How to dictate an Austin procedure

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PREOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity, left first metatarsal.

POSTOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity, left first metatarsal.

OPERATION PERFORMED:  Austin bunionectomy with internal fixation, left first metatarsal.

SURGEON:  John Doe, D.P.M.

HEMOSTASIS:  Pneumatic ankle tourniquet set at 250 mmHg.

ANESTHESIA:  MAC with local.



PROPHYLAXIS: Ancef 1 gram 30 minutes prior to incision.

DESCRIPTION OF OPERATION:  The patient was placed on the operating room table in the supine position. Following adequate sedation, a Mayo block was performed utilizing 10 mL of 0.5% Marcaine plain around the first metatarsal. The pneumatic ankle tourniquet was then placed around a well-padded left ankle. The left lower extremity was then scrubbed, prepped, and draped in the usual sterile fashion. Attention was directed to the left and an Esmarch was then utilized for exsanguination. The pneumatic ankle tourniquet was then inflated on the left lower extremity to 250 mmHg. A 6 cm linear longitudinal incision was then made medial and parallel to the extensor hallucis longus involved with the contour deformity. The incision was then deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were electrocauterized as necessary.

At this time, a linear capsulotomy was then performed over the dorsal aspect of the first metatarsophalangeal joint. The periosteal and capsular structures were then carefully dissected free of their osseous attachments and reflected medial and laterally exposing the head of the first metatarsal at the operative site. A sagittal bone saw was then utilized to resect all noted medial prominence. Attention was then directed to the first interspace by the original skin incision, where the extensor hallucis longus was observed and retracted out of the way, exposing the extensor hallucis brevis, which was identified and retracted out of the way. Dissection was then continued deep using blunt dissection down to the level of the fibular sesamoid, which was freed from its soft tissue attachments proximally, laterally, and distally. The conjoined tendon of the abductor hallucis muscle was then identified and resected at its attachment to the base of the proximal phalanx at the hallux. At this time, the level of the contracture present on the hallux was noted to be reduced and the sesamoid apparatus was noted to flow in a normal corrected position.

At this time, attention was directed to the medial aspect of the first metatarsal head at which time a 0.45 inch K-wire was then driven from the medial to lateral in a perpendicular fashion across the head of the first metatarsal, being perpendicular to the line of the second metatarsal with no dorsiflexion or plantarflexion noted. At this time, a V-type osteotomy was created in the metaphyseal region of the bone utilizing a sagittal bone saw. After this was created and placement of the guidewire, the apex of the deformity was pointed distally and the arms were approximated plantarly and proximal, dorsally. Upon completion of the osteotomy, the capital fragment was distracted and shifted laterally into a more corrected position impacted on the first metatarsal shaft. At this time, a 0.45 inch K-wire from the DePuy screw set was then driven from dorsal to plantar across the osteotomy site to serve as temporary fixation.

Following standard AO technique procedures, one 20 x 2.7 mm FRS DePuy bone screw was then inserted and placed across the osteotomy site with excellent compression noted. At this time, the K-wire was then removed and attention was then directed to the medial bone shelf, which was resected utilizing a sagittal saw and passed from the operative site. A power rasp was then utilized to smooth all bony prominences. Correction of the deformity was then reassessed at this time, both clinically and utilizing intraoperative fluoroscopy, and the position of the screw and correction of the deformity was noted to be excellent. The wound was then flushed with copious amounts of sterile normal saline and a medial capsulorrhaphy was then performed. The capsule and the periosteal structures were then reapproximated utilizing 4-0 Vicryl. The subcutaneous layer was then reapproximated utilizing 4-0 Vicryl and the skin was closed in a subcuticular stitch fashion using 4-0 Monocryl. Benzoin and Steri-Strips were then applied.

Upon completion of the procedure, the incisions were then dressed with dilute Betadine-soaked Adaptic covered with dilute Betadine-soaked gauze, Kling, Kerlix and Coban. The pneumatic ankle tourniquet on the left ankle was then rapidly deflated with a prompt hyperemic response noted to all digits of the left foot. A DonJoy ice dressing was then incorporated into the wound dressing, after initial dry sterile dressings. The patient tolerated the procedure and anesthesia well and was transferred to the recovery room in satisfactory condition with vital signs stable and vascular status intact to all digits bilaterally.

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