Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam evaluate vascular status if severe vascular dysfunction may require revascularization procedure prior to amputation wound healing potential check with nutrition labs: albumin, prealbumin, transferrin, total lymphocyte count soft tissue injury severe soft tissue injury has the highest impact on decision whether to amputate or reconstruct lower extremity in trauma cases infection CRP, ESR neuropathy trauma vascular exam Doppler (ischemic index) ABI transcutaneous oxygen pressure toe pressures 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: 3-4 day Postoperative Visit wound management place a new well padded walking cast over a soft dressing continue non weightbearing until the wound is healed and it is mature enough to bear weight this usually takes 4 to 8 weeks diagnose and management of early complications wound healing infection DVT 6 Postop: ~ 3 month Postoperative Visit diagnosis and management of late complications wear a molded shoe with reduced motion and a double upright ankle brace for several months for protection 7 Postop: 1 year Postoperative Visit 8 Treat postoperative complications B Advanced Evaluation and Management 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 Operative Techniques 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 major orthopedic set oscillating saw 2 Room setup and equipment standard OR table fluoroscopy 3 Patient positioning place patient supine place small bump under ipsilateral hip to internally rotate the leg place a thigh tourniquet G Plantar Approach 1 Mark the elliptical incision around the ulcer 2 Make the incision make a longitudinal elliptical incision around the ulcer or a portion of the ulcer 3 Excise the diseased tissue excise the skin portion of the ulcer H Deep Dissection 1 Identify the vasculature in the middle portion of the wound, identify the lateral plantar artery 2 Retract the lateral plantar artery to the medial side of the bony mass 3 Place retractors use blunt and sharp dissection to place the retractors around the mass I Mass Excision 1 Isolate the mass once the retractors are placed, delineate the mass 2 Remove the mass remove the mass using a power saw or osteotome the mass should be removed until the calcaneocuboid joint is exposed and the cuboid has been resected dorsal to the calcaneus J Tissue Sampling 1 Take bone cultures K Wound Closure 1 Obtain hemostasis remove the tourniquet elevate the limb if soft tissue bleeding is present, use suture ligatures place bone wax to control the bleeding of the cancellous bone 2 Perform a single layer closure close the wound in a single layer using 2-0 nylon on large needles with a near far, far near stitch to reduce the amount of dead space 3 Dressings and immobilization apply a bulky compression dressing large burn dressings work well 4 Apply a short leg cast Postoperative Patient Care O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 3-4 days 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 evaluate vascular status if severe vascular dysfunction may require revascularization procedure prior to amputation wound healing potential check with nutrition labs: albumin, prealbumin, transferrin, total lymphocyte count soft tissue injury severe soft tissue injury has the highest impact on decision whether to amputate or reconstruct lower extremity in trauma cases infection CRP, ESR neuropathy trauma vascular exam Doppler (ischemic index) ABI transcutaneous oxygen pressure toe pressures 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: 3-4 day Postoperative Visit wound management place a new well padded walking cast over a soft dressing continue non weightbearing until the wound is healed and it is mature enough to bear weight this usually takes 4 to 8 weeks diagnose and management of early complications wound healing infection DVT 6 Postop: ~ 3 month Postoperative Visit diagnosis and management of late complications wear a molded shoe with reduced motion and a double upright ankle brace for several months for protection 7 Postop: 1 year Postoperative Visit 8 Treat postoperative complications B Advanced Evaluation and Management 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 major orthopedic set oscillating saw 2 Room setup and equipment standard OR table fluoroscopy 3 Patient positioning place patient supine place small bump under ipsilateral hip to internally rotate the leg place a thigh tourniquet G Plantar Approach 1 Mark the elliptical incision around the ulcer 2 Make the incision make a longitudinal elliptical incision around the ulcer or a portion of the ulcer 3 Excise the diseased tissue excise the skin portion of the ulcer H Deep Dissection 1 Identify the vasculature in the middle portion of the wound, identify the lateral plantar artery 2 Retract the lateral plantar artery to the medial side of the bony mass 3 Place retractors use blunt and sharp dissection to place the retractors around the mass I Mass Excision 1 Isolate the mass once the retractors are placed, delineate the mass 2 Remove the mass remove the mass using a power saw or osteotome the mass should be removed until the calcaneocuboid joint is exposed and the cuboid has been resected dorsal to the calcaneus J Tissue Sampling 1 Take bone cultures K Wound Closure 1 Obtain hemostasis remove the tourniquet elevate the limb if soft tissue bleeding is present, use suture ligatures place bone wax to control the bleeding of the cancellous bone 2 Perform a single layer closure close the wound in a single layer using 2-0 nylon on large needles with a near far, far near stitch to reduce the amount of dead space 3 Dressings and immobilization apply a bulky compression dressing large burn dressings work well 4 Apply a short leg cast
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 3-4 days R Complex Patient Care 1 Develops unique, complex post-operative management plans