Sample Report: Austin Bunionectomy

Preoperative Diagnoses

1. Metatarsus primus varus deformity, left foot.

2. Bunion hallux valgus deformity, left foot.

Postoperative Diagnoses

1. Metatarsus primus varus deformity, left foot.

2. Bunion hallux valgus deformity, left foot.

Procedures

1. Base wedge osteotomy with internal cannulated screw fixation, left first metatarsal.

2. Modified Austin bunionectomy/first metatarsal wedge osteotomy with release of contracted fibular sesamoid ligament, release of contracted adductor hallucis tendon, and internal rigid fixation with 3-mm cannulated screw; medial capsule repair and abductor hallucis tendon repair, left foot; and application of well-padded posterior splint.

Anesthesia: IV sedation administered by Versed anesthesia group and Mayo block of left first metatarsal, 2% Xylocaine plain mixed with an equal amount of 0.5% Xylocaine with epinephrine 1:100,000.

Findings: The patient had severe metatarsus primus varus angle of the left foot requiring separate base wedge osteotomy to reduce the intermetatarsal angle. The patient has a bunion hallux valgus deformity with displacement of the sesamoid apparatus, which was not arthritic in appearance. Central articular cartilage was normal in appearance. No osteophyte formation was noted about the first metatarsal head dorsally. Small osteophyte over the area of the bunion prominence was noted. Bone stock was excellent.

Description of Procedure: With the patient lying supine under suitable IV sedation, 2 g of intravenous Ancef was administered. Local anesthesia was then administered to the left foot. The left foot was prepped and draped in the usual aseptic manner, and no tourniquet was used.

Attention was turned to the dorsal aspect of the left foot where medial to the extensor hallucis longus tendon an incision 5 cm in length was made proximally at the base of the first metatarsal and extending distally. This incision was deepened, small bleeding vessels were clamped and coagulated, and vital structures were retracted. The extensor tendon was released medially and retracted. The periosteum was exposed over the base of the metatarsal. A linear longitudinal periosteal incision was made extending from the metatarsal cuneiform articulation distally with the metatarsal shaft. A Freer elevator was used to separate the periosteum from the planned osteotomy site and, using an oscillating bone saw, an oblique first metatarsal wedge osteotomy was performed extending from the proximal medial to distal lateral with the wedge of bone resected and sent for pathologic examination. A test fit of the osteotomy site indicated good closure of the osteotomy site, and the proximal hinge was preserved. The osteotomy site was lavaged with Betadine saline solution. A single 3-mm cannulated Synthes bone screw, 26 mm in length, was then used to fixate the osteotomy site with excellent approximation of the osteotomy surfaces and slight plantar displacement of the distal fragment indicating no metatarsus primus elevatus. With the internal fixation in place, the osteotomy site was very stable. The wound was lavaged with Betadine saline solution. The periosteum was closed with 3-0 Vicryl. The subcutaneous tissue was approximated and maintained with a suture of 3-0 Vicryl. The skin was closed with interrupted 5-0 nylon suture.

Attention was then turned to the left first metatarsophalangeal joint where a curvilinear longitudinal incision, 6 cm in length, was made underlying the bunion deformity. This incision was deepened, and small bleeding vessels were clamped and coagulated; the vital structures were retracted. Dissection was carried down to the level of the first MP joint. The extensor hallucis longus tendon was identified. The hood ligament was resectioned. The brevis tendon was identified. A medially placed, distally based U-shaped capsular flap was fashioned at the first MTP joint capsule to include the abductor hallucis tendon. The capsular flap was separated from the bunion and reflected distally. The bunion was exposed in the wound and resected with the oscillating bone saw. The first metatarsal head was reflected dorsally. The sesamoid pad was reflected in a plantar direction. The contracted fibular sesamoid ligament was sectioned. An intracapsular approach was used to sever the contracted adductor hallucis tendon. Then, using the oscillating bone saw, modified Austin wedge osteotomy was performed in the first metatarsal head with the wedge being based medially to reduce the proximal articular facet angle. With the osteotomy complete, the wedge of bone was resected and sent for pathologic examination. The osteotomy site was lavaged with Betadine saline solution. The first metatarsal head was then translocated laterally, approximately one-third the width of the metatarsal shaft, to further close down the intermetatarsal angle to 0.

With the osteotomy complete in its new position, the first MTP joint range of motion was tested and found to be excellent, and the tibial sesamoid was positioned in the proper portion underneath the metatarsal condyle. A single 3-mm cannulated Synthes screw, 24 mm in length, was then placed across the osteotomy site from dorsal proximal to distal medial. With this point of fixation in place, the osteotomy stability was excellent. The redundant medial stump of metatarsal was resected with the oscillating bone saw and rasped smooth.

The wound was lavaged with Betadine saline solution. The redundant medial capsule was resected. The medial capsule repair and abductor hallucis tendon repair was afforded with 0 Surgidac and additional capsular closure with 3-0 Vicryl. The subcutaneous tissue was approximated and maintained with suture of 3-0 Vicryl. The skin was closed with an interrupted 5-0 nylon. Postoperatively, 0.25% Marcaine plain was instilled approximately at the operative site for postoperative pain. Vaseline gauze and dry sterile compression dressings were applied. Then, a well-padded posterior splint was applied with the knee bent and the foot at 90 degrees and held in place with two Ace wraps.

The patient tolerated the procedure well, had no untoward intraoperative events. She was discharged awake and in good condition, transferred to the recovery room stable. She will be sent to the surgical day care unit where she will be given medication, wound care, and home care instructions. She will then be discharged to recuperate at home, nonweightbearing on crutches for six weeks which was taught preoperatively. She will see me in one week in the office for surgical redressing