POSTOPERATIVE DIAGNOSIS: Right bimalleolar fracture.

OPERATION PERFORMED: Open reduction and internal fixation.

SURGEON: George Washington, M.D.

ANESTHESIA: General endotracheal anesthesia.

INDICATIONS FOR PROCEDURE: The patient is a 59-year-old active female who sustained a displaced bimalleolar fracture a couple of days ago. She has been splinted and she has been elevating the extremity to control her swelling. She is brought to the operating room now to reduce her fractures and to restore her mortis congruity and stability. The risks and benefits as well as the alternatives to surgical treatment were discussed. The risks discussed included, but were not limited to, bleeding, infection, nerve or vessel injury, malunion, nonunion, failure of fixation, need for further operation, painful and retained hardware, as well as continued postoperative stiffness, pain, and inability to return to desired level of function. The risks associated with general anesthetic likewise were discussed and consent obtained to proceed.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operating room where, in a supine position, general endotracheal anesthesia was induced. The right lower extremity was then prepped and draped in the usual sterile fashion. The limb was exsanguinated with gravity and the tourniquet inflated to 300 mmHg. The surgical incisions were marked out with a pen, prior to inflation. Medially, she did have some fracture blisters proximally but they were proximal to the proposed medial incision, as anticipated.

Attention was turned to the lateral malleolus first. An approximately 10-cm longitudinal incision was made with the #15 blade. Dissection was carried down sharply to the level of the fracture site. Fracture hematoma and interposed soft tissue was cleared. A pointed reduction clamp was used to facilitate reduction and it was reduced nicely under direct visualization. Anteriorly, there was some comminution associated with a soft tissue attachment, but the primary fracture line was nicely reduced. An interfragmentary screw was then placed from anterior to posterior after overdrilling the proximal cortex. It was measured, tapped, and then a screw of appropriate length was placed. The fracture site was then stable. The mini C-arm was brought in and this demonstrated that the fibular link had been nicely restored. A six-hole one-third tubular plate was then contoured to fit the lateral aspect of the fibula. It was then affixed to the fibula using cortical and cancellous screws of appropriate length. All achieved good fixation. Titanium implants were used because the patient has a nickel allergy. The fluoroscan was brought in again and it verified again appropriate position of all the implants. A single distal screw was a little bit too long, about 1-mm or so into the ankle joint itself, so this was exchanged.

Attention was then turned medially. An approximately 3-cm longitudinal incision was made, centered over the medial malleolus. A #15 blade was used to create this and dissection was carried down sharply to the fracture site itself. Once again, fracture hematoma was cleared as well as some interposed soft tissue. After restoring the fibular length, the ankle mortis was nicely reduced. The medial malleolar fragment was then reduced directly using a sharp reduction instrument and it was nicely reduced externally. A 2-mm K-wire was introduced from distal to proximal to secure this fragment. A 2.5-mm drill was then used in a parallel fashion posterior to this. The C-arm was brought in and this verified that the medial malleolus was nicely reduced and the mortis was congruent. For that reason, the K-wire and the drill were both replaced using partially-threaded cancellous screws which achieved good interfragmentary fixation. The small C-arm was once again brought in and this verified once again that the fracture fragments were nicely reduced. The mortis was congruent and the implants were in appropriate position. The fixation was stable throughout a full passive range of motion. This was verified in all views. Both wounds were then copiously irrigated. The subcutaneous tissues were closed using interrupted 3-0 Vicryl. The skin was closed using interrupted 3-0 nylon, both medially and laterally. A sterile compressive dressing was applied. A very well-padded posterior splint was then applied with medial and lateral supports so as to keep the foot in a position of neutral dorsiflexion. The tourniquet was released. The foot was well perfused.

The patient was awakened, extubated, and transferred to a recovery room bed. She was transferred to the recovery room in stable condition.

POSTOPERATIVE DIAGNOSES: (1) Massive tear of the right rotator cuff. (2) Acromioclavicular arthritis. (3) Severe impingement syndrome of the right shoulder.

OPERATION PERFORMED: (1) Manipulation under anesthesia. (2) Anterior and inferior acromioplasty. (3) Mumford procedure. (4) Repair of the right rotator cuff.

SURGEON: A. Lincoln, M.D.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 20 cc.

POSTOPERATIVE IMMOBILIZATION: Sling.

DESCRIPTION OF OPERATIVE PROCEDURE: Under satisfactory anesthesia, the patient was put in a semi-sitting position on the table and the right shoulder was prepped and draped in the usual sterile manner.

An anterior incision was made from the acromioclavicular joint distally and it was carried down through the subcutaneous fascia. The deltoid muscle and fascia were exposed. The portion between the anterior and lateral segment of the muscle was opened bluntly and anterior capsule of the joint was exposed. The incision was then extended proximally in a T-shape and the horizontal portion was on the acromion. This gave an access to the acromion laterally and also to the acromioclavicular joint medially. The joint was then cleaned, and protecting the soft tissue, 1-cm of the clavicle was excised. A significant impingement was encountered due to an overhanging anterior acromion. Acromioplasty was done using the oscillating saw and the anterior acromion was excised and this was followed by removal of the inferior acromion, creating a significant amount of room for the subacromial contents. After this was accomplished, the bursa was opened and a very large tear of the right supraspinatus was noted. The edge of the tendon was freshened with a fresh knife and approximately 1-mm of that edge was removed in order to gain fresh tissue. The greater tuberosity was then trimmed and a raw bone was produced by the oscillating saw. Two drill holes were introduced into the greater tuberosity from distal to proximal part, with the hole exiting just next to the ruptured portion of the cuff. Two #5 Ethibond were then passed through those holes and through the ruptured portion of the cuff and was tightly sutured. This completely closed the gap which he had due to the rupture. Several small 0-Ethibond sutures were used to reinforce the cuff on the lateral and medial side. The arm was put on internal rotation and no major tear was encountered in the infraspinatus and the teres minor.

Next, was repair of the deltoid back to the acromion two drill holes. A corner suture was applied on the acromion accommodating the two portions of the deltoid, medially and laterally. This was followed by closing the acromioclavicular joint and the rest of the tissue of the incision laterally, using 0-Ethibond suture. The rest of the deltoid fascia was closed using 2-0 Vicryl. The subcutaneous tissue was then closed using 2-0 Vicryl. The skin was closed using 4-0 Monocryl in a subcuticular fashion. Then a sterile dressing and a sling were applied. The patient returned to the postanesthesia care unit in satisfactory condition.

POSTOPERATIVE DIAGNOSIS: Impingement syndrome, left shoulder, with acromioclavicular spurs.

OPERATION: Arthroscopic evaluation of the glenohumeral joint, followed by arthroscopic bursectomy and anterior acromioplasty with co-planing of the acromioclavicular joint spurs.

ANESTHESIA: General.

SURGEON: Andrew Jackson, M.D.

ASSISTANT: A. Lincoln, S.A.

SUMMARY: The patient was given a general anesthetic and placed in the beach-chair position with the head rest. He was secured and strapped down. His shoulder was prepped and draped free in a standard sterile fashion.

A posterior approach was made to the glenohumeral joint and the probe and shaver were introduced through an anterior portal which was just medial to the coracoid. The shoulder was inspected and no undersurface tears were identified. There was some redundant synovitis in the joint superiorly along the labral attachment and that was debrided back. The long head was intact. We then withdrew and went into the subacromial space. A portal was established at the anterolateral corner and a shaver was introduced laterally. The shaver was introduced laterally and used to debride the bursa. The debridement was swept anteriorly and the subacromial space was opened up. The Bovie electrocautery instrument was introduced from the lateral portal and we started in the center of the acromion and worked our way anteriorly and medially to the acromioclavicular joint. The acromioclavicular joint was exposed because we knew that he had spurs there that needed debriding. The anterior edge of the anterior acromial space was identified and opened up. The coracoacromial ligament was divided. Hemostasis was achieved with the ArthroCare wand. Once the anterior acromial spur and the acromioclavicular joint spurs were well identified, the portals were switched and we placed the bur from the posterior portal and the scope anteriorly. The flat spot of the acromion was identified and an anterior acromioplasty was done, removing about 5-6 mm anteriorly. The ridge of spurs on the acromioclavicular joint were also debrided with the bur. We did the majority of the bony burring from the posterior portal and then switched the bur laterally to round off the anterior edge of the acromion and smooth out the acromioclavicular joint. The exterior of the rotator cuff was inspected and no defects or tears were encountered.

The wound was flushed out and the portals were closed with a single stitch. A sterile dressing was applied and the patient was recovered from his anesthetic and taken to the recovery room in good condition.

POSTOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.

OPERATION PERFORMED: Neurolysis of the median nerve, right carpal canal.

SURGEON: Michael Jones, M.D.

ANESTHESIA GIVEN: Local sedation.

DESCRIPTION OF OPERATIVE PROCEDURE: After adequate anesthesia was obtained, the patient's right arm was prepped and draped in the usual sterile fashion. After exsanguination with an Esmarch bandage, the tourniquet was inflated to 250 mmHg. At this point, an intrathenar incision was made from the level of the distal palmar crease and in line with the flexion crease. It was carried down to the subcutaneous tissue. The transverse carpal ligament was identified and incised. A hemostat was placed on the ulnar side of the carpal canal. The transverse carpal ligament was lysed from proximal to distal. The forearm fascia was split proximally. The median nerve was neurolysed in its entirety. The floor of the carpal canal was inspected and noted to be free of osteophytes and tumors. The wound was irrigated out and was infiltrated with Marcaine. The skin was then closed with 5-0 nylon sutures. A sterile dressing with a volar splint was applied. The patient was taken from the operating room to the recovery room in good condition.

FINAL DIAGNOSIS: Right carpal tunnel syndrome.

POSTOPERATIVE DIAGNOSIS: Right hip comminuted intertrochanteric hip fracture.

OPERATION PERFORMED: Open reduction and internal fixation of right intertrochanteric hip fracture, with a four-hole, 135-degree DHS plate an 80-mm hip screw.

ESTIMATED BLOOD LOSS: Approximately 100 cc.

DRAINS: None.

ANESTHESIA GIVEN: Spinal.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is an 88-year-old female, who sustained a right intertrochanteric hip fracture after a fall. She was admitted for a preoperative medical clearance and to be taken to the operating room for an open reduction and internal fixation of the right hip fracture. Consent is signed on the chart. All risks and benefits regarding the procedure were explained: Risks of death, infection, nerve or blood vessel injury or bleeding, need for blood transfusion, blood clots, failure to heal, need for further surgery were all explained and consent was signed.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was given Ancef 1 gram intravenously in the holding area. She with then taken to the operating room where a spinal anesthetic was placed by the anesthesia service on the hospital bed. She was then transferred over to the fracture table in the supine position where a well-padded post was positioned. The left lower extremity with a thigh-high TED stocking was placed into the thigh/leg support with foam padding over all bony prominences. The left lower extremity had abundant padding placed around the foot and ankle region and was then placed in the foot and ankle support. Next, the right hip was visualized under AP and lateral fluoroscopic views. The femoral head and neck were well-visualized in both planes at this time. Next, the right hip was prepped and draped in the usual sterile fashion utilizing Betadine prep followed by toweling out and holding the towels with staples, followed by drying, followed by placement of a shower curtain. Next, a guidepin was placed over the hip and an AP fluoroscopic view taken.

