trose45116
Expert
PREOPERATIVE DIAGNOSIS: Nonunion of left fifth metatarsal.
POSTOPERATIVE DIAGNOSIS: Nonunion of left fifth metatarsal.
PROCEDURE: The patient underwent bone grafting from ipsilateral medial malleolar area to left fifth metatarsal nonunion.
ANESTHESIA: General.
COMPLICATIONS: None.
INDICATIONS: Jaime is a 28-year-old female who has had a development of a nonunion on the base of her fifth metatarsal on the left foot. It has continued to give her significant symptoms. Because of her continued symptoms, the recommendation was for operative treatment. She understood the risks and benefits of this procedure of bone grafting. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: After preoperative medical testing and clearance, she was brought to the operating room where she was placed supine on the operating table. A general anesthetic was administered. Preoperative antibiotics were given. A pneumatic tourniquet was placed on the left thigh. A bolster was placed underneath the left buttock, and the leg was then prepped and draped in sterile fashion. An appropriate timeout was performed.
I began by making an incision over the base of the fifth metatarsal longitudinally. This was carried down through skin only. Blunt dissection was carried down to the fifth metatarsal where the sural nerve was noted and identified and was integrated within the fracture fibrotic area. We freed the nerve and brought it anteriorly and then noted the nonunion site. This was picked with a dental pick and was not taken completely down but enough in order to bone graft this without taking away some of its inherent stability, since this was a small fragment, and fixation would have potentially fractured the piece. Following this, we were very satisfied with the trough that was made and tried to open up the intermedullary area at least distally with the dental pick. Following this, we then made an incision longitudinally just proximal to the medial malleolus and carried down through skin. With blunt dissection, it was carried down to the periosteum, posterior to the saphenous structures. The periosteum was incised in an H-like fashion, and a window was made approximately 1 cm2, and the cortical area was lifted off. The cancellous bone was curetted, approximately 1 cc. We then placed our trapdoor back, cortical bone, into position and this was held together with periosteum over the top as we sutured it with 4-0 Vicryl. The subcutaneous tissue was then closed with 4-0 Vicryl, and the skin was then closed with 4-0 Monocryl subcuticular stitch with Benzoin Steri-Strips. We went back to our original area. We then placed bone graft tamping it into position which we were very satisfied with. We kept the sural nerve a little more anteriorly in order for it not to get involved with the bone graft. We then closed the subcutaneous tissue with a 4-0 Vicryl, and the skin was then closed with a Monocryl.
A sterile dressing was then applied with Betadine Adaptic and 4 x 4's. A splint was then placed with medial and lateral splints with the foot in neutral position. The patient tolerated the procedure well. Sponge and needle count was correct. She did leave the recovery room in very satisfactory condition.
POSTOPERATIVE DIAGNOSIS: Nonunion of left fifth metatarsal.
PROCEDURE: The patient underwent bone grafting from ipsilateral medial malleolar area to left fifth metatarsal nonunion.
ANESTHESIA: General.
COMPLICATIONS: None.
INDICATIONS: Jaime is a 28-year-old female who has had a development of a nonunion on the base of her fifth metatarsal on the left foot. It has continued to give her significant symptoms. Because of her continued symptoms, the recommendation was for operative treatment. She understood the risks and benefits of this procedure of bone grafting. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: After preoperative medical testing and clearance, she was brought to the operating room where she was placed supine on the operating table. A general anesthetic was administered. Preoperative antibiotics were given. A pneumatic tourniquet was placed on the left thigh. A bolster was placed underneath the left buttock, and the leg was then prepped and draped in sterile fashion. An appropriate timeout was performed.
I began by making an incision over the base of the fifth metatarsal longitudinally. This was carried down through skin only. Blunt dissection was carried down to the fifth metatarsal where the sural nerve was noted and identified and was integrated within the fracture fibrotic area. We freed the nerve and brought it anteriorly and then noted the nonunion site. This was picked with a dental pick and was not taken completely down but enough in order to bone graft this without taking away some of its inherent stability, since this was a small fragment, and fixation would have potentially fractured the piece. Following this, we were very satisfied with the trough that was made and tried to open up the intermedullary area at least distally with the dental pick. Following this, we then made an incision longitudinally just proximal to the medial malleolus and carried down through skin. With blunt dissection, it was carried down to the periosteum, posterior to the saphenous structures. The periosteum was incised in an H-like fashion, and a window was made approximately 1 cm2, and the cortical area was lifted off. The cancellous bone was curetted, approximately 1 cc. We then placed our trapdoor back, cortical bone, into position and this was held together with periosteum over the top as we sutured it with 4-0 Vicryl. The subcutaneous tissue was then closed with 4-0 Vicryl, and the skin was then closed with 4-0 Monocryl subcuticular stitch with Benzoin Steri-Strips. We went back to our original area. We then placed bone graft tamping it into position which we were very satisfied with. We kept the sural nerve a little more anteriorly in order for it not to get involved with the bone graft. We then closed the subcutaneous tissue with a 4-0 Vicryl, and the skin was then closed with a Monocryl.
A sterile dressing was then applied with Betadine Adaptic and 4 x 4's. A splint was then placed with medial and lateral splints with the foot in neutral position. The patient tolerated the procedure well. Sponge and needle count was correct. She did leave the recovery room in very satisfactory condition.