OT notes · Orthopaedics

Posteromedial soft-tissue release for CTEV

Usual anaesthesia
General anaesthesia
Position
Prone, with a thigh tourniquet
Setting
elective

Operative note template for posteromedial (with or without posterolateral) soft-tissue release for rigid or resistant congenital talipes equinovarus, with a filled example for a selective modified McKay release through a Cincinnati incision in an infant with a foot that did not correct with Ponseti casting.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

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 edge necrosis or skin slough, especially when the foot is placed in the corrected position
  • injury to the medial plantar nerves and vessels
  • under-correction or recurrence of deformity
  • over-correction into heel valgus (higher if the interosseous talocalcaneal ligament is cut)
  • stiff foot and ankle in later life
  • damage to the blood supply of the talus (avascular necrosis)
  • ankle instability from over-release of the deltoid ligament
  • pin-site problems; further anaesthesia for cast change and pin removal
  • long period in casts and a brace afterwards

Pre-operative details for this operation

  1. Side, age and weight
  2. Previous treatmentnumber of Ponseti casts, tenotomy (date), brace use and compliance, any previous surgery
  3. Type of clubfootIdiopathic, rigid / resistantRecurrent after PonsetiTeratologic / syndromicNeuromuscular (e.g. myelomeningocele)Older child at presentation
  4. Deformity componentsequinus, heel varus, forefoot adduction, cavus, calcaneal internal rotation; which are rigid
  5. Skinmedial crease, scars from previous surgery
  6. X-raysstanding / stress AP and lateral if taken
  7. Planposterior only / posteromedial / posteromedial + posterolateral; K-wires; cast plan

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionProneSupine
  3. Tourniquetthigh, pressure (mmHg), time up and down

Operative findings

  1. Tight structures foundAchilles tendon, posterior capsule, calcaneofibular ligament, posterior tibial tendon, FHL / FDL, spring ligament, talonavicular capsule, abductor hallucis, plantar fascia
  2. Talonavicular jointnavicular displaced medially onto talar neck? reducible?
  3. Talusshape of head and neck; cartilage seen on the body when talus rolls back
  4. Neurovascular bundleposition, any variation

Procedure (steps)

  1. IncisionTransverse circumferential (Cincinnati)Posteromedial curvedTwo incisionssural nerve and lateral veins protected
  2. Achilles tendonZ-lengthened, length gained (at least 2.5 cm), plane of cut; lateral calcaneal attachment kept if sagittal Z
  3. Posterior releaseposterior ankle and subtalar capsule, posterior talofibular ligament (if needed)
  4. Posterolateral releaseNot donePeroneal sheath opened, calcaneofibular ligament cut close to calcaneus, lateral talocalcaneal capsule released
  5. Neurovascular bundledissected into the arch and protected with vessel loop / Penrose
  6. Medial releaseabductor hallucis origin; posterior tibial tendon Z-lengthened (at least 2.5 cm above medial malleolus) or detached; FDL and FHL sheaths; talonavicular capsule, spring ligament, superficial deltoid; bifurcate (Y) ligament if needed; plantar fascia
  7. Interosseous talocalcaneal ligamentPreservedDivided (reason)
  8. Reduction checkedtalus rolled back with at least 1.5 cm of body cartilage visible; foot long axis 85 to 90 degrees to bimalleolar axis; heel in slight valgus
  9. K-wire fixationtalonavicular wire (size, entry, exit); calcaneotalar wire only if interosseous ligament cut, not into ankle joint; cut or bent, under / outside skin
  10. Toe flexorsNot tightFHL tenodesed to FDL at knot of Henry and dividedFHL fractional / Z-lengthenedFHL and FDL Z-lengthened together
  11. Tendon repairsposterior tibial and Achilles repaired snugly with foot in slight dorsiflexion; suture used
  12. Peroneal sheaths and posterior tibial sheath repairedperoneal sheaths to fibrofatty flap to prevent subluxation
  13. Tourniquet released, skin perfusion checked in the planned cast position

