Operative report Hallux rigidus/Limitus

Operative report 1

Preoperative Diagnosis

1. Hallux rigidus, right foot.

2. Degenerative osteoarthritis of the first metatarsophalangeal joint.

Postoperative Diagnosis

Same.

Procedure Performed

Cheilectomy of the first metatarsophalangeal joint for correction of hallux rigidus, right foot.

Indication

The patient presented with progressive pain, stiffness, and limited dorsiflexion of the right great toe associated with difficulty during ambulation, stair climbing, and shoe wear. Conservative management including shoe modifications, rigid-soled footwear, orthotics, activity modification, nonsteroidal anti-inflammatory medications, and corticosteroid injections failed to provide lasting relief. Weight-bearing radiographs demonstrated dorsal osteophyte formation, mild-to-moderate degenerative arthritis, preservation of a significant portion of the joint cartilage, and dorsal impingement consistent with hallux rigidus. Because joint preservation remained feasible, surgical correction with cheilectomy was recommended. The risks, benefits, alternatives, and expected postoperative recovery were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and positioned supine on the operating table. Monitored anesthesia care with an ankle block was administered. A well-padded thigh tourniquet was applied. The right lower extremity was prepped with chlorhexidine solution and draped in the standard sterile orthopedic fashion.

Following exsanguination using an Esmarch bandage, the tourniquet was inflated. A formal surgical time-out confirmed the correct patient, operative extremity, planned procedure, and administration of prophylactic intravenous antibiotics.

Exposure of the First Metatarsophalangeal Joint

A longitudinal dorsal incision measuring approximately 5 cm was made directly over the first metatarsophalangeal joint.

Sharp dissection was carried through the subcutaneous tissues while carefully identifying and protecting the dorsal medial cutaneous nerve. Hemostasis was maintained with bipolar electrocautery throughout the procedure.

The extensor hallucis longus tendon was identified, mobilized, and gently retracted laterally.

A longitudinal dorsal capsulotomy was performed. The capsule was elevated subperiosteally from the metatarsal head and the base of the proximal phalanx, allowing complete exposure of the first metatarsophalangeal joint.

Inspection demonstrated advanced dorsal osteophyte formation involving the metatarsal head and the dorsal base of the proximal phalanx with degenerative synovitis and localized cartilage wear primarily involving the dorsal articular surface. The plantar articular cartilage remained largely preserved, making the joint suitable for preservation.

Cheilectomy

Large dorsal osteophytes arising from the first metatarsal head were removed using an oscillating microsagittal saw. Additional osteophytes along the medial and lateral margins of the metatarsal head were excised using a rongeur.

Approximately the dorsal 25% to 30% of the metatarsal head was resected to eliminate dorsal impingement while preserving joint stability and plantar cartilage.

Prominent osteophytes at the dorsal base of the proximal phalanx were likewise removed using a combination of rongeurs and an oscillating saw.

Residual irregular cortical bone was contoured with a bone rasp to obtain smooth articular margins.Hypertrophic synovium and inflamed fibrous tissue were excised using a rongeur to improve joint mobility.

The joint was copiously irrigated with sterile normal saline to remove all osseous debris.

Assessment of Motion

The first metatarsophalangeal joint was gently mobilized through passive dorsiflexion and plantarflexion.

Following completion of the cheilectomy, dorsiflexion improved substantially with complete elimination of dorsal bony impingement. Smooth, unrestricted motion was achieved without crepitus or residual mechanical block.

Fluoroscopic images obtained in anteroposterior, lateral, and oblique projections confirmed complete removal of the dorsal osteophytes, satisfactory contouring of the metatarsal head, preservation of joint congruity, and absence of residual dorsal impingement.

The operative field was irrigated once more with copious sterile saline solution.

Meticulous hemostasis was achieved.

The capsule was repaired using interrupted absorbable sutures while avoiding excessive tightening.

The subcutaneous tissues were closed with interrupted 3-0 absorbable sutures.

The skin was closed using interrupted 4-0 nylon sutures.

The tourniquet was released. Immediate capillary refill was confirmed in the hallux and all remaining toes with excellent distal perfusion.

Sterile Xeroform, gauze, Webril padding, and a soft compressive dressing were applied. A postoperative surgical shoe was placed.The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery room in stable condition.

Findings

Moderate hallux rigidus with extensive dorsal osteophyte formation of the first metatarsal head and proximal phalanx, dorsal synovitis, and localized dorsal cartilage degeneration with preservation of the plantar articular surface. Successful cheilectomy resulted in complete removal of impinging osteophytes and marked improvement in first metatarsophalangeal joint dorsiflexion.

Implants : None.

Check your answer

CPT 28289 is the standard code for joint-preserving hallux rigidus surgery (cheilectomy).

It includes:

• Dorsal osteophyte excision.

• Partial dorsal metatarsal head resection (when performed as part of the cheilectomy).

• Debridement of the first MTP joint.

• Synovectomy and capsular release as necessary.

It does not include implant arthroplasty or arthrodesis, which are reported with different CPT codes.

Operative report 2

Preoperative Diagnosis

1. Advanced hallux rigidus, right foot.

2. Degenerative osteoarthritis of the first metatarsophalangeal joint with painful limitation of motion.

Postoperative Diagnosis

Same.

Procedure Performed

Correction of hallux rigidus with cheilectomy, synovectomy, capsular release, debridement of the first metatarsophalangeal joint, and silicone implant arthroplasty, right great toe.

Indication

The patient presented with longstanding pain, stiffness, and markedly decreased motion of the right first metatarsophalangeal joint. The patient had significant difficulty with ambulation, push-off during gait, stair climbing, and shoe wear. Conservative treatment including rigid-soled shoes, orthotics, activity modification, anti-inflammatory medications, and corticosteroid injections failed to provide adequate relief. Radiographs demonstrated advanced hallux rigidus with extensive dorsal osteophyte formation, degenerative joint disease, joint space narrowing, and preservation of adequate bone stock for implant arthroplasty. After discussing treatment options including arthrodesis and implant arthroplasty, the patient elected to proceed with silicone implant arthroplasty. Informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care with an ankle block was administered. A well-padded thigh tourniquet was applied. The right lower extremity was prepped with chlorhexidine solution and draped in the standard sterile orthopedic fashion.

Following exsanguination using an Esmarch bandage, the tourniquet was inflated. A formal surgical time-out confirmed the correct patient, operative extremity, planned procedure, and administration of prophylactic intravenous antibiotics.

A longitudinal dorsal incision measuring approximately 5 cm was made over the first metatarsophalangeal joint.

Sharp dissection was carried through the subcutaneous tissues while carefully protecting the dorsal medial cutaneous nerve. Hemostasis was maintained with bipolar electrocautery.

The extensor hallucis longus tendon was identified and retracted laterally. A longitudinal dorsal capsulotomy was performed, and the capsule was elevated subperiosteally to expose the first metatarsal head and the base of the proximal phalanx.

Inspection demonstrated severe degenerative osteoarthritis with extensive dorsal osteophyte formation involving the metatarsal head and proximal phalanx, hypertrophic synovitis, loose osteochondral debris, cartilage erosion, and significant restriction of joint motion.

Hypertrophic synovium was excised using rongeurs and curettes.

Loose osteochondral fragments and degenerative fibrous tissue were removed.

The remaining joint surfaces were thoroughly debrided until stable margins of healthy tissue were identified.

Cheilectomy

Large dorsal osteophytes arising from the metatarsal head were resected using an oscillating microsagittal saw.Additional osteophytes involving the dorsal aspect of the proximal phalanx were excised with a rongeur.Approximately the dorsal one-quarter of the metatarsal head was resected to eliminate dorsal impingement.

Remaining irregular cortical bone was contoured using a bone rasp until smooth.

Residual capsular contracture limiting dorsiflexion was identified.

Selective release of the contracted dorsal capsule and periarticular soft tissues was performed to restore joint mobility.Following capsular release, passive dorsiflexion improved substantially.

Implant Arthroplasty

Attention was directed toward preparation for implant placement.

Using the manufacturer's instrumentation, the medullary canals of the first metatarsal and proximal phalanx were sequentially prepared with broaches and rasps.

Trial implants were inserted to determine the appropriate implant size and confirm restoration of joint alignment, stability, and range of motion.

After satisfactory trialing, the definitive silicone flexible implant was inserted into the prepared metatarsal and proximal phalanx canals.

The implant was fully seated and demonstrated excellent stability.

The joint was reduced, and passive dorsiflexion and plantarflexion were performed.

Excellent restoration of motion was achieved without impingement, instability, or excessive laxity.

Fluoroscopic imaging obtained in anteroposterior, lateral, and oblique projections confirmed appropriate implant position, satisfactory joint alignment, restoration of joint space, and absence of fracture or malposition.

The operative field was copiously irrigated with sterile normal saline solution.Meticulous hemostasis was achieved.The joint capsule was repaired with interrupted absorbable sutures while avoiding excessive tension around the implant.The subcutaneous tissues were approximated using interrupted 3-0 absorbable sutures.The skin was closed using interrupted 4-0 nylon sutures.The tourniquet was released, and immediate capillary refill was present in the hallux with excellent distal perfusion.

Sterile Xeroform, gauze, Webril padding, and a compressive dressing were applied. A postoperative surgical shoe was placed.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery room in stable condition.

Findings

Advanced hallux rigidus with severe degenerative osteoarthritis, extensive dorsal osteophyte formation, hypertrophic synovitis, loose osteochondral debris, and marked limitation of first metatarsophalangeal joint motion. Successful cheilectomy, synovectomy, capsular release, debridement, and silicone implant arthroplasty restored joint alignment and significantly improved passive range of motion.

Implants

* One silicone flexible first metatarsophalangeal joint implant.

Check your answer

This documentation supports CPT 28291, which includes:

• Cheilectomy.

• Debridement/synovectomy.

• Capsular release.

• Implant arthroplasty (e.g., silicone implant) of the first MTP joint.

The implant insertion is an integral component of 28291 and is not separately reported.

Operative report 3

Preoperative Diagnosis

Rigid hammertoe deformity of the second toe, right foot.

Postoperative Diagnosis

Same.

Procedure Performed

Correction of rigid hammertoe deformity of the right second toe with proximal interphalangeal joint arthrodesis, resection of the head of the proximal phalanx, collateral ligament release, and Kirschner wire fixation.

Indication

The patient presented with a longstanding rigid hammertoe deformity of the right second toe associated with chronic pain, dorsal proximal interphalangeal joint prominence, recurrent shoe irritation, painful corns, and progressive difficulty with ambulation. Conservative treatment including accommodative footwear, toe sleeves, splinting, padding, and orthotics failed to provide adequate symptom relief. Due to the fixed nature of the deformity and persistent symptoms, surgical correction was recommended. Risks, benefits, alternatives, and expected postoperative recovery were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care with a digital nerve block of the second toe was administered. A well-padded ankle tourniquet was applied. The right foot was prepped with chlorhexidine solution and draped in the usual sterile orthopedic fashion.

Following exsanguination with an Esmarch bandage, the tourniquet was inflated. A formal surgical time-out confirmed the correct patient, operative extremity, and planned procedure. Intravenous prophylactic antibiotics had been administered prior to incision.

A longitudinal dorsal incision approximately 3 cm in length was made directly over the proximal interphalangeal joint of the second toe.

Sharp dissection was carried through the subcutaneous tissue while carefully protecting the medial and lateral digital neurovascular bundles. Hemostasis was maintained throughout the procedure using bipolar electrocautery.

The extensor tendon was identified and divided longitudinally in line with its fibers. The tendon was elevated medially and laterally to expose the underlying proximal interphalangeal joint capsule.

Capsulotomy and Collateral Ligament Release

A longitudinal capsulotomy was performed over the proximal interphalangeal joint.

The medial and lateral collateral ligaments were sharply released from both sides of the joint using a #15 blade, allowing complete exposure of the articulation and mobilization of the rigid deformity.

Remaining periarticular contractures were released until the toe could be fully reduced.

Resection of the Proximal Phalanx

The head and neck of the proximal phalanx were completely exposed.

Using a rongeur, the head of the proximal phalanx was resected in a controlled fashion. Residual bone was contoured until a smooth surface was obtained.

The remaining articular cartilage at the base of the middle phalanx was removed using a curette and rongeur to expose healthy cancellous bone suitable for arthrodesis.

The prepared fusion surfaces were inspected and demonstrated satisfactory apposition.

Arthrodesis and Internal Fixation

The toe was placed into an anatomic position with correction of the hammertoe deformity.

A 0.045-inch Kirschner wire was introduced in an antegrade fashion through the middle phalanx and distal phalanx. The wire was then advanced retrograde across the prepared proximal interphalangeal joint into the proximal phalanx, maintaining the toe in neutral alignment.

Excellent compression and stability of the arthrodesis site were achieved.

Clinical assessment confirmed restoration of proper toe alignment without rotational deformity.Intraoperative fluoroscopic imaging obtained in anteroposterior and lateral projections confirmed satisfactory resection, proper Kirschner wire placement, excellent alignment of the proximal interphalangeal joint, and stable fixation.

The operative site was thoroughly irrigated with copious sterile normal saline solution.

Meticulous hemostasis was achieved.The extensor tendon was repaired using interrupted absorbable sutures.The joint capsule was reapproximated with absorbable sutures.

The subcutaneous tissue was closed with interrupted 4-0 absorbable sutures.

The skin was closed using interrupted 4-0 nylon sutures.The Kirschner wire was cut, bent, and protected with a sterile pin cap.The tourniquet was released. Immediate capillary refill was present in the operative toe, confirming satisfactory distal perfusion.

Sterile Xeroform, gauze, Kling, and a compressive forefoot dressing were applied. A well-padded short-leg fiberglass walking cast was then applied with the toe maintained in corrected alignment.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery room in stable condition.

Findings

Rigid hammertoe deformity of the second toe with fixed flexion contracture of the proximal interphalangeal joint, contracted collateral ligaments, degenerative changes of the joint surfaces, and dorsal prominence. Successful correction was achieved with collateral ligament release, resection of the proximal phalangeal head, proximal interphalangeal joint arthrodesis, and stable Kirschner wire fixation.

Implants

* One 0.045-inch Kirschner wire for proximal interphalangeal joint arthrodesis.

Check your answer

28285

The resection of the proximal phalangeal head, collateral ligament release, preparation of the fusion surfaces, PIP arthrodesis, and K-wire fixation are all integral components of CPT 28285 and are not separately reported.