Next, the proposed skin incision of approximately 12-cm in length was marked on the skin. The skin incision was then made with a #10 blade, going down through the skin and subcutaneous tissue. Hemostasis was achieved with electrocautery. The IT-band was split longitudinally with electrocautery. Next, the vastus lateralis was elevated and the posterior one-third was split longitudinally with electrocautery, also with use of a Key elevator, followed by placement of a Bennett leg loose retractor. The vastus lateralis was further developed with electrocautery at this time to expose the lateral femoral shaft. Next, the 135-degree guide with the pin was placed on the lateral femoral shaft and the guidepin was advanced through the lateral cortex into the femoral neck and checked under the lateral view, found to be in good position, and advanced into the head region, again checked under AP view, and then advanced into subchondral bone, again checked on the lateral view, and found to be in good position. This was then measured. It measured 90-mm. We therefore decided to triple ream to 80-mm and place an 80-mm hip screw. Triple reaming was performed under AP fluoroscopic guidance. Next, the 80-mm hip screw was placed, again under fluoroscopic guidance, and once felt to be in the correct position, it was checked again under the lateral view and found to be within the femoral head nicely. Back to the AP view, it was again visualized. The fracture was well reduced. The screw was in good position. The four-hole, 135-degree plate was advanced over the connector onto the screw and gently seated against the lateral femoral cortex. The connectors and guidepin were then removed. The plate was gently impacted with a plastic impactor and mallet. Once fully seated, it was manually held in this position. The most distal hole in the plate was filled by drilling through both cortices, followed by depth gauge tapping, and placement of a propylene fully-threaded 4.5 cortical screw. The remainder of the holes in the plate were filled in a similar manner by drilling through both cortices, followed by depth gauge, and placement of the appropriate length 4.5, fully-threaded self-tapping screws. All screws were again securely tightened. The locking nut/screw was placed into the hip screw portion and was fully tightened. The entire contents were again checked under AP and lateral fluoroscopic views with hard copies printed off the C-arm. Everything looked nicely reduced and all hardware was in good position.

The site was again copiously irrigated with normal saline solution. The IT-band was closed with 0-Vicryl figure-of-eight interrupted sutures. The subcutaneous tissue was again irrigated with normal saline solution and the subcutaneous tissue was closed with 2-0 Vicryl interrupted sutures and the skin was closed with staples, followed by placement of Adaptic, 4x4s, ABD dressing, and elastic tape. The patient was then gently transferred back to the hospital bed and transferred to recovery without difficulty.

POSTOPERATIVE DIAGNOSIS: Painful right total knee replacement.

OPERATION PERFORMED: (1) Revision right total knee patellar component. (2) Polyethylene exchange, right total knee. (3) Open arthrolysis, right knee.

ANESTHESIA GIVEN: Epidural.

INDICATIONS FOR PROCEDURE: See the History and Physical report.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operating room. He was placed supine on the operating room table. After a suitable anesthetic had been obtained by an epidural anesthesia, the right lower extremity was prepped and draped in the usual sterile fashion. The right lower extremity was then exsanguinated with the use of an Esmarch bandage and the tourniquet was inflated to 350 mmHg.

The operation commenced with a midline right knee incision that incorporated his previous right total knee replacement incision. This incision was deepened through skin and subcutaneous tissues and the extensor mechanism was exposed. A standard medial parapatellar incision was then made and a laterally-based quadriceps snip was performed to allow for safer mobility of the patella. Subperiosteal dissection was performed along the medial tibial plateau and remaining osteophytes were removed. The patellar tendon was seen to be fibrotic and thickened and the undersurface of the patellar tendon was debrided. With the patella everted, rongeurs and Bovie electrocautery were used to expose the patellar component. The polyethylene was removed, leaving the undersurface metal backing. This was seen to be extremely well affixed and it was felt that to downsize the patella to eliminate patellar overstuffing, that the patella would need to be revised. Flexible and rigid, straight and curved, osteotomes were utilized to separate the metal backing from the underlying bone. This resulted in a significant amount of fragmentation of the periphery of the patella.

The patellar component was ultimately removed, and again, was seen to be well affixed, including bone ingrowth on the three fixation pegs. Attention was now turned towards the tibial side. The tibial bone interface was exposed medially and laterally and there was seen to be no gross motion of the patella. This was performed after removing the rotating patellar platform. The osteotomes were used along the anterior edge and cephalad directed burs with mallet in several different positions were attempted, again without any evidence of tibial side loosening. At this point, it was felt that with the expected bone ingrowth along the tibial stem, that to remove the tibial component would create a significant undue stress on normal bone, and it was felt that the majority of the patient's complaints could be addressed by addressing patellar overstuffing and arthrofibrosis. Arthrolysis was completed in both medial and lateral gutters in the suprapatellar pouch region and in the parapatellar region.

A standard plus/large size 10-mm thick rotating platform trial was then implanted and the knee was taken through a range of motion. There was seen to be approximately 5-10 degrees of recurvatum and flexion easily to 120 degrees. There was good medial, lateral, and AP stability noted. It was felt that this would be the appropriate polyethylene sized insert to implant. The implant was removed and the knee was then copiously irrigated with pulsatile lavage containing antibiotic solution. Deep cultures were obtained for aerobic and anaerobic cultures. A DePuy LCS standard plus/large sized deep dish rotating platform insert was then placed. The knee was then brought back into extension and once again, range of motion and stability were checked.

Attention was now turned towards the patellar side. Using a three-peg polyethylene guide, three drill holes were made in the base of the patella and an LCS three-peg polyethylene patellar insert of standard plus size was cemented into position. Excessive cement was retrieved and loose bone from the patella as well as bone removed from the prominent tibial tubercle ossicle (history of Osgood-Schlatter disease), was morcellized and placed around the periphery of the polyethylene insert. These morcellized bone segments were then gently secured with 2-0 Vicryl by closure of soft tissues around the implant. Patellar tracking was checked and was felt to be excellent and preparations were made for closure.

Consta Vac drains were brought out superiorly and the medial parapatellar incision and lateral leg of the quadriceps snip were repaired with interrupted #2 Ethibond and interrupted 0-Ethibond suture. Once again, the wound was irrigated. The subcutaneous tissue was closed with 2-0 Vicryl. The skin was closed with staples. A light compressive dressing was applied followed by Ace bandage wrap. The tourniquet was deflated. A right lower extremity knee immobilizer was placed. The patient was recovered from the anesthetic and returned to the recovery room in stable condition. There were no complications.

POSTOPERATIVE DIAGNOSIS: Right knee pain and medial meniscus tear.

PROCEDURES PERFORMED: (1) Right knee examination under anesthesia with diagnostic arthroscopy. (2) Partial medial meniscectomy, right knee.

DESCRIPTION OF OPERATIVE PROCEDURE: After placement of general anesthesia, the patient's right knee was prepped and draped in the routine fashion for knee arthroscopy. Examination revealed no instability and full range of motion. The knee was arthroscoped through the standard medial and lateral portals. The entire knee joint was evaluated. The suprapatellar region showed fairly normal appearing patella with minimal chondromalacia. There was a medial shelf plica present which was small and appeared to be within normal limits. The medial compartment, however, showed a complex horizontal cleavage tear of the medial meniscus, involving the posterior 40-50% of the undersurface of the meniscus. Fragmented tissue was present in the joint. Photographic record was made.

The anterior cruciate ligament was intact and the lateral compartment showed an intact lateral meniscus. With the motorized debrider and basket forceps, the meniscus was trimmed to a smooth, stable rim. Only the torn tissue was resected.

The knee was then copiously irrigated. All fragmented tissue was removed. The arthroscope was removed. The skin portals were closed with a single 4-0 nylon stitch. The knee was injected with 20 cc of Marcaine and 1 cc of Kenalog 40. The patient was awakened and taken to the recovery room in stable condition. There were no complications. All sponge and instrument counts were correct.

The operation commenced with creation of the inferolateral portal. The arthroscope was directed into the suprapatellar pouch with the knee held in extension. A systematic examination of the right knee was begun arthroscopically. The patellofemoral articulation was visualized and the findings were as noted above. The majority of the patellar articulating surface was felt to be in good shape. The medial gutter was entered. No loose bodies were identified. The medial compartment was then entered and the inferomedial portal was established under direct visualization. The arthroscopic probe was used to inspect the contents of the medial compartment with the findings as noted above.

At this point, using a series of straight upbiting and curved meniscal punches, the posterior horn of the medial meniscus was resected to a stable base. This was further improved with the use of a 4.5 sucker shaver. The notch was then visualized. The anterior cruciate ligament was inspected with the findings as noted above. Intraoperative Lachman's testing was negative. The arthroscope was directed into the lateral compartment with the findings as noted above.

The instruments were then removed. The portals were closed with 4-0 nylon and Xeroform and a light compressive dressing was applied. A mixture of Marcaine and Astramorph was injected into the right knee and Ace bandage wrap was applied. The tourniquet was deflated and a Dura-Kold compression ice wrap was applied. The patient was recovered from his anesthetic and was returned to the recovery room in stable condition. There were no complications.

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