Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam check neurovascular status 2 Appropriately orders and interprets advanced imaging studies/lab studies radiographs weightbearing ankle series AP mortise lateral view Canale view to evaluate the sinus tarsi CT scan determines the severity of the arthritis and anatomy 3 Prescribes and manages nonoperative treatment activity modification NSAIDS intraarticular steroid injection ankle foot orthosis or UCBL orthosis patellar tendon bearing brace to unload the subtalar joint rockerbottom shoes 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures remove cast place in short weight bearing fiberglass cast diagnose and management of early complications postop: ~ 6 week postoperative visit obtain radiographs remove cast place in walking orthosis diagnosis and management of late complications postop: 12 week post operative visit obtain radiographs to confirm union start gentle range of motion exercises B Advanced Evaluation and Management 1 Provides patient specific non-operative treatment diagnostic injections 2 Modifies and adjusts post-operative treatment plan as needed C Preoperative H & P 1 Obtain history and perform basic physical exam check neurovascular status identify medical co-morbidities that might impact surgical treatment diabetes, smoking and previous surgery all affect union rates 2 Order basic imaging studies order weigh-bearing triplanar radiographs of the ankle 3 Perform operative consent describe complications of surgery including infection nonunion malalignment symptomatic hardware superficial wound breakdown RSD Operative Techniques E Preoperative Plan 1 Radiographic templating CT scan determine length and placement of the implant 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 guidepins 6.5 mm and 4.0 mm large fragment cannulated lag screws 2 Room setup and equipment standard OR table bring fluoroscopy from the contralateral side 3 Patient positioning supine position align sole of the foot with the end of the bed place a soft bump under the ipsilateral sacrum to internally rotate the foot place tourniquet around the upper thigh G Approach 1 Mark and make incision start incision 1 cm below the tip of the lateral malleolus. continue incision distally until the base of the fourth metatarsal is reached 2 Incise the subcutaneous tissue in line with the skin incision use cautery to cauterize any crossing vessels for hemostasis 3 Identify the peroneal tendons leave them undisturbed in there sheath H Deep Dissection 1 Identify anatomical structures identify the sural nerve identify the origin of the extensor digitorum brevis and the sinus tarsi fat pad 2 Elevate the EDB and Sinus Tarsi fat pad together as one flap leave a small cuff of tissue proximally for reattachment of the flap 3 Identify and release the talocalcaneal ligament this allows better exposure of the joint surfaces and the middle and anterior facet I Preparation of Arthrodesis Site 1 Visualize the lateral aspect of the subtalar joint use a rongeur to remove any remaining soft tissues 2 Remove articular cartilage use a straight curette or chisel to remove cartilage from the lateral half of the inferior talus and superior aspect of the calcaneal facets insert a lamina spreader and remove the remaining medial articular cartilage 3 Create a vascular channel use curettes and osteotomes to create bleeding subchondral bone use a 2.0 mm drill to create small perforations in bone these channels aid in the fusion 4 Compress bone together to assess contact of surfaces 5 Reattach the extensor digitorum brevis to its origin if bone graft is inserted reattach tendon after insertion of graft J Harvesting and Placement of the Tibial Bone Graft (optional) 1 Create bone window make a 1 cm incision distal to the distal aspect of the tibial tubercle and 1 cm lateral to the anterior tibial crest. incision should be 4 cm long divide the fascia over the anterior compartment musculature in line with the skin incision elevate the muscle and the periosteum over the anterolateral face of the tibia using a periosteal elevator to expose the anterolateral cortex create a 1 by 1 cm square or elliptical window in the center of the anterolateral face 2 Remove cancellous graft insert a curette into the window and remove the cancellous graft seal the window with the previously removed bone plug 3 Perform layered closure perform a layered closure of the fascia, subcutaneous tissue and the skin 4 Place retrieved graft into the subtalar joint make sure to place graft within 30 minutes of harvest K Alignment and Final Fixation 1 Place guidepins under fluoroscopy create 1 cm incision at the apex of the heel for insertion of the guidepin 2 Place ankle in 7 degrees of valgus assess alignment with radiographs use kwire for provisional fixation 3 Place guidepin use the Harris heel and lateral views to drive guidepin through the tuberosity, across the subtalar joint and into the talar neck. make a second 1 cm incision just medial to the anterior tibialis tendon use the Harris heel and lateral views to drive guidepin through the dorsomedial aspect of the talar neck across the subtalar joint into the posterior calcaneal tuberosity 4 Place cannulated screws with short threads insert a 6.5 or 8 mm large fragment cannulated lag screws after minimal countersinking repeat the procedure for the second guidepin except use a small fragment cannulated screw this screw is usually 3.5 to 4.0 mm depth of this screw is best judged by axial view of the calcaneus 5 Confirm hardware position obtain final fluoroscopic images to ensure proper screw position L Wound Closure 1 Irrigation, and hemostasis ensure hemostasis using cautery 2 Superficial closure use 3-0 nylon horizontal mattress sutures for skin 3 Deep closure use 2-0 vicryl for the subcutaneous layer 4 Dressing and immediate immobilization place in well padded non-weightbearing short leg plaster cast split cast in recovery room to allow for post op swelling Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders pain meds IV fluids DVT prophylaxis advance diet as tolerated check appropriate labs foley out when ambulating wound care physical therapy non-weightbearing strict elevation check postoperative films 2 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam check neurovascular status 2 Appropriately orders and interprets advanced imaging studies/lab studies radiographs weightbearing ankle series AP mortise lateral view Canale view to evaluate the sinus tarsi CT scan determines the severity of the arthritis and anatomy 3 Prescribes and manages nonoperative treatment activity modification NSAIDS intraarticular steroid injection ankle foot orthosis or UCBL orthosis patellar tendon bearing brace to unload the subtalar joint rockerbottom shoes 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures remove cast place in short weight bearing fiberglass cast diagnose and management of early complications postop: ~ 6 week postoperative visit obtain radiographs remove cast place in walking orthosis diagnosis and management of late complications postop: 12 week post operative visit obtain radiographs to confirm union start gentle range of motion exercises B Advanced Evaluation and Management 1 Provides patient specific non-operative treatment diagnostic injections 2 Modifies and adjusts post-operative treatment plan as needed C Preoperative H & P 1 Obtain history and perform basic physical exam check neurovascular status identify medical co-morbidities that might impact surgical treatment diabetes, smoking and previous surgery all affect union rates 2 Order basic imaging studies order weigh-bearing triplanar radiographs of the ankle 3 Perform operative consent describe complications of surgery including infection nonunion malalignment symptomatic hardware superficial wound breakdown RSD
E Preoperative Plan 1 Radiographic templating CT scan determine length and placement of the implant 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 guidepins 6.5 mm and 4.0 mm large fragment cannulated lag screws 2 Room setup and equipment standard OR table bring fluoroscopy from the contralateral side 3 Patient positioning supine position align sole of the foot with the end of the bed place a soft bump under the ipsilateral sacrum to internally rotate the foot place tourniquet around the upper thigh G Approach 1 Mark and make incision start incision 1 cm below the tip of the lateral malleolus. continue incision distally until the base of the fourth metatarsal is reached 2 Incise the subcutaneous tissue in line with the skin incision use cautery to cauterize any crossing vessels for hemostasis 3 Identify the peroneal tendons leave them undisturbed in there sheath H Deep Dissection 1 Identify anatomical structures identify the sural nerve identify the origin of the extensor digitorum brevis and the sinus tarsi fat pad 2 Elevate the EDB and Sinus Tarsi fat pad together as one flap leave a small cuff of tissue proximally for reattachment of the flap 3 Identify and release the talocalcaneal ligament this allows better exposure of the joint surfaces and the middle and anterior facet I Preparation of Arthrodesis Site 1 Visualize the lateral aspect of the subtalar joint use a rongeur to remove any remaining soft tissues 2 Remove articular cartilage use a straight curette or chisel to remove cartilage from the lateral half of the inferior talus and superior aspect of the calcaneal facets insert a lamina spreader and remove the remaining medial articular cartilage 3 Create a vascular channel use curettes and osteotomes to create bleeding subchondral bone use a 2.0 mm drill to create small perforations in bone these channels aid in the fusion 4 Compress bone together to assess contact of surfaces 5 Reattach the extensor digitorum brevis to its origin if bone graft is inserted reattach tendon after insertion of graft J Harvesting and Placement of the Tibial Bone Graft (optional) 1 Create bone window make a 1 cm incision distal to the distal aspect of the tibial tubercle and 1 cm lateral to the anterior tibial crest. incision should be 4 cm long divide the fascia over the anterior compartment musculature in line with the skin incision elevate the muscle and the periosteum over the anterolateral face of the tibia using a periosteal elevator to expose the anterolateral cortex create a 1 by 1 cm square or elliptical window in the center of the anterolateral face 2 Remove cancellous graft insert a curette into the window and remove the cancellous graft seal the window with the previously removed bone plug 3 Perform layered closure perform a layered closure of the fascia, subcutaneous tissue and the skin 4 Place retrieved graft into the subtalar joint make sure to place graft within 30 minutes of harvest K Alignment and Final Fixation 1 Place guidepins under fluoroscopy create 1 cm incision at the apex of the heel for insertion of the guidepin 2 Place ankle in 7 degrees of valgus assess alignment with radiographs use kwire for provisional fixation 3 Place guidepin use the Harris heel and lateral views to drive guidepin through the tuberosity, across the subtalar joint and into the talar neck. make a second 1 cm incision just medial to the anterior tibialis tendon use the Harris heel and lateral views to drive guidepin through the dorsomedial aspect of the talar neck across the subtalar joint into the posterior calcaneal tuberosity 4 Place cannulated screws with short threads insert a 6.5 or 8 mm large fragment cannulated lag screws after minimal countersinking repeat the procedure for the second guidepin except use a small fragment cannulated screw this screw is usually 3.5 to 4.0 mm depth of this screw is best judged by axial view of the calcaneus 5 Confirm hardware position obtain final fluoroscopic images to ensure proper screw position L Wound Closure 1 Irrigation, and hemostasis ensure hemostasis using cautery 2 Superficial closure use 3-0 nylon horizontal mattress sutures for skin 3 Deep closure use 2-0 vicryl for the subcutaneous layer 4 Dressing and immediate immobilization place in well padded non-weightbearing short leg plaster cast split cast in recovery room to allow for post op swelling
O Perioperative Inpatient Management 1 Write comprehensive admission orders pain meds IV fluids DVT prophylaxis advance diet as tolerated check appropriate labs foley out when ambulating wound care physical therapy non-weightbearing strict elevation check postoperative films 2 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans