Right ankle surgical consultation

4/28/2021  2:10 PM

NEW PATIENT VISIT

 CHIEF COMPLAINT  Pain of the Right Ankle

 HISTORY OF PRESENT ILLNESS

45-year-old female presents today for evaluation of right ankle injury.  Patient is at ultra endurance athlete, formally ran up to 100 miles at a time.  Has a history of significant trouble running and has had numerous prior ankle sprains.  She was running about a month ago when she plantar flexed her foot and felt something catch.  She had an acute onset of pain.  She did not roll her ankle.  She reports that this seemed to be locked for a few days and since that time when she is plantar flex or dorsiflex her ankle she has felt a catching sensation which is accompanied by pain.  When this happens her ankle does swell up.  Has not noticed any significant changes instability.  Has not trialed any bracing.  Got MRI and was referred here for further evaluation.

PAST MEDICAL HISTORY

She  has a past medical history of Coronary artery dissection (2018 (42-43y)), HLD (hyperlipidemia), Irritable bowel syndrome, Labral tear of left hip joint, Osteopenia, and Vitamin D deficiency.

PAST SURGICAL HISTORY

She  has a past surgical history that includes pr otoplasty protruding ear w/wo size rdctj; Hip surgery; Bone biopsy; and Coronary stent placement (2018).

 

INITIAL REVIEW OF MEDICATIONS

She has a current medication list which includes the following prescription(s): aspirin, atorvastatin, calcium carb/vit d3/minerals, cholecalciferol, magnesium citrate, mirena, multivitamin, nitrofurantoin monohydrate, nitroglycerin, 

SOCIAL HISTORY

She  reports that she has never smoked. She has never used smokeless tobacco. She reports that she does not drink alcohol and does not use drugs.

FAMILY HISTORY

Her family history includes Alzheimer's disease in her maternal grandfather; Diabetes type II in her paternal grandfather; Epilepsy in her father; Neuropathy in her mother; Other in her father; Thyroid disease in her mother and sister.

PHYSICAL EXAMINATION

Ht 167.6 cm (5' 6")  | Wt 64 kg (141 lb)  | BMI 22.76 kg/m² 

The patient is alert and oriented x3 and in no apparent distress. Hearing is intact to the spoken word.  There are no audible wheezes with breathing.    Standing examination demonstrates some swelling of the right ankle compared to the left.  Heals in appropriate valgus.  Can do a toe rise.  Has strong dorsalis pedis and posterior tibialis pulses.  Sensation intact to light touch throughout SP, DP, tib, saphenous sural distributions.  Ankle range of motion is 05/07/40.  Has crepitus with ankle range of motion and can feel something catching on the lateral side of her ankle.  Is markedly tender to palpation at the lateral talar dome.  Has increased translation with anterior drawer as well as talar tilt.  Tender to palpation along the ATFL.  None along the CFL.  Along the PT FL.

REVIEW OF X-RAYS/STUDIES

Reviewed x-rays and MRI today.  X-rays demonstrate an osteochondral fragment in the anterior lateral ankle that is visible in the syndesmosis.  This is confirmed on MRI which shows a small approximately 8 mm osteochondral fracture and the superior lateral talar dome.  There is some slight edema underneath this.  There is incongruity of the ATFL

IMPRESSION/DIAGNOSIS

45-year-old female with history of chronic ankle instability now with osteochondral fracture of the talar dome.  Discussed options for treatment with her today including non operative and operative.  Discussed that given her high level of activity would recommend operative treatment.  Discussed we would recommend modified Brostrom lateral ligament reconstruction as well as osteochondral fragment debridement.  Discussed pluses and minuses of microfracture with her today.  Discussed we would likely just do debridement at this time to get her back to activity.  She expressed understanding.  Will call us to schedule surgery.

TREATMENT/PLAN

1. Plan for right ankle arthroscopy with debridement of osteochondral lesion and Brostrom lateral ligament reconstruction. The patient understood the risks and benefits of surgery, including, but not limited to bleeding, infection, nerve or muscle injury, need for reoperation.  The expected post-operative course was discussed in detail.  We have discussed expectations after surgery to include expected physical therapy, anticipated shoewear and the expected duration of swelling.  All of the patient's questions were answered.  Informed consent for the surgery was obtained in clinic today.  

All of the patient's questions were answered, and the patient was agreeable with the plan.

FOLLOW UP

Time of surgery