Total ankle arthroplasty

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• wound breakdown over the anterior incision
• infection of the prosthesis
• loosening or subsidence of the components
• persistent pain
• instability
• numb patch medial to the scar from a cut branch of the superficial peroneal nerve
• injury to the anterior tibial artery or deep peroneal nerve
• later conversion to ankle fusion

Pre-operative details for this operation

1. Diagnosis and cause of arthritisPost-traumaticOsteoarthritisInflammatory (rheumatoid)duration of pain, conservative treatment tried
2. SideRightLeft
3. Deformity above or below the ankletibial and hindfoot alignment on standing X-rays; any deformity must be corrected before or with the implant
4. Risk factors checkedHbA1c, BMI, serum albumin, ASA grade
5. Implant system and sizes availableMobile-bearing, three componentFixed-bearing, two component
6. Skin over the front of the ankleold scars, swelling, skin quality

Anaesthesia and position

1. AnaesthesiaGeneralSpinalpopliteal block for post-op analgesia: yes / no
2. PositionSupine, sandbag or bump under ipsilateral hip
3. Tourniquetthigh; pressure in mmHg; inflation and deflation times
4. Ankle distractorApplied mediallyNot usedamount of distraction in mm
5. C-armUsed

Operative findings

1. Articular cartilage of tibial plafond and talar domeextent of loss, bone exposed
2. Osteophytesanterior tibial lip, talar neck, medial and lateral gutters
3. Bone quality and cystsany cyst needing graft
4. Ligament stability after trialsstable / lax medially or laterally
5. Range of motion with trialsdorsiflexion and plantarflexion in degrees

Procedure (steps)

1. Deformity correctionNone neededDone at same sittingwhat was corrected and how
2. Anterior incisionlength (about 10 cm from above the joint); interval between tibialis anterior and extensor hallucis longus
3. Superficial peroneal nerve branchesprotected and retracted / small medial branch divided
4. Deep intervalEHL sheath opened and EHL retracted (record direction: the book text says medial, the figure legend says lateral is more common); anterior tibial artery, vein and deep peroneal nerve retracted laterally with EDL
5. Capsulotomy and exposurelongitudinal capsulotomy, capsule reflected to medial and lateral gutters
6. Osteophytes removedanterior tibia, dorsal talonavicular area, gutters; osteotome used
7. Alignment guide and tibial cutguide in line with the tibial axis; checked on C-arm in both planes
8. Talar cut and preparationper the implant technique guide
9. Trial reductiontrial sizes, poly thickness, alignment, stability, range of motion
10. Final componentsUncementedCementedfixation as the implant system requires; tibial, talar and polyethylene sizes; cement batch if cemented
11. Syndesmosis fusion (only if the implant requires it)Not requiredDone with screws and local bone graft
12. Final C-arm imagesAP and lateral saved

Closure, drains and dressing

1. Irrigationsaline volume
2. Capsuleclosed over the prosthesis, suture
3. DrainClosed suction drainNone
4. Superior extensor retinaculumclosed over the EHL sheath
5. Skinlayered closure, suture used
6. Dressing and splintcompression dressing, posterior splint
7. Tourniquet timetotal minutes

Specimens and implants

1. Tibial componentmake, size, batch/lot, sticker pasted
2. Talar componentmake, size, batch/lot, sticker pasted
3. Polyethylene insertthickness, batch/lot, sticker pasted
4. Syndesmosis screws / cementif used: size, batch
5. Bone or synovium for HPE / cultureNot sentSent

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Limb elevation and toe circulationcapillary refill, toe movement, sensation, hourly for the first few hours
2. Drainrecord output; plan for removal
3. Analgesiapopliteal block, then oral analgesics
4. Antibioticsdrug and number of post-op doses, if any
5. DVT prophylaxisLMWH in hospital; aspirin after discharge only if risk factors
6. Weight bearingtouch-down weight bearing with walker; full weight bearing usually delayed 4 to 6 weeks
7. Splint and wound checksplint kept till wound check; active ankle motion once the wound has healed, about 2 weeks
8. Check X-raysAP and lateral ankle before discharge
9. Follow-upsuture removal at 2 weeks; walking boot from 4 to 6 weeks

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery