Sample Name: Arthrodesis
Description: Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Congenital myotonic muscular dystrophy with bilateral planovalgus feet.
POSTOPERATIVE DIAGNOSIS: Congenital myotonic muscular dystrophy with bilateral planovalgus feet.
PROCEDURE: Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.
ANESTHESIA: Surgery performed under general anesthesia. The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.
TOURNIQUET TIME: Tourniquet time was 53 minutes on the left and 45 minutes on the right.
HARDWARE USED: Staple 7/8 inch x1 on each side.
HISTORY AND PHYSICAL: The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening. This was explained to the mother in detail. This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. All questions were answered and the mother agreed to the above plan.
POSTOPERATIVE PLAN: The patient will be hospitalized overnight for pain as per parents' request. The patient is to be strict nonweightbearing for at least 6 weeks. He is to follow up in the next 10 days for a check. We will plan of changing to short-leg casts in about 4 weeks postop.
Keywords: orthopedic, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, surgery, subtalar, achilles, anesthesia, planovalgus, foot, bilateral,