A Intermediate Evaluation and Management 1 Perform focused history ask about onset, frequency, intensity and duration of pain find out about factors which worsen and lessen the pain elicit history of ankle sprains question about flatfoot deformity 2 Perform focused physical exam test ankle and subtalar range of motion examine for other potential causes of pain 3 Interprets basic imaging studies imaging studies plain radiographs, including oblique advanced imaging (CT or MRI) to look for other coalitions 4 Makes informed decision to proceed with operative treatment makes sure appropriate conservative measures have been tried describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop:2 week postoperative visit cast is removed felt and button are removed from medial hindfoot foot orthotic (over-the counter or custom) is used when wearing shoes begin range of motion exercises increase activity: walking, biking, jogging, swimming diagnose and manage early complications postop:4 week postoperative visit increase activity as tolerated may need physical therapy if range and strength are significantly limited at this time remind patient and family that resumption of complete, full activity usually occurs 3 months post-op postop:3 months postoperative visit check to make sure activities are back to near normal tell the patient and family, the patient should follow-up in another 3 months if not back to normal by that time 6 Capable of diagnosis and early management of complications appropriate evaluation for wound complications and infection complex regional pain syndrome is rare, but can occur after foot surgery in children with chronic pain B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies CT or MRI scan useful to delineate the extent of the coalition and presence of multiple coalitions 2 Completes comprehensive pre-operative planning with alternatives 3 Modifies and adjusts post-operative treatment plan as needed recognize deviations from typical postoperative course C Preoperative H & P 1 Obtains history and performs basic physical exam identify medical co-morbidities that might impact surgical treatment 2 Order appropriate imaging studies triplanar radiographs of the foot advanced imaging to assess for other coalitions and their extent 3 Prescribe nonoperative treatments activity modification foot orthotic immobilization with a cast or walking boot 4 Perform operative consent describe complications of surgery including recurrent coalition presence of other, unidentified, coalitions stiffness deformity ongoing pain infection wound complications
E Preoperative Plan 1 Template coalitions template the extent and number of coalitions present 2 Execute surgical walkthrough describe key steps of the operation verbally to attending prior to beginning of case describe potential complications and the steps to avoid them. explain whether or not (and why) a calcaneal osteotomy is needed F Room Preparation 1 Surgical instrumentation osteotomes rongeurs Senn retractors bone wax straight (Keith) needles sterile felt button 2 Room setup and equipment set up OR with a radiolucent operating table. C-arm comes in from the opposite side. monitor is in surgeon's direct line of site on opposite side of the OR table. 3 Patient positioning supine with the foot at end of the bed. bump under ipsilateral buttock. tourniquet placed high on thigh with webril underneath G Ollier Incision 1 Make incision over the coalition along the Langer lines incision is over the sinus tarsi just over the coalition take the incision down to the level of EDB fascia be aware of the lateral branches of the superficial peroneal nerve H Deep Dissection 1 Expose the EDB 2 Expose the coalition release the insertion of the EDB elevate from distal to proximal I Calcaneonavicular Coalition Identification 1 Identify the coalition identify the coalition between the calcaneus and the navicular identify the center of the coalition (may be cartilaginous). this will mark the center of the coalition excision 2 Identify the talonavicular and calcaneocuboid joints these facilitate guidance of coalition excision. freer elevators may be placed here. J Excise the Calcaneonavicular Coalition 1 Resect calcaneonavicular coalition resect the coalition with a 1.2 cm osteotome be careful to avoid the surface of the cuboid and head of the talus remove the bone wedge complete excision rongeurs may be used to complete the resection. a 1cm x 1cm gap between the calcaneus and navicular is needed to minimize the risk of recurrence. 2 Confirm excision is adequate confirm the adequacy of the excision with internal rotation radiographic images 3 Test range of motion check hindfoot and subtalar range of motion these should be significantly improved if the coalition has been excised if motion is not sufficient, be wary of insufficient excision and/or the presence of other coalitions in the same foot. look to see if the navicular and the calcaneus independently K Fat Graft Harvest 1 Identify raw bone edges of calcaneus and navicular 2 Apply bone was to raw edges 3 Remove excess bone wax. 4 Remove excess bone wax L EDB interposition 1 Fill the site of the excised coalition with EDB muscle. place absorbable suture in distal edge of EDB place straight (Keith) needle on each end of suture. advance needles through site of excised coalition and bring out through medial hindfoot. the needles and suture are brought through the piece of felt and button on the medial hindfoot make sure that the EDB fills the gap where the coalition has been excised. 2 Secure the EDB. the sutures over the medial hindfoot are tied over the felt and button N Wound Closure 1 Irrigation and hemostasis irrigate the wound prior to closure 2 Superficial closure close subcutaneous tissue with 2-0 vicryl close skin with 3-0 monocryl 3 Immobilization A below-knee walking cast is worn for 2 weeks.
O Perioperative Outpatient Management 1 Discharge patient appropriately pain meds weight-bearing as tolerated cast care instructions schedule follow-up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans