly explored for any evidence of necrotic tissue, proximal tracking any abscess or signs of infections. The remaining proximal phalanx bone
was noted to be healthy in nature with no evidence of necrotic bone or tissue. The tendon of the extensor hallucis longus and flexor hallucis longus was thoroughly incised in order to ensure no tracking proximally. The skin edges were then closed and reapproximated utilizing 2-0 Prolene in a palm sole and simple interrupted suture technique. A dressing was applied consisting of Betadine soaked Adaptic, 4 x 4, ABD pad, Webril, and Ace.
The patient tolerated procedure well, had no complications, was transferred to the PACU with vital signs stable and vascular status intact to the right foot. The patient tolerated the procedure well and was transferred to the floor with vital signs are stable. The patient is to remain in-house until pathology results come back to ensure clearance fragment is negative of osteomyelitis. The patient is to continue his floor antibiotics, vancomycin and Zosyn until
cultures are obtained.