# Need ankle expert please!! unsure on this??



## Bella Cullen (Jan 31, 2012)

1. Rt ankle arthroscopy w/synovectomy- either inclusive to #2 or 29895
2. Arthroscopic distal tibial bone spur excision- 29894
3. medial malleolar osteotomy w/ repair- 28302 ? or 27766 or both?
4. open debridement and microfracture OCD lesion, rt medial talar dome ?? not sure
5. open exostosis excision, dorsal talus- 28100

PROCEDURE:  The patient was brought into the operating room and placed supine
 on the operating room table.  After institution of adequate general
 endotracheal anesthesia, a preoperative dose of IV antibiotics was given
 prior to initiation of the procedure.  A popliteal nerve block had been
 previously placed by the anesthesia team in the holding area.  This was done
 under ultrasound guidance.  The patient was then repositioned with all bony
 prominences well padded.  A leg holder was placed under the right thigh
 holding the hip and knee in flexion.  A pad was used to cover the leg holder
 to protect the peroneal nerve.  Tourniquet was placed on the distal thigh.
 The entire right lower extremity was prepped and draped in the usual sterile
 fashion.

The bony landmarks were palpated and the superficial peroneal nerve also
 identified and drawn out on the skin.  A lateral portal was created first
 with the introduction of an 18-gauge needle.  The insufflation of the joint
 was about 20 mL of saline.  With the capsule distended, the skin was incised
 with a #15 blade and a mosquito clamp used to spread down to the capsular
 layer.  This was then penetrated and the blunt cannula introduced.  A
 diagnostic arthroscopy was then performed.  The portal had been created in
 the standard anterolateral position.  There was an extremely large amount of
 synovium throughout the ankle, which limited visualization.  This was
 especially true across the front of the ankle where the impingement was.  The
 dome of the talus itself looked good and there were no lesions on the distal
 fibula.  The medial malleolus also looked good once the synovium had been
 cleared.  There was a large spur off the front of the distal tibia, but with
 the foot in traction since a gentle traction device had been used to distend
 the joint and had been applied to the table in standard fashion, the
 exostosis on the talus was not visualized.  At that point, a standard medial
 portal was created under direct visualization.  Limited synovectomy was
 performed at that time.  The lesion in the medial talar dome was just barely
 visualized since it was over the back; a full glimpse was not obtainable.  At
 that point, the decision was made that a medial malleolar osteotomy was
 necessary.

 The surgical portion of the arthroscopy involved extensive synovectomy of the
 entire front of the ankle and both gutters.  This was done with a 2.9
 full-radius shaver.  A motorized bur was then used to take off the distal
 tibial spur.  This was checked with large fluoroscopic guidance to make sure
 enough was resected.  Once this was done, final arthroscopic pictures were
 taken and medial malleolar osteotomy performed.

A 4-5 cm slightly curved incision was made over the medial malleolus and
 taken down to the deeper subcutaneous tissue with a combination of blunt and
 sharp dissection.  Bovie electrocautery was used throughout the case for
 hemostasis.  Care was taken not to straighten to forward distally or
 posteriorly and injure the posterior tibial nerve.  Two threaded guidewires
 were passed up through the medial malleolus into the distal tibial under
 fluoroscopic guidance and these were over drilled with the
 cannulated drill.  Two  44-mm partially threaded screws were then advanced
 into the bone and these were done before the osteotomy was made so afterwards it
 could be anatomically reduced.  Once this was done, these were then removed
 and saved on the back table.  Guidewire was then passed obliquely coming down
 from proximal to distal and from medial to lateral to enter the joint space
 at roughly the medial angle.  At that point, a small drill was used to make
 drill holes in the bone and an osteotome used to complete the osteotomy.
 This is then reflected distally, carefully teasing soft tissue off the
 anterior and posterior aspects allowing to reflect.  This opened up the joint
 space nicely.  The lesion on the talus was clearly visualized.  It was
 roughly a comma shaped and was probably just over 1 cm, maybe closer to 1.5
 cm in length.  It was longer than it was wide.  The widest portion extended
 onto the medial aspect, but also up on to the top of the dome where most the
 damage was.  Actually had very good borders and a curette was used to sharpen
 these borders further down to bone.  A 0.62 K-wire was then used to drill
 into the bone creating stable base.  Once this was done, wound was copiously
 irrigated.  The osteotomized medial malleolus was then put back in place and
 two guidewires passed back through the drill holes.  Both screws were then
 re-advanced with excellent compression across the osteotomy site.  C-arm
 confirmed this with a good reduction of the joint surface.  At that point, it
 was determined that the distal bone spur on the dorsal talus had to be
 excised independently.  A 3-cm incision was made directly over this and was 
done roughly middle portion of the ankle centered over the spur.  This was
 probably a little bit more medial then midline.  Blunt dissection was used
 under the skin taking care not to injure the neurovascular bundle or any of the underlying tendons, which were encountered.  These were retracted out of
 the place.  The spur was easily palpable and visualized and was removed with
 a rongeur.  No residual bump or evidence of impingement was noted with a full
 range of motion.  At that point, final fluoroscopic pictures were taken.

Both wounds and the portals were then closed.  A 0 Vicryl and 2-0 Vicryl was
used for the deeper, then subcutaneous tissues, with 3-0 Prolene used for the
 skin.  A dry sterile dressing was applied with a trilaminar splinted in
 neutral position.  The patient was then transferred to the recovery room in
 satisfactory condition without complication.


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