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Removal of Plantar-Hindfoot-Midfoot Bony Mass

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 major orthopedic set
  • oscillating saw

2

Room setup and equipment

  • standard OR table
  • fluoroscopy

3

Patient positioning

  • place patient supine
  • place small bump under ipsilateral hip to internally rotate the leg
  • place a thigh tourniquet

Technique

D

Plantar Approach

1

Mark the elliptical incision around the ulcer

2

Make the incision

  • make a longitudinal elliptical incision around the ulcer or a portion of the ulcer

3

Excise the diseased tissue

  • excise the skin portion of the ulcer
E

Deep Dissection

1

Identify the vasculature

  • in the middle portion of the wound, identify the lateral plantar artery

2

Retract the lateral plantar artery to the medial side of the bony mass

3

Place retractors

  • use blunt and sharp dissection to place the retractors around the mass
F

Mass Excision

1

Isolate the mass

  • once the retractors are placed, delineate the mass

2

Remove the mass

  • remove the mass using a power saw or osteotome
  • the mass should be removed until the calcaneocuboid joint is exposed and the cuboid has been resected dorsal to the calcaneus
G

Tissue Sampling

1

Take bone cultures

H

Wound Closure

1

Obtain hemostasis

  • remove the tourniquet
  • elevate the limb
  • if soft tissue bleeding is present, use suture ligatures
  • place bone wax to control the bleeding of the cancellous bone

2

Perform a single layer closure

  • close the wound in a single layer using 2-0 nylon on large needles with a near far, far near stitch to reduce the amount of dead space

3

Dressings and immobilization

  • apply a bulky compression dressing
  • large burn dressings work well

4

Apply a short leg cast

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 3-4 days
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • evaluate
  • vascular status
  • if severe vascular dysfunction may require revascularization procedure prior to amputation
  • wound healing potential
  • check with nutrition labs: albumin, prealbumin, transferrin, total lymphocyte count
  • soft tissue injury
  • severe soft tissue injury has the highest impact on decision whether to amputate or reconstruct lower extremity in trauma cases
  • infection
  • CRP, ESR
  • neuropathy
  • trauma
  • vascular exam
  • Doppler (ischemic index)
  • ABI
  • transcutaneous oxygen pressure
  • toe pressures
  • 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: 3-4 day Postoperative Visit

  • wound management
  • place a new well padded walking cast over a soft dressing
  • continue non weightbearing until the wound is healed and it is mature enough to bear weight
  • this usually takes 4 to 8 weeks
  • diagnose and management of early complications
  • wound healing
  • infection
  • DVT

6

Postop: ~ 3 month Postoperative Visit

  • diagnosis and management of late complications
  • wear a molded shoe with reduced motion and a double upright ankle brace for several months for protection

7

Postop: 1 year Postoperative Visit

8

Treat postoperative complications

N

Advanced Evaluation and Management

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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