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Percutaneous Achilles Tendon Lengthening

Planning

B

Preoperative Plan

1

Radiographic templating

2

Execute surgical workthrough

  • describes the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • basic orthopedic set

2

Room setup and equipment

  • standard OR table
  • fluoroscopy

3

Patient positioning

  • place patient prone
  • place a thigh tourniquet

Technique

D

Draw Anatomic Landmarks and Tenotomy Site

1

Draw anatomic landmarks

  • draw medial and lateral border and insertion in calcaneus
E

Perform Tenotomies

1

Perform first tenotomy

  • make the first medial cut at the insertion of the tendon onto the calcaneus
  • this cut should be one half of the width of the Achilles tendon
  • if the heel is in varus , place the first and third cuts on the medial side
  • if the heel is in valgus place the first and third cuts on the lateral side

2

Perform second tenotomy

  • make the second tenotomy proximally and medially just below the musculotendinous junction

3

Perform third tenotomy

  • Makes cut midway between the 2 first cuts.
  • make the third cut laterally through half the width of the tendon midway between the two medial cuts
F

Perform Controlled Lengthening

1

Position the ankle

  • dorisflex the ankle to the desired angle
G

Wound Closure

1

Cover the incisions

  • these incisions do not require closure
  • place a sterile dressing on each incision

2

Place immobilization

  • place a long leg cast with the knee in full extension
  • weightbearing as tolerated on the leg

Patient Care

K

Preoperative H & P

1

Perform basic medical and orthopaedic history and physical

  • check neurovascular status to determine level of amputation

2

Order basic imaging studies

  • weightbearing images
  • AP/Lat views of foot, ankle, and tibia/fibula

3

Perform operative consent

  • describe complications of surgery including
  • recurrence
  • superficial and deep infections
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • outpatient PT
  • schedule follow up in 4 weeks
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • evaluate
  • vascular status
  • infection
  • neuropathy
  • trauma
  • vascular exam
  • need to assess associated injuries and comorbidities (diabetes)
  • documental baseline neurovascular exam

2

Appropriately interprets basic imaging studies

  • AP/Lat views of foot, ankle, and tibia/fibula
  • MRI of the to look for integrity of soft tissue and infection

3

Appropriately orders and interprets advanced imaging studies

  • CT and MRI w/ or w/o contrast)

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Postop: 4 week Postoperative Visit

  • wound management
  • diagnose and management of early complications
  • wound healing
  • infection
  • DVT

6

Treat postoperative complications

N

Advanced Evaluation and Managment

1

Provides complex non-operative treatment

  • multiple co-morbidities
  • non-compliant
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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