Closure, drains and dressing

  1. Subcutaneous tissuesuture and size
  2. SkinInterruptedSubcuticular absorbableV-Y flap for tension
  3. CastLong leg cast, foot in plantarflexion, knee 90 degrees (change at 2 weeks)Short leg castpadded, applied loosely

Specimens and implants

  1. K-wiresnumber, diameter, make, batch number; left outside skin or buried

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. Toe circulationcolour and capillary refill of toes, checked regularly and most often in the first 24 hours; inform the surgeon at once if toes are pale or dusky
  2. Limb elevation
  3. Analgesia and feedspaediatric doses as per anaesthesia chart; feeds when awake
  4. Cast carekeep dry; watch for soakage or smell
  5. Cast change at 2 weeksunder sedation / GA; wound check; foot brought to corrected position
  6. Pin and cast removal at 6 weeksin OT
  7. Braceankle-foot orthosis to maintain correction; compliance explained to parents
  8. Follow-upwatch for recurrence and over-correction with growth

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

Worked example

Fictional case: Baby R.T., male, 11 months, 9 kg, right idiopathic clubfoot. Treated with 9 Ponseti casts and a percutaneous tenotomy at 3 months, then bracing. Rigid recurrence: fixed equinus 20 degrees, heel varus and midfoot adduction not correcting with a further 4 casts.

Case details

Date: 08/10/2026. Elective. Paediatric OT.

In OT 08:45. GA induced 08:55. Tourniquet up 09:20. Tourniquet down 10:35. Cast completed 11:00.

Surgeon: Dr C. (Consultant, Paediatric Orthopaedics). Assistant: Dr A. (2nd-year resident), did the Achilles Z-lengthening and closure. Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: rigid recurrent right idiopathic CTEV after Ponseti treatment, not correctable by repeat casting.

Skin over medial side healthy, old tenotomy scar healed. Hb 11.2 g/dl.

Consent: taken from both parents in Hindi. Explained skin necrosis, nerve and vessel injury, under- or over-correction, stiffness, talar avascular necrosis, cast change at 2 weeks and pin removal at 6 weeks under anaesthesia, long-term brace.

WHO checklist sign in and time out done. Right foot marked. Inj cefazolin 270 mg IV (30 mg/kg) at 09:05 (K-wires to be used).

Anaesthesia and position

General anaesthesia. Prone. Right thigh tourniquet at 220 mmHg after Esmarch exsanguination. Parts painted with povidone-iodine and draped.

Findings

Tight, short Achilles tendon. Thick posterior ankle and subtalar capsule. Tight posterior tibial tendon. Navicular displaced medially onto the talar neck with a thick spring ligament.

Calcaneofibular ligament short and thick. FHL tight after correction. Neurovascular bundle in normal position.

Procedure

Transverse circumferential (Cincinnati) incision from the naviculocuneiform joint, below the medial malleolus, across the Achilles tendon at ankle level, to just below the lateral malleolus. Sural nerve protected.

Achilles tendon Z-lengthened in the coronal plane, 2.5 cm gained, ends tagged.

Peroneal sheaths opened; calcaneofibular ligament cut close to the calcaneus. Posterior ankle and subtalar capsule incised from lateral to medial, protecting the FHL and neurovascular bundle.

Medial and lateral plantar neurovascular bundle dissected into the arch and held in a vessel loop. Abductor hallucis origin released.

Posterior tibial tendon Z-lengthened starting 2.5 cm above the medial malleolus. Talonavicular capsule opened medially, inferiorly and dorsally, spring ligament and superficial deltoid cut close to the navicular. Dorsal talar blood supply not disturbed.

Interosseous talocalcaneal ligament preserved.

Talus rolled back into the ankle with about 1.5 cm of body cartilage visible. Navicular reduced on the talar head. Foot axis at 90 degrees to the bimalleolar axis, heel in slight valgus.

