MY MT Helper.com
Orthopedics Samples

LEFT KNEE ARTHROSCOPY

PREOPERATIVE DIAGNOSIS:  Internal derangement of left knee.

POSTOPERATIVE DIAGNOSIS:  Internal derangement of left knee with medial meniscus tear.

PROCEDURE:  Left knee arthroscopy with partial medial meniscectomy. 

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE:  The patient presented to the Orthopedic Clinic with the chief complaint of left knee pain.  The patient had previously undergone a left knee arthroscopy in the past at which time he was found to have moderate osteoarthritis of the knee.  The patient complained of left knee pain and occasional swelling and some mechanical-type symptoms.  After failure of conservative treatment, the patient was offered arthroscopy of the knee with possible meniscectomy if necessary.  According to the patient with the knowledge of him having significant arthritis of the knee, the chances of complete pain relief with an arthroscopy and meniscectomy were unlikely.  The patient understood all risks and benefits of the procedure and wished to proceed. 

DETAILS OF PROCEDURE:  After obtaining appropriate consents and marking the correct leg in the Holding Area, the patient was taken to the Operating Room and placed supine on the Operating Room table.  After the induction of general anesthesia by the Anesthesia Service without complication, a nonsterile tourniquet was placed on the left leg and all bony prominences were well padded. 

The left leg was then placed in the arthroscopic leg holder and the left leg was then prepped and draped in standard sterile orthopedic fashion. 

A 1-cm stab incision was then made on the lateral side of the knee as the superior pole of the patella for the superolateral portal to be used for the water inflow.  Another 1-cm stab incision was then made just lateral to the patellar tendon at the joint line as an anterolateral portal.  The arthroscopic blunt trocar was then used to introduce into the knee joint and placed in the suprapatellar pouch.  The arthroscope was then attached and the suprapatellar pouch examined. 

The patient was found to have a mild amount of chondromalacia in the patellofemoral joint.  The arthroscope was then passed into the lateral gutter where there was no loose bodies seen.  The arthroscope was then passed into the lateral compartment of the knee which was found to have a mild-to-moderate degree of chondromalacia.  The lateral meniscus was then visualized and found to be intact with no evidence of any tears.  The arthroscope was then passed back to the lateral gutter up into the patellofemoral joint space and then passed into the medial gutter.  Again, there was no evidence of any loose bodies in the medial gutter.  The arthroscope was then passed into the medial compartment of the knee. 

Under direct visualization with the arthroscope, a spinal needle was then passed into this medial joint space just medial to the patellar tendon.  When it was found that the needle would pass all the way back into the posterior portion of the medial compartment, a 1-cm stab incision was then made for the anteromedial portal.  A meniscus probe was then inserted into the medial joint space for examination of the medial meniscus.  It was found that the patient had a small degenerative tear in the posteromedial portion of the meniscus as well as all the way to the most posterior portion of the meniscus there was another small horizontal tear.

The arthroscopic shaver was then placed through the working anteromedial portal and used to debride the smaller more medial tear to a smooth transitional rim.  Attention was then turned to the larger tear in the most posterior portion of the meniscus. 

Through a combination of a small straight biters and the small upcurved biters as well as the arthroscopic shaver, the torn portion of the meniscus was excised and then debrided to a stable transition.  It was also noted that the patient had moderate-to-severe chondromalacia of the medial femoral condyle.  The intercondylar notch was then examined and the anterior cruciate ligament was found to be intact.  The medial meniscus was then examined again using the meniscus probe to ensure that there were no further tears and that the debridement and partial meniscectomy was adequate.  When this was verified, the instruments were removed from the anteromedial portal and the arthroscope was removed from the anterolateral portal.  The inflow as then disconnected from the inflow cannula and 0.25% Marcaine was then injected through the inflow cannula for local anesthetic.  The inflow cannula was then removed and a sterile dressing applied. 

The drapes were then removed and all counts were reported as correct.  The patient was then awakened from the general anesthesia without complications.  The patient was then taken to the Recovery Room in stable condition.

