Hillcrest Case 7 Operative

OPERATIVE REPORT Patient: T. J. Moreno Patient ID: 110497DOB: 02/15Age: 44Sex: M Date of Admission: 10/09/2013 Date of Procedure: 10/09/2013 Admitting Physician: Patrick Keathley, MD Endocrinology Surgeon : Dr. Max Hirsch, MD Orthopedics Assistant: Markus Leroy Johnson PAC (Surgical assistant was used for soft tissue protection and retraction and also for maintaining reduction during temporary and permanent fixation use of surgical assistant was medically necessary, and to prove the safety and efficacy of the procedure. Preoperative Diagnosis: Left hindfoot osteoarthritis. Postoperative Diagnosis: Left hindfoot osteoarthritis. Operative Procedure: 1) Triple arthrodesis . 2) Popliteal sciatic block placed by surgeon explicitly for postoperative pain management. Anesthesia: General by Chuck Delaney, MD. Condition during anesthesia, stable. Specimen Removed: Nine. IV Fluids: See nurse’s notes. Estimated Blood Loss: See nurse’s notes. Urine output: See nurse’s notes. Complications: None. Postoperative condition: Stable (Continued) OPERATIVE REPORT Patient: T. J. Moreno

Patient ID: 110497DOB: 02/15Age: 44Sex: M Page: 2 INDICATION: A 44 year old male with hindfoot osteoarthritis pain, who has failed conservative management after reviewing risks, benefits and alternatives, he has agreed to proceed with surgical management. Risks of delayed healing, non-healing and infection, nerve vessel tendon injury, ongoing pain and discomfort, procedure failure, need for revision surgery, and/or hardware removal noted. The fact that he will have a stiffed hindfoot noted. Patient’s questions were answered, and he was consented for the planned procedure.

PROCEDURE IN DETAIL: The patient was taken to the operating room where general anesthesia was induced. Time out was taken indicating the appropriated site, procedure, and patient. Operative site was initialed, one gram of Ancef given IV. Popliteal block was placed medial to lateral hamstring, 3 fingerbreadths proximal flexion crease to the knee. Intraneural injection of avoided by reducing the amperage to below 1 milliamp, seeing an obliteration of motor response. The extremity was prepped and draped in the usual fashion. Extremity exsanguinated, tunicate inflated.

No equinus was present. Metier incision made from the tip of the fibula to the base of the fourth metatarsal. Extensor digitorum brevis and fat pad were elevated off the inferior peroneal retinaculum. Calcaneocuboid and subtalar joints were carefully exposed, denuded of cartilage, and prepared with a 4mm osteotome for arthrodesis. The calcaneocuboid joint was exceptionally osteoarthritic. The talonevicular joint linear incision was made in line with the posterior tibial course, sharp dissection carried down through skin with blunt dissection of subcutaneous tissues.

Saphenous vein was retracted in a dorsal postion, linear incision made in the periosteum. The calcaneo and the talonavicular joint were carefully exposed. Cartillage, or what was remaining of cartilage was removed. There were extreme osteoarthritic thoughout. Essentially 5%-10% of cartilage remained. The osteophytes were carefully excised with osteotome, the joint was prepared with microfracture using an osteotome on both sides of the joint. (Continued) OPERATIVE REPORT Patient: T. J. Moreno Patient ID: 110497DOB: 02/15Age: 44Sex: M Page: 3

Shortly the incision made off the weight bearing surface of the posterior heel. Guide wire from the 70 cannulated set was advanced across the posterior heel across the subtalar joint into the talor neck body junction. This was done while the heel was held in a slight valgus position. After verifying position and measuring, the wire was advanced to the anterior ankle, held with a hemostat. This was followed by sequential reaming with 4. 0 and then 7. 0 cannulated reamers. Next, after tapping, a fully threaded 100 mm screw was placed over a washer. Care was taken to avoid soft tissue impingement posteriorly.

Excellent compression, fixation, subtalar joint were obtained without impingement of the ankle. Next the talonavicular joint was reduced to a foot plantar grade position, held with two 4. 0 cannulated screws starting at the naviculocuneiform joint. Next the calcaneocuboid joint again was adjusted to allow for plantar grade foot position. The joint was held with 4 staples from the 3M 15X16mm stabilizer. All wounds were irrigated with normal saline, excellent compression was present in each position, the medial periosteal was repaired with 3. 0 vicral suture.

Subcutaneus tissues closed with 3. 0 vicral and skin closed with skin clips. On the lateral side, extensor digitorum brevis was repaied to the inferior peroneal retinaculum as was the fat pad. Subcutaneous tissue was closed with 3. 0 vicral. Skin closed with 4. 0 nylon. The posterior heel was irrigated and closed with 4. 0 nylon suture. A sterile dressing was applied plus telfa dressing, sponge, Webril, cotton roll, and plaster splint. The foot was at a final plantar grade position. Image intensification showed well placed hardware, extra articular to the ankle.

Patient was taken to the recovery room in stable condition with no known complications. POST-OPERATIVE PLAN: The patient will be observed overnight with pain control maintained. Once he is surgically stable, patient will be transferred to endocrinology for evaluation and care of his newly diagnosed diabetes and hypertension. He is to follow up in my office in one week for wound check. _______________________________________________________________ Max L. Hirsch, MD Orthopedic Surgery mh/xx D: 10/15/20 T: 10/15/20