Preoperative Patient Care A Intermediate Evaluation and Management 1 Perform focused physical exam test ankle range of motion test subtalar range of motion take a thorough history on causes of pain identify factors that worsen and better the pain 2 Interprets basic imaging studies radiographs look for C-sign on lateral radiograph indicative of talocalcaneal coalition 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop:1 week postoperative visit Continue cast and continue non-weight bearing check radiographs diagnose and management of early complications postop:2-3 week postoperative visit remove the cast start active range of motion exercises postop:6 week postoperative visit cleared for activity as tolerated tell patients that the ankle will not feel normal for about 6 months postop:1 year postoperative visit 5 Capable of diagnosis and early management of complications B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies CT 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 significant valgus of the calcaneus may need to addressed with a osteotomy at the same time as the coalition resection 2 Order basic imaging studies Triplanar radiographs of the foot May need CT to fully visualize coalition Need CT to rule out any coexistent coalitions 3 Prescribe nonoperative treatments place in short leg cast 4 Perform operative consent describe complications of surgery including infection wound dehiscence continued pain stiffness Operative Techniques 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 F Room Preparation 1 Surgical instrumentation Kerrison rongeurs osteotomes high speed burr Freer elevators small Hoffman retractors Allis clamp 2 Room setup and equipment setup OR with standard operating table C-arm at the foot of bed monitor in surgeon's direct line of site on opposite side of OR table 3 Patient positioning supine with the foot at edge of the bed tourniquet placed high on upper thigh with webril underneath G Approach 1 Mark out the incision over the sustentaculum tali incision is over the sustentaculum tali just over the coalition this should be approximately 1.5 to 2cm distal to the medial malleolus 2 Make the incision identify and coagulate the crossing branches of the saphenous vein H Deep Dissection 1 Identify the tendons of the tarsal tunnel 2 Expose the coalition free the posterior tibial tendon from its sheath retract to the tibialis posterior dorsally identify the FDL extend the toes and look for movement within the sheath incise the sheath in line with its fibers retract the FDL plantarly incise the deep sheath to expose the coalition I Identify Talocalcaneal Coalition 1 Identify the synchondrosis identify the synchondrosis between the talus and calcaneus use a curette or rongeur to unroof the periosteum look for a cartilaginous interface this should be the center of the resection J Excise Talocalcaneal Coalition 1 Resect talocalcaneal coalition start the resection of the coalition with a 1 cm osteotome remove the bone wedge complete excision complete the resection with a 3-4 mm kerrison rongeur a gap of 1cm X 1cm is usually needed to complete the excision place bone wax on the surface of the newly exposed bone 2 Test hindfoot range of motion place a freer elevator into the middle facet defect to the posterior facet free up the joint by removing capsular adhesions 3 Confirm excision is adequate resection is complete when range of motion is improved and the entire posterior facet is visualized confirm excision with internal rotation radiographs K Harvest Fat Graft 1 Identify gluteal crease on ipsilateral leg 2 Make skin incision make 4 cm incision at the gluteal crease on the ipsilateral leg take incision through the dermis only 3 Excise the fat graft elevate the dermis proximally off the buttock this should be done 1 cm on each side of the wound place an Allis clamp on the fat pad excise a 3cm long x 1cm wide x 1 cm deep fat pad 4 Prepare wound for closure pack of the area until the foot wound is closed 5 Close wound after foot closure close the subcutaneous tissue with 0 and 3-0 vicryl close the skin with 3-0 monocryl L Fat Graft Placement 1 Fill the coalition with harvest graft place harvest graft hold in place with freer elevator 2 Secure the fat graft place the tendon sheath over the fat graft secure with a 1-vicryl suture N Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Superficial closure close subcutaneous tissue with 2-0 vicryl close skin with 3-0 monocryl 3 Immobilization place a short leg fiberglass cast Postoperative Patient Care O Perioperative Inpatient Management 1 Discharge patient appropriately pain meds cast care non weightbearing manage swelling monitor neurological and vascular status schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Intermediate Evaluation and Management 1 Perform focused physical exam test ankle range of motion test subtalar range of motion take a thorough history on causes of pain identify factors that worsen and better the pain 2 Interprets basic imaging studies radiographs look for C-sign on lateral radiograph indicative of talocalcaneal coalition 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop:1 week postoperative visit Continue cast and continue non-weight bearing check radiographs diagnose and management of early complications postop:2-3 week postoperative visit remove the cast start active range of motion exercises postop:6 week postoperative visit cleared for activity as tolerated tell patients that the ankle will not feel normal for about 6 months postop:1 year postoperative visit 5 Capable of diagnosis and early management of complications B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies CT 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 significant valgus of the calcaneus may need to addressed with a osteotomy at the same time as the coalition resection 2 Order basic imaging studies Triplanar radiographs of the foot May need CT to fully visualize coalition Need CT to rule out any coexistent coalitions 3 Prescribe nonoperative treatments place in short leg cast 4 Perform operative consent describe complications of surgery including infection wound dehiscence continued pain stiffness
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 F Room Preparation 1 Surgical instrumentation Kerrison rongeurs osteotomes high speed burr Freer elevators small Hoffman retractors Allis clamp 2 Room setup and equipment setup OR with standard operating table C-arm at the foot of bed monitor in surgeon's direct line of site on opposite side of OR table 3 Patient positioning supine with the foot at edge of the bed tourniquet placed high on upper thigh with webril underneath G Approach 1 Mark out the incision over the sustentaculum tali incision is over the sustentaculum tali just over the coalition this should be approximately 1.5 to 2cm distal to the medial malleolus 2 Make the incision identify and coagulate the crossing branches of the saphenous vein H Deep Dissection 1 Identify the tendons of the tarsal tunnel 2 Expose the coalition free the posterior tibial tendon from its sheath retract to the tibialis posterior dorsally identify the FDL extend the toes and look for movement within the sheath incise the sheath in line with its fibers retract the FDL plantarly incise the deep sheath to expose the coalition I Identify Talocalcaneal Coalition 1 Identify the synchondrosis identify the synchondrosis between the talus and calcaneus use a curette or rongeur to unroof the periosteum look for a cartilaginous interface this should be the center of the resection J Excise Talocalcaneal Coalition 1 Resect talocalcaneal coalition start the resection of the coalition with a 1 cm osteotome remove the bone wedge complete excision complete the resection with a 3-4 mm kerrison rongeur a gap of 1cm X 1cm is usually needed to complete the excision place bone wax on the surface of the newly exposed bone 2 Test hindfoot range of motion place a freer elevator into the middle facet defect to the posterior facet free up the joint by removing capsular adhesions 3 Confirm excision is adequate resection is complete when range of motion is improved and the entire posterior facet is visualized confirm excision with internal rotation radiographs K Harvest Fat Graft 1 Identify gluteal crease on ipsilateral leg 2 Make skin incision make 4 cm incision at the gluteal crease on the ipsilateral leg take incision through the dermis only 3 Excise the fat graft elevate the dermis proximally off the buttock this should be done 1 cm on each side of the wound place an Allis clamp on the fat pad excise a 3cm long x 1cm wide x 1 cm deep fat pad 4 Prepare wound for closure pack of the area until the foot wound is closed 5 Close wound after foot closure close the subcutaneous tissue with 0 and 3-0 vicryl close the skin with 3-0 monocryl L Fat Graft Placement 1 Fill the coalition with harvest graft place harvest graft hold in place with freer elevator 2 Secure the fat graft place the tendon sheath over the fat graft secure with a 1-vicryl suture N Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Superficial closure close subcutaneous tissue with 2-0 vicryl close skin with 3-0 monocryl 3 Immobilization place a short leg fiberglass cast
O Perioperative Inpatient Management 1 Discharge patient appropriately pain meds cast care non weightbearing manage swelling monitor neurological and vascular status schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans