Preoperative Patient Care 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 wound check and remove sutures check radiographs postop: ~ 4 week Postoperative Visit check radiograph postop: 10-12 week Postoperative Visit remove walking boot if radiographic signs of union are present advance rehabilitation B Advanced Evaluation and Management 1 Recognizes concomitant associated injuries 2 Appropriately orders and interprets advanced imaging studies CT Scan 3 Modifies and adjusts post-operative treatment plan as needed 4 Provides comprehensive assessment of complex fracture patterns on imaging studies 5 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities non-compliance 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 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies weigtbearing AP, lateral and sesamoid views 4 Perform operative consent describe complications of surgery including wound breakdown superficial and deep infections malunion nonunion Operative Techniques 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 MTP plating system 2 Room setup and equipment standard OR table with radiolucent end 3 Patient positioning supine position with a bump under the ipsilateral buttock G Joint Exposure 1 Mark a dorsolateral incision center the dorsolateral incision over the first MTP joint in the interval between the medial and lateral common digital nerves 2 Extend the incision span the incision from a point just proximal to the IP joint of the hallux to 3 to cm proximal to the MTP joint H Deep Dissection 1 Expose the synovium deepen the dissection along the medial aspect of the EHL tendon through the extensor hood and the joint capsule perform a thorough synovectomy 2 Inspect the MTP locate osteophytes and loose bodies determine the extent of articular damage I Joint Resection and Decompression 1 Remove the articular surface remove a thin section of articular surface from the distal first metatarsal and proximal phalanx with a sagittal saw 2 If shortening required resect more bone from the metatarsal head use a sagittal saw to resect the medial eminence J Metatarsal Head Preparation 1 Place K-wire drive a 0.062 K wire in a proximal direction at the center of the metatarsal head 2 Determine the appropriate reamer compare the diaphyseal width of the metatarsal with the inner width of the reamer 3 Prepare the canal engage the power reamer with the K wire drive the K wire in a proximal direction shave the metatarsal subchondral surface and metaphysis to the cup shaped convex surface remove any excess bone along the periphery with a rongeur 4 Increase the surface area for arthrodesis remove the K-wire use the K-wire to perforate the prepared metatarsal head in multiple places to increase the surface area for arthrodesis K Proximal Phalangeal Preparation 1 Place the K-wire center a 0.062 K-wire on the base of the proximal phalanx drive the K-wire distally 2 Prepare the surface use the smallest convex cannulated phalangeal reamer to prepare the surface use larger reamers to enlarge the phalangeal surface so that it matches the size of the prepared metatarsal surface 3 Remove the K-wire 4 Increase the surface area of the joint surface collect cancellous bone shavings throughout the entire process and place in a small cup to place in between the prepared surfaces L Joint Alignment and Internal Fixation 1 Place autograft place the autograft between the joint surfaces coapt the cancellous joint surfaces to the desired amount of varus, valgus, doriflexion, plantarflexion and rotation 2 Place the joint in the appropriate position the optimal position is 20 to 25 degrees of dorsiflexion , 10 to 15 degrees f valgus and neutral rotation all angular measurements relate the axis of the first metatarsal shaft 3 Place provisional fixation temporarily stabilize the arthrodesis site with 1 or 2 crossed 0.062 K-wires 4 Apply the plate use a rongeur to smooth the the dorsal aspect of the first metatarsal and proximal phalanx to allow the plate to sit flush on the bone 5 Place Screws place bicortical self-tapping screws to fix the plate to the metatarsal use locking screws in the instance of osteopenic bone fix the plate to the proximal phalanx with a screw placed in compression remove the K-wire place a cross-compression screw to augment the fixation construct N Wound Closure 1 Irrigation and Hemostasis copiously irrigate the wound 2 Close capsule 3 Superficial wound closure use 3-0 vicryl for subcutaneous tissue use 3-0 monocryl for skin 4 Dressing wrap the foot in a gauze and tape compression dressing after surgery Postoperative Patient Care 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 ambulate with a short walking boot 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
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 wound check and remove sutures check radiographs postop: ~ 4 week Postoperative Visit check radiograph postop: 10-12 week Postoperative Visit remove walking boot if radiographic signs of union are present advance rehabilitation B Advanced Evaluation and Management 1 Recognizes concomitant associated injuries 2 Appropriately orders and interprets advanced imaging studies CT Scan 3 Modifies and adjusts post-operative treatment plan as needed 4 Provides comprehensive assessment of complex fracture patterns on imaging studies 5 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities non-compliance 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 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies weigtbearing AP, lateral and sesamoid views 4 Perform operative consent describe complications of surgery including wound breakdown superficial and deep infections malunion nonunion
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 MTP plating system 2 Room setup and equipment standard OR table with radiolucent end 3 Patient positioning supine position with a bump under the ipsilateral buttock G Joint Exposure 1 Mark a dorsolateral incision center the dorsolateral incision over the first MTP joint in the interval between the medial and lateral common digital nerves 2 Extend the incision span the incision from a point just proximal to the IP joint of the hallux to 3 to cm proximal to the MTP joint H Deep Dissection 1 Expose the synovium deepen the dissection along the medial aspect of the EHL tendon through the extensor hood and the joint capsule perform a thorough synovectomy 2 Inspect the MTP locate osteophytes and loose bodies determine the extent of articular damage I Joint Resection and Decompression 1 Remove the articular surface remove a thin section of articular surface from the distal first metatarsal and proximal phalanx with a sagittal saw 2 If shortening required resect more bone from the metatarsal head use a sagittal saw to resect the medial eminence J Metatarsal Head Preparation 1 Place K-wire drive a 0.062 K wire in a proximal direction at the center of the metatarsal head 2 Determine the appropriate reamer compare the diaphyseal width of the metatarsal with the inner width of the reamer 3 Prepare the canal engage the power reamer with the K wire drive the K wire in a proximal direction shave the metatarsal subchondral surface and metaphysis to the cup shaped convex surface remove any excess bone along the periphery with a rongeur 4 Increase the surface area for arthrodesis remove the K-wire use the K-wire to perforate the prepared metatarsal head in multiple places to increase the surface area for arthrodesis K Proximal Phalangeal Preparation 1 Place the K-wire center a 0.062 K-wire on the base of the proximal phalanx drive the K-wire distally 2 Prepare the surface use the smallest convex cannulated phalangeal reamer to prepare the surface use larger reamers to enlarge the phalangeal surface so that it matches the size of the prepared metatarsal surface 3 Remove the K-wire 4 Increase the surface area of the joint surface collect cancellous bone shavings throughout the entire process and place in a small cup to place in between the prepared surfaces L Joint Alignment and Internal Fixation 1 Place autograft place the autograft between the joint surfaces coapt the cancellous joint surfaces to the desired amount of varus, valgus, doriflexion, plantarflexion and rotation 2 Place the joint in the appropriate position the optimal position is 20 to 25 degrees of dorsiflexion , 10 to 15 degrees f valgus and neutral rotation all angular measurements relate the axis of the first metatarsal shaft 3 Place provisional fixation temporarily stabilize the arthrodesis site with 1 or 2 crossed 0.062 K-wires 4 Apply the plate use a rongeur to smooth the the dorsal aspect of the first metatarsal and proximal phalanx to allow the plate to sit flush on the bone 5 Place Screws place bicortical self-tapping screws to fix the plate to the metatarsal use locking screws in the instance of osteopenic bone fix the plate to the proximal phalanx with a screw placed in compression remove the K-wire place a cross-compression screw to augment the fixation construct N Wound Closure 1 Irrigation and Hemostasis copiously irrigate the wound 2 Close capsule 3 Superficial wound closure use 3-0 vicryl for subcutaneous tissue use 3-0 monocryl for skin 4 Dressing wrap the foot in a gauze and tape compression dressing after surgery
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 ambulate with a short walking boot 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