Sample Report: Plate and Screw Hardware Removal
Preoperative Diagnosis: Metatarsalgia, left foot.
Postoperative Diagnoses
1. Metatarsalgia, left foot.
2. Stable nonunion, left first metatarsophalangeal joint.
Operations Performed
1. Removal of hardware, left foot.
2. Bone biopsy, left first metatarsal bone.
3. Shortening osteotomies, left second and third metatarsals.
Description of Procedure: The patient was brought to the operating room and placed on the operating table in a supine position. Following the administration of intravenous sedation, an infiltrative block of 0.5% Marcaine plain was administered to the left foot in ankle block fashion. The left foot was then prepped and draped in the usual sterile manner. A well-padded pneumatic tourniquet was placed on the left ankle and the limb exsanguinated via gravity. Upon adequate exsanguination of the limb, the cuff was inflated to 250 mmHg. Attention was now directed to the left foot where a surgical scar was noted over the dorsal aspect of the first metatarsophalangeal joint.
In the first metatarsophalangeal joint area, a dorsal incision was performed over the previous surgical scar. This incision was deepened in the same plane, taking care to clamp, cauterize, or ligate any superficial bleeders as necessary. Blunt and sharp dissection was utilized to penetrate the soft tissue layers, with care being taken to preserve and retract all vital structures. Moderate scar tissue was noted in the surgical area, consistent with multiple previous surgeries.
Blunt and sharp dissection was utilized to penetrate the soft tissue layers until reaching the level of the internal fixation plate and screws. The hardware was exposed via sharp dissection. Bony growth was noted around the metallic plate overlying the dorsal aspect of the fusion site. The internal fixation screws were removed utilizing the AO screwdriver in the standard AO technique. The periosteal elevator was then utilized to free the plate and remove it from the surgical field in toto. There, overlying the plate and screws, was abnormal-appearing fibrous tissue which was sent for pathology. There was no evidence of abscess formation in the area. Inspection of the plate and screws did not demonstrate any evidence of biocorrosion or infection.
Upon removal of the hardware, the first metatarsophalangeal joint area was manipulated. Inspection demonstrated fibrous tissue at the fusion site at the interface of the proximal phalanx and first metatarsal. The interface of the metatarsal and graft proximally appeared solid and well healed. Motion was noted across the fusion site with manipulation of the area distally.
Wound cultures were also taken in this area due for aerobic and anaerobic bacterial cultures. In addition, a deep bone biopsy was taken for pathology to rule out pseudoarthrosis versus osteomyelitis. The surgical site was flushed copiously with normal saline and closed in a layered fashion utilizing 2-0 and 3-0 Vicryl to reapproximate the deep tissues, 4-0 Vicryl to reapproximate the subcutaneous tissues, and 4-0 nylon to reapproximate the skin margins.
Attention was now directed to the lesser metatarsals where a dorsal incision was performed between the second and third metatarsal bones. This incision was deepened in the same plane, taking care to clamp, cauterize, or ligate any superficial bleeders as necessary. Blunt and sharp dissection was utilized to penetrate soft tissue layers with care being taken to preserve and retract all vital structures. Attention was first directed towards second metatarsal bone, where the extensor tendon and neurovascular structures were retracted from the surgical site. Upon reaching the level of the periosteum and joint capsule, this tissue layer was incised in a linear fashion to provide exposure to the distal aspect of the second metatarsal bone and second metatarsal head. The periosteum was reflected from its underlying bony attachments to facilitate exposure. A 0.045 K-wire was then driven from dorsal to plantar through the metatarsal neck, slightly medial to center point to serve as an axis guide. The power bone saw was then utilized to perform a V-shaped osteotomy with the apex oriented distally and long medial arm through the metatarsal bone. Upon completion of the osteotomy, the axis guide was removed. An approximate 3-mm wedge of bone was then removed from the shorter lateral arm of the osteotomy to provide for shortening of the second metatarsal bone. Temporary fixation was achieved via K-wire and bone clamp fixation. Attention was then directed to the third metatarsal bone where a similar V-shaped osteotomy with long medial arm was performed. A 3-mm wedge of bone was removed from the shorter lateral arm of the osteotomy to also provide for shortening of the metatarsal bone. Temporary fixation was achieved via bone clamps, and intraoperative radiographs were taken. The radiographs demonstrated shortening of the metatarsal bones and rebalancing of the forefoot.
Permanent fixation of the osteotomies was achieved utilizing 2-mm cortical screws inserted parallel from medial to lateral across the metatarsal bone in standard AO fashion. Upon permanent fixation, a second set of intraoperative radiographs was taken. They demonstrated preservation of the metatarsal parabola through the shortening osteotomies of the second and third metatarsal bones. It was not deemed necessary to perform an additional osteotomy beneath the fourth metatarsal bone at this time as this area remained clinically asymptomatic for him. The surgical site was flushed copiously with normal saline, and the wound was closed in a layered fashion utilizing 3-0 Vicryl to reapproximate the periosteal and capsular tissues, 4-0 Vicryl to reapproximate the subcutaneous tissues and 5-0 Vicryl to reapproximate the skin margins in continuous subcuticular fashion.
The patient left the operating room in good condition with all digits warm and viable. The left lower extremity was immobilized in a well-padded fiberglass posterior splint beneath compressive dressings.