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Any thoughts would be appreciated.
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Tobi C.
Thanks in advance.
The foot exsanguinated and the tourniquet inflated. A classic Mann style distal soft tissue release was done and then a proximal osteotomy of the 1st metatarsal using the Mau osteotomy with the PROMO system. An excellent correction was obtained. Fixation was with the plate and the additional 3.0 mm lag screw. Partial resection of the medial eminence was done and medial capsule plication done too. Closure done with the tourniquet deflated. The adductor hallucis tendon sutured to the medial eminence.
. Thank you.
Procedure(s): Right second toe amputation including the entire second metatarsal bone and removal of the remainder of the first metatarsal bone of the right foot
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The patient was placed on the operating table in supine position and underwent successful general endotracheal anesthesia. Timeout was called to verify the operation to perform was the second right toe transmetatarsal amputation with debridement of wound . The right foot was then prepped in its entirety including the lower portion of the leg to the mid calf area with ChloraPrep and sterilely draped. A circumferential incision made around the base of right second toe and carried on down to the MP joint space and which time it was disarticulated at the joint space and removed from the operative field. Using the periosteal elevators the second metatarsal bone was then dissected free of surrounding tissues back to the cuneiform bone and it was then disarticulated at its joint space with the osteotome and removed removed from the operative field. Hemostasis controlled with the Bovie cautery and there was brisk leading in the entire wound. The residual portion of the first metatarsal bone from the prior transmetatarsal amputation right great toe was then dissected free from the surrounding tissues and was disarticulated from the cuneiform bone and it was removed the operative field. The articular surfaces of the cuneiform bones were then rongeured back to cancellous bone to remove the cartilaginous portions. After this been accomplished the open wound was then irrigated with 3 L of bacitracin solution using the Pulsavac irrigating system. Further hemostasis controlled with Bovie cautery and then the wound was packed open using orthopedic solution soaked Kerlix packed into the wound and then dry 4 x 4’s between the toes and the entire dressing was wrapped with Curlex with #8 Spandage tube net dressing to hold the Kerlix bandage in place. The sponge and needle count were correct ×2 . The blood loss was approximately 200 mL’s. The necrotic tissue surrounding the MP joint space was sent for aerobic and anaerobic cultures fungal smear and culture and AFB smear and culture. The residual portion of the first metatarsal bone as well as the second metatarsal bone was sent for pathological identification as well as the second toe.
Following satisfactory placement of the patient supine on the operating table satisfactory timeout was accomplished, satisfactory general anesthesia was induced by Dr. taken, and sterile prep and drape of the left lower extremity was accomplished. The left first metatarsal head had osteomyelitis and an underlying plantar ulcer. As such a 3-1/2 cm longitudinal incision was made with a 15 blade overlying the metatarsal head and distal shaft of the metatarsal. The incision was carried down through the subcutaneous tissues down onto the metatarsal shaft and carried through to the metatarsal head. Dissection proceeded to free up the metatarsal and then a micro-oscillating saw was used to transect the metatarsal shaft at the distal third. Once transected the metatarsal shaft was grasped with a towel clip was a brittle bone and it splintered. But with a grasping elevation was accomplished away from the underlying soft tissues in the plantar surface along with tenderness insertions and these were debrided and excised the sesamoid bone was also identified and excised. The metatarsal head was separated from the proximal great toe at the joint space. The proximal area of the first metatarsal shaft was sent for culture and the metatarsal head was sent for culture and pathologic examination. The sesamoid bone was also sent for culture and for pathologic examination. Following this the surgical bed was irrigated with saline and then closed with 3-0 Monocryl for the subcutaneous tissue after satisfactory hemostasis and the skin was closed with interrupted 4-0 Prolene sutures. Sterile dressing Kling and Ace wrap was applied. Patient tolerated procedure well was taken to recovery room in stable condition.