A Basic Preoperative 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 generates appropriate differential diagnosis 4 Make informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 Week Postoperative Visit wound check and remove sutures check radiographs postop: ~ 4 week Postoperative Visit check radiograph start physiotherapy 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 check the hallux Valgus angle intermetatarsal angle, sesamoid position, joint congruency and the distal metatarsal articular angle 4 Perform operative consent describe complications of surgery including wound breakdown superficial and deep infections hallux varus malposition
E Preoperative Plan 1 Template osteotomy 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 Lateral Soft Tissue Release 1 Mark a dorsal incision over the first web space the incision should be 3 cm over the 1st webspace continue with blunt dissection 2 Expose the first webspace place a lamina spreader and Langenbeck retractor to expose the first webspace 3 Open the lateral capsule divide the lateral joint capsule superior to the lateral sesamoid place one or two sutures between the lateral capsule of the 1st MTP joint and the periosteum of the second metatarsal H Joint Exposure P 1 Make the second incision externally rotate the leg make a second incision at the medial aspect of the first MTP joint Pearls Add bolster to help internally rotate leg. Have resident hold. 2 Identify neurovascular structures identify and protect the dorsomedial nerve 3 Expose the joint capsule open the medial MTP joint capsule with an inverted L type incision 4 Inspect the joint for degenerative changes I Metatarsal Head Preparation 1 Place retractors in appropriate position expose the metatarsal head and place hohmann retractors dorsal and plantar just extraarticular of the first MTP joint the plantar hohmann retractor protects the plantar artery to the metatarsal head the dorsal retractor protects the dorsal inrta-articular blood supply that originates from the capsule 2 Create a plane surface shave the medial eminence to achieve a plane surface preserve as much metatarsal head as possible J Osteotomy 1 Place K-wire drill a 1.0 mm K wire slightly dorsal to the center of the exposed medial eminence incline the wire 20 degrees from medial to lateral aiming the wire at the 4th metatarsal 2 Perform the osteotomy use the saw guide to make two cuts with an oscillating power saw so that they cuts form a 60 degree angle proximal to the drill hole K Final Fixation 1 Reduce the metatarsal shaft use a towel clip to pull the metatarsal shaft medially while at the same time push the metatarsal head laterally with the help of the thumb of the other hand 2 Place a guidewire for cannulated screw insertion insert a guidewire for a cannulated charlotte multiuse compression screw from the distal dorsal metatarsal shaft obliquely to the lateral plantar of the metatarsal head 3 Check the position of the osteotomy with a C arm 4 Measure the length of the screw with a cannulated depth gauge 5 Insert the screw L Capsule Closure 1 Excise the medial eminence in line with the metatarsal shaft be careful for soft tissue 2 Close the capsule place the great toe in a slightly overcorrected position and repair the medial joint capsule with U typed sutures and tighten the first webspace sutures 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 wrap the foot in a gauze and tape compression dressing after surgery place in OFA Rathgerber shoe continue for 4 weeks
O Postoperative Immediate 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 ambulate with a postoperative shoe 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