A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam evaluate vascular status infection neuropathy trauma vascular exam 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: 4 week Postoperative Visit wound management diagnose and management of early complications<br /> wound healing infection DVT 6 Treat postoperative complications B Advanced Evaluation and Managment 1 Provides complex non-operative treatment multiple co-morbidities non-compliant C 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
E 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 F Room Preparation 1 Surgical instrumentation basic orthopedic set 2 Room setup and equipment standard OR table fluoroscopy 3 Patient positioning place patient prone place a thigh tourniquet G Draw Anatomic Landmarks and Tenotomy Site 1 Draw anatomic landmarks draw medial and lateral border and insertion in calcaneus H Perform Tenotomies 1 Perform first tenotomy make the first medial cut at the insertion of the tendon onto the calcaneus this cut should be one half of the width of the Achilles tendon if the heel is in varus , place the first and third cuts on the medial side if the heel is in valgus place the first and third cuts on the lateral side 2 Perform second tenotomy make the second tenotomy proximally and medially just below the musculotendinous junction 3 Perform third tenotomy Makes cut midway between the 2 first cuts. make the third cut laterally through half the width of the tendon midway between the two medial cuts I Perform Controlled Lengthening 1 Position the ankle dorisflex the ankle to the desired angle J Wound Closure 1 Cover the incisions these incisions do not require closure place a sterile dressing on each incision 2 Place immobilization place a long leg cast with the knee in full extension weightbearing as tolerated on the leg
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 4 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans