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: ~ 6 week Postoperative Visit check radiograph full weightbearing 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 3 Provides comprehensive assessment of complex fracture patterns on imaging studies 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 4 Perform operative consent describe complications of surgery including wound breakdown superficial and deep infections malposition 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 Midmedial Approach 1 Mark and make skin incision incise the skin and subcutaneous tissue sharply to expose the first MTP joint capsule 2 Protect neurovascular bundle protect the medial dorsal and plantar cutaneous nerves H Opening of Capsule 1 Remove a portion of the capsule perform a vertical capsular resection to remove 3 to 5 mm of capsule just proximal to the base of the proximal phalanx I Release of the Lateral Joint Structures 1 Release the lateral soft tissues after distraction release the lateral soft tissues from within the MTP joint after distraction of the sesamoids from the first metatarsal with a lamina spreader first use a blunt freer elevator to develop some room cut the capsular tissue with a sharp no. 15 blade 2 Confirm that the release is complete complete release is confirmed when the toe can be brought into about 15 degrees of varus through the MTP joint 3 Expose the proximal first metatarsal dorsally and plantarly J Metatarsal Osteotomy 1 Outline the osteotomy confirm the location of the TMT joint mark a point about 20 mm distal from the first metatarsal joint for the apex of the osteotomy and at the midpoint in the dorsal plantar direction 2 Perform the osteotomy perform a chevron osteotomy at an angle of 60 degrees using a microsagittal saw complete the release both in plantarly and dorsally 3 Angulate fragments to the proper position grasp the proximal fragment with a towel clamp angulate the distal fragment laterally the distal fragment should be translated 3 to 5 mm laterally and plantarly enough to coapt the superior portion of the chevron leaving an opening in the plantar portion of the osteotomy K Osteotomy Fixation 1 Provide temporary fixation secure the translated position temporarily with a 0.062 inch K wire 2 Prepare the fragments for fixation clean the prominent proximal fragment of periosteum and removed flush with the distal fragment the largest removed portion is placed as bone graft between the fragments at the opening created in the chevron osteotomy from the plantar translation 3 Place the permanent fixation place a four hole locking plate to bridge the osteotomy medially remove the medial eminence 1 mm medial to the sagittal sulcus remove the K wire 4 Confirm the implant confirm the stability confirm the correction and alignment with fluoroscopy L Capsule Closure 1 Close the capsule with the toe in the appropriate position close the capsule with 2-0 vicryl while performing the closure hold the toe in slight varus and supination close the deep tissues over the plate 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 apply bunion dressings 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 heel weightbearing only 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: ~ 6 week Postoperative Visit check radiograph full weightbearing 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 3 Provides comprehensive assessment of complex fracture patterns on imaging studies 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 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 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 Midmedial Approach 1 Mark and make skin incision incise the skin and subcutaneous tissue sharply to expose the first MTP joint capsule 2 Protect neurovascular bundle protect the medial dorsal and plantar cutaneous nerves H Opening of Capsule 1 Remove a portion of the capsule perform a vertical capsular resection to remove 3 to 5 mm of capsule just proximal to the base of the proximal phalanx I Release of the Lateral Joint Structures 1 Release the lateral soft tissues after distraction release the lateral soft tissues from within the MTP joint after distraction of the sesamoids from the first metatarsal with a lamina spreader first use a blunt freer elevator to develop some room cut the capsular tissue with a sharp no. 15 blade 2 Confirm that the release is complete complete release is confirmed when the toe can be brought into about 15 degrees of varus through the MTP joint 3 Expose the proximal first metatarsal dorsally and plantarly J Metatarsal Osteotomy 1 Outline the osteotomy confirm the location of the TMT joint mark a point about 20 mm distal from the first metatarsal joint for the apex of the osteotomy and at the midpoint in the dorsal plantar direction 2 Perform the osteotomy perform a chevron osteotomy at an angle of 60 degrees using a microsagittal saw complete the release both in plantarly and dorsally 3 Angulate fragments to the proper position grasp the proximal fragment with a towel clamp angulate the distal fragment laterally the distal fragment should be translated 3 to 5 mm laterally and plantarly enough to coapt the superior portion of the chevron leaving an opening in the plantar portion of the osteotomy K Osteotomy Fixation 1 Provide temporary fixation secure the translated position temporarily with a 0.062 inch K wire 2 Prepare the fragments for fixation clean the prominent proximal fragment of periosteum and removed flush with the distal fragment the largest removed portion is placed as bone graft between the fragments at the opening created in the chevron osteotomy from the plantar translation 3 Place the permanent fixation place a four hole locking plate to bridge the osteotomy medially remove the medial eminence 1 mm medial to the sagittal sulcus remove the K wire 4 Confirm the implant confirm the stability confirm the correction and alignment with fluoroscopy L Capsule Closure 1 Close the capsule with the toe in the appropriate position close the capsule with 2-0 vicryl while performing the closure hold the toe in slight varus and supination close the deep tissues over the plate 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 apply bunion dressings
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 heel weightbearing only 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