One 1.6 mm (0.062 inch) K-wire passed from the back of the talus through the head, across the talonavicular joint and cuneiforms, out on the dorsum lateral to the first metatarsal, while the forefoot was held out of adduction. Wire bent and left outside the skin.

FHL tight: tenodesed to FDL at the knot of Henry and divided distal to it.

Posterior tibial and Achilles tendons repaired snugly with the foot in slight dorsiflexion. Posterior tibial tendon replaced in its sheath; peroneal sheaths sutured to the fibrofatty flap.

Tourniquet released at 10:35 (75 min). Wound edges pink with foot in plantarflexion. Haemostasis secured.

Closure

Subcutaneous tissue with polyglactin 910 (Vicryl) 2-0. Skin with subcuticular poliglecaprone (Monocryl) 4-0.

Non-adherent dressing. Loose, well-padded long leg cast with the foot in plantarflexion and knee at 90 degrees.

Specimens and implants

K-wire 1.6 mm x 1, make and lot number recorded, sticker pasted. No specimen.

End of procedure

Blood loss about 40 ml. No transfusion. Mop, needle and instrument count correct.

No intra-operative complications.

Shifted to paediatric ward, stable. Toes pink, capillary refill under 2 seconds.

Post-op orders

Check toe colour and capillary refill regularly, more often in the first 24 hours. Call the resident at once if toes are pale or blue.

Right leg elevated on a pillow.

Analgesia and feeds as per paediatric anaesthesia chart.

Cast change under GA at 2 weeks: wound check and foot placed in corrected position.

Cast and K-wire removal in OT at 6 weeks, then ankle-foot orthosis.

Signature

Dr A., JR-2, Orthopaedics, for Dr C. Reg. no. ________. 08/10/2026, 11:15.

Must document for this operation

  • Previous treatment (Ponseti casts, tenotomy, brace compliance) and why surgery is now needed. Surgery gives poorer long-term results than Ponseti, so the note must show conservative treatment was exhausted.
  • Every structure released or lengthened, and the length gained. If the foot relapses, the next surgeon plans around what was already cut.
  • Whether the interosseous talocalcaneal ligament was kept or cut. Cutting it greatly raises the risk of over-correction into valgus.
  • Final foot position and how it was checked. It records the correction achieved on the table against which recurrence is judged.
  • K-wire size, path and whether left outside the skin. The team removing it at 6 weeks needs to know where it is and how many there are.
  • Cast position and the planned cast change. Casting in full correction on day one can cause skin necrosis, so the staged plan must be clear.
  • Tourniquet pressure and time. Tourniquet time is often missing in orthopaedic notes and matters in a small child.

Common mistakes in these notes

  • Writing 'PMR done' without listing the structures released.
  • Not stating whether the talonavicular joint was opened and pinned.
  • Not recording the interosseous ligament decision.
  • Leaving out the number and size of K-wires.
  • Not writing the skin perfusion check before casting.

Indian practice and paperwork

  • For a child, consent is taken from the parents or guardian. It must explain the procedure, risks, benefits, alternatives and who will operate, in a language they understand. (NABH 5th ed. (2020), PRE.4(c))
  • Record the batch number of the K-wires in the case sheet; NABH also asks for implant details in the implant logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed. (2020), COP.14(e) and (f))

Sources

  • Azar FM, Sawyer JR, et al., eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 31, Congenital anomalies of the lower extremity: congenital clubfoot; Ponseti method (Technique 31.10); Cincinnati incision (Technique 31.12); extensile posteromedial and posterolateral release, modified McKay (Technique 31.13); recalcitrant clubfoot, pp. 1051-1059.
  • Saghieh S, Weinstein SL, Hoballah JJ, eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 12, Posteromedial release for clubfoot (Khoury JG), pp. 39-41.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin paediatric dose 30 mg/kg within 60 min before incision; cefazolin recommended when internal fixation devices are implanted. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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