A Intermediate Evaluation and Management 1 Obtain a focused history and performs focused exam check soft tissue differential diagnosis and physical exam tests 2 Interpret basic imaging studies interpret radiographs AP, lateral and sesamoid views 3 Make informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 Week Postoperative Visit remove cast wound check and remove sutures check radiographs place another cast postop: ~ 6 week Postoperative Visit check radiograph start physiotherapy remove cast start swimming and biking in 2 weeks post-op visit 3 months start strenuous activity B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies CT Scan 2 Modifies and adjusts post-operative treatment plan as needed C Preoperative H & P 1 Obtain history and perform basic physical exam history age gender history of present illness [HPI] past medical history [PMHx] social history physical exam range of motion neurovascular status pain with narrow shoes 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies weightbearing AP, lateral and oblique views check the hallux Valgus angle intermetatarsal angle, sesamoid position, joint congruency and the distal metatarsal articular angle 4 Perform operative consent describe complications of surgery including wound breakdown superficial and deep infections malposition
E Preoperative Plan 1 Template arthrodesis with radiographs 2 Execute surgical walkthrough describe the steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation compression screws 2 Room setup and equipment standard OR table with radiolucent end 3 Patient positioning supine position with a bump under the ipsilateral buttock G Approach 1 Mark and make the incision make a 6 cm incision over the dorsum of the first TMT joint identify the interval between the EHL and the EHB 2 Expose of the Joint incise the capsule over the first and second TMT joints release the capsule along the medial and lateral aspect of the capsule H Joint Preparation 1 Prepare the joint for fusion remove the articular surface of the first TMT joint using small osteotomes and rongeurs if the first metatarsal is shortened then remove only the articular cartilage if the metatarsal is long then remove a small laterally based wedge from the medial cuneiform if the first metatarsal needs to be plantar flexed then perform a plantar based osteotomy perforate the subchondral bone with a 2 mm drill expose and decorticate the medial aspect of the base of the second metatarsal and the lateral base of the first metatarsal I Lateral Soft Tissue Release 1 Make the second incision make a 2 cm incision over the first web space 2 Identify significant structures identify the adductor hallucis tendon using blunt dissection identify and protect the terminal branch of the deep peroneal nerve 3 Complete the lateral release incise the adductor hallucis tendon at the lateral aspect of the fibular sesamoid incise the lateral capsule longitudinally for reduction of the sesamoid force the MTP joint into varus to complete the lateral releases J Medial Exostectomy 1 Make the medial incision make a direct medial incision over the first MTP joint 2 Incise the capsule incise the capsule in line with the incision if needed remove a wedge of capsule to facilitate the reduction of the sesamoid 3 Remove any residual prominence K Reduction and Fixation 1 Reduce the metatarsal to the appropriate position reduce the first metatarsal so that its parallel to the second metatarsal confirm that the metatarsal is parallel and properly rotated 2 Place compression screws use a compression technique to place a 3.5 mm cortical screw across the first TMT joint from proximal to distal place a second 3.5 mm cortical screw from the medial aspect of the base of the first metatarsal into the base of the second metatarsal 3 Place bone graft place any bone graft that was obtained from removal of the medial prominence into the first –second intermetatarsal space to augment the fusion 4 Confirm reduction and fixation use intraoperative imaging to confirm the screw placement and the reduction L Capsule Repair 1 Close the medial capsule use absorbable sutures and perform a medial capsulectomy it should not be needed to overtighten the capsule to maintain alignment of the MTP joint N Wound Closure 1 Irrigation and Hemostasis copiously irrigate the wound 2 Superficial wound closure use 3-0 vicryl for subcutaneous tissue use 3-0 monocryl for skin 3 Dressing place a slipper great toe spica fiberglass cast
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids prescribe DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care appropriately orders and interprets basic imaging studies check radiographs of the foot in post op 2 Appropriate medical management and medical consultation 3 Physical Therapy Nonweightbearing for 4 weeks 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans 2 Capable of evaluating and treating postoperative complications 3 Surgically treats complex complications