DECOMPRESSIVE LAMINECTOMY

PREOPERATIVE DIAGNOSIS: 

POSTOPERATIVE DIAGNOSIS: 

OPERATION: The patient had an L1 to L5 decompressive laminectomy; L2-3, L3-4, L4-5 reexploration decompression; L2, L3, L4, and L5 pedicle screw placement with a posterolateral fusion; L2-3, L3-4, L4-5 interbody fusion; and repair of CSF fistula. 

ESTIMATED BLOOD LOSS: Final blood loss of 1600. 

INTRAVENOUS FLUIDS: He received 7800 of crystalloid.  No blood, his starting hematocrit was 49 and a hematocrit check midway was 37. 

INDICATIONS: The patient presents after having 2 laminectomies in the past.  He has had increasing difficulties with right leg pain.  He had an MRI which revealed severe multilevel spondylolisthesis and stenosis.  Because of his recurrent and significant pain, he presents for reexploration as he had significant scoliosis and anterolisthesis.  He presents for fusion. 

PROCEDURE: He was taken to the OR and placed in a prone position, prepped and draped.  

Incision was made from L2 down to the sacrum.  Subperiosteal dissection was carried out along L3, L4, and L5, L2.  Please note that there was a lot of scar present.  We very carefully accessed these levels and then I obtained access to the transverse processes of L2, L3, and L4.  An upbiting curette was used to separate scar tissue from the thecal sac at the L4-5 level.  There was a lot of scar tissue present.  I was able to obtain access into the epidural space and performed a laminoforaminotomy first at L4-5, by finding the L5 nerve root.  Following that out laterally, and with a curette, separating the scar working my way up towards L4.  I then went up to T12, L1-2; I used an upbiting curette at the L2 level.  I was able to obtain access underneath the lamina.  Please note that there was scar present and I did obtain access intradural here.  I put Gelfoam and I went down to L3-4 on the left side.  I separated scar from the L4 nerve root and the L3 nerve root.  I did a mesiofacetectomy of the L3 lamina and L4 lamina.  I used the upbiting curette to obtain access to the L2 nerve root and L3 nerve root and then up towards the L2 pedicle at the L1-2 level.  The CSF fistula was closed with 4 interrupted sutures of silk sutures.  Please note that later on we placed fibrin glue and Gelfoam over this.  I obtained access to L2 nerve root on the right side.  There was scar present.  I used the upbiting curette.  I soon found the pedicle of L2.  I interrupted the scar in the inferior articular process of L3.  I obtained access to the superior articular process of L4 and then I was able to find the exit zone of the L3 nerve root and the L3 pedicle.  I was able to use the L-8NS drill, the upbiting curette to obtain access to the L4 nerve root region.  The L4 pedicle.  I used an upbiting curette as well and I obtained access all the way to the L5 pedicle.  An upbiting curette was used to obtained access to that pedicle.  Please note that once I obtained pedicular access at L5, L4, L3, and L2, I utilized the awl, the tap, and placed 50-mm screws in L5, L4, L3, and L2 on the right and L5, L4, L3, and L2 on the left.  Excellent pedicular access was obtained.  I then was able to put a rod.  I compressed down at L1-2, L2-3, L3-4 and final tightened those screws.  I distracted at L4-5 and after completion of my distraction, I was able to obtain access to the disk space.  A complete diskectomy was carried out at the L4-5 level using multiple pituitaries, using multiple curettes, downbiting curettes, side burs as well.  Access was obtained towards the midline and out laterally.  Once I obtained access to the interbody region, I was able to curettage the endplate. 

As the next step, please note that I was able to obtain access with the rasp.  Now I used the shavers, the 8, the 9, and a 10 shaver and I seen that an 11 mm would be the size.  I then used the trials, the 8, the 9, the 10, and the 11 size trial, Leopard.  Please note that once that was completed, I was able to rasp the endplates.  I got all the disk material out.  I placed a lot of bone pieces in the interbody location after I obtained bone marrow aspirate.  I used laminectomy fragments.  I used allograft as well.  I was able to cut them into very small pieces.  I mixed this with the bone marrow aspirate and I was able to place this combination in the interbody location.  All soft tissue had been removed from the laminectomy fragments. 

I then placed the #11 carbon fiber cage.  I compressed on the cage and final tightened my screws.  We then proceeded to decorticate the L2 region, L2, L3, L4, and L5 laterally including the pars, transverse process in the joints.  I got within the joints of L2-3 and L3-4.  I put crushed up bone into the interbody location at L2-3, L3-4, and L4-5.  We then were able to place fibrin glue over the dural leak with Gelfoam and a Surgicel piece overlying this region.  We then placed a #7 JP and closed the fascia very tightly from cranial to caudal.  Once the fascia was closed, 3-0 Vicryl was utilized for the subcutaneous tissue and staples were utilized for the skin.  With the final blood loss of 1600.  He received 7800 of crystalloid.  No blood, his starting hematocrit was 49 and a hematocrit check midway was 37. 

 

RIGHT MIDDLE FINGER VOLAR PLATE REPAIR

PREOPERATIVE DIAGNOSIS: Right middle finger volar plate transection, right middle finger flexor digitorum profundus laceration in zone 1, and right middle finger radial digital nerve laceration.

POSTOPERATIVE DIAGNOSIS: Right middle finger volar plate transection, right middle finger flexor digitorum profundus laceration in zone 1, and right middle finger radial digital nerve laceration.

OPERATION:
1. Right middle finger volar plate repair.
2. Right middle finger flexor digitorum profundus repair.
3. Right radial digital nerve neurorrhaphy with NeuraGen tube.

INDICATIONS: The patient was unfortunately injured approximately 2 weeks ago when he had a near amputation of his right middle finger using a saw. At that time, the viability of the finger was present, based merely on the radial digital artery as the ulnar digital artery and nerve had been lacerated. At that time, repair of an open fracture, dislocation of the DIP was performed as well as the extensor mechanism of the finger, and the wounds were closed. It was decided at that time not to repair the FDP, the volar plate, or the digital nerve as additional incisions would have had to been made, which may have significantly impacted on the viability of the nearly amputated part. Therefore, the patient was brought back to the office. The wounds were checked. The patient continued on antibiotics and a planned repair of the FDP, volar plate, and ulnar digital nerve was scheduled for August 1, 2004. The risks and benefits were explained to the patient. The risks including but not limited to bleeding, infection, poor motion, need for re-operation were discussed. All questions were answered and the patient agreed to proceed.

PROCEDURE: The patient was identified and brought to the operating room and placed supine on the operating room table. After the institution of an axillary block and MAC anesthesia, a digital block was also performed by injecting 1% lidocaine mixed in a 1:1 ratio with 0.25% bupivacaine as a digital block for the right middle finger.

Attention was immediately directed to the laceration of the finger. The laceration of the finger extended from the volar-ulnar aspect of the DIP joint through the radial aspect of the DIP joint to the dorsal ulnar aspect of the DIP joint. There appeared to be excellent healing, however, examination revealed FDP laceration as well as radial digital nerve laceration and a volar plate laceration, along with the previously described injuries.

Attention was first directed to the volar plate. This could be seen to be totally lacerated; however, the 2 ends of the volar plate were present. Therefore, these were debrided and using 4-0 Prolene sutures in a horizontal mattress fashion, this was reapproximated. Attention was then directed to the FDP tendon. Originally, the plan was to use surgical steel and a pullout button for the FDP repair in zone 1; however, the distal stump was large enough to take suture, therefore, 3-0 braided nylon sutures were used to repair the FDP in zone 1, using a modified Kessler locking stitch. This allowed for a 2-strand repair which was sutured down and showed excellence excursion with passive motion. To further augment a repair, a horizontal mattress suture of 3-0 braided nylon suture was also placed and a 5-0 Vicryl suture was used to tidy the epitendinous portions of the repair. In order to access the operative sites, a 1.5 Brunner incision was made from the ulnar aspect of the laceration to the volar aspect of the middle phalanx. Hemostasis was achieved using the bipolar cautery. The lacerated digital nerves could be seen at the radial aspect of the wound. There were 3 strands to this digital nerve, indicating that the trifurcation of the digital nerve was occurring at this location. The ends were debrided sharply and the 3 branches were found distally as well. These were also debrided sharply and in order to repair the 3 branches of the digital nerve at this location, it was felt that a digital nerve tube would be used. A 2-mm NeuraGen tube was soaked in saline for 10 minutes and then implanted using an 8-0 nylon suture by placing the 3 ends of the proximal ends into the tube and suturing this into place in the usual fashion with a horizontal mattress suture, and then the 3 distal ends were placed into the tube as well and this was sutured into place as well with the 8-0 nylon suture in a horizontal mattress fashion. The tube was then filled with normal saline. The tourniquet was then released. There was no bleeding within the tube or at the surgical sites. The finger did pink up well with good capillary refill. Therefore, the wound was closed using a combination of interrupted and horizontal mattress 4-0 Prolene sutures. A light dressing consisting of Xeroform, gauze, and a 2-inch Kling were used, and the patient was then placed into a prefabricated splint with the wrist in flexion and the MP is in flexion, and the fingers extended.

At the end of the case, the patient had tolerated the procedure well. He was essentially awake for the entire case, and the case was discussed with the patient at that time. All counts were reportedly correct and the patient was able to be transferred to the recovery room in excellent condition. 

PROGRESS NOTE

 

HISTORY:  The patient is seen today in clinic for follow up of left shoulder pain.  The patient has been diagnosed with some impingement as well as arthritic changes of her left shoulder.  The patient has been doing physical therapy and taking some anti-inflammatories which have helped her with the pain.  She states she is better today; however, she does still have some pain with overhead activities.  She feels as if she is continuing to improve. 

PHYSICAL EXAMINATION:  The patient’s left shoulder: She is mildly tender to palpation throughout her shoulder.  She has full forward flexion.  Her abduction is to about 120 degrees.  Internal rotation is a little bit painful; however, she does go to approximately 20 degrees, and her external rotation is about 35 degrees.  She is otherwise neurovascularly intact.  She has negative Hawkins sign. 

IMPRESSION:  I believe the patient has a combination of arthritis over her left shoulder which is mild, along with some rotator cuff tendinosis. 

PLAN:  We recommended that she continued taking the sulindac which she was taking before.  She was taking 200 twice a day and did well with these.  We gave her a refill on these.  We also recommended that she continue her physical therapy as she is doing.  She will be scheduled for a follow up with us in six months, at which time we will take some repeat x-rays and see how she is doing.  The patient understands this treatment plan and agrees with this.

CHART NOTE 1

SUBJECTIVE:  The patient is seen today follow up of secondary change to painful foot bilateral.  The patient has been given functional and accommodated orthotics which has failed.  The patient has tried several different nonsteroidal, which has not improved his condition.  The patient seen an outside physician and was given a steroid injection of medial arch which has failed.  Modification of inserts does not improve condition also. 

OBJECTIVE FINDINGS:  Unchanged.  Point tenderness along the plantar aspect of the foot. 

ASSESSMENT:  Possible tarsal tunnel versus early signs of any Charcot Marie Tooth.

PLAN:  The patient will be scheduled for electromyogram and a nerve conduction velocity to rule out tarsal tunnel or any other abnormalities.  The patient can be followed up in Podiatry after initial test is done. 

 

CHART NOTE 2

SUBJECTIVE:  The patient is seen today having similar problems with painful right foot seen in the past for interdigital lesion, fourth web space.  Same complaints today, although, the patient does have upper body complaints of painful left ear, possible ear infection. 

OBJECTIVE FINDINGS:  A change of lesion noted fourth web space.  Negative signs of soft tissue infection. 

ASSESSMENT:  Interdigital keratoma. 

PLAN: 
1.  Debridement of lesion with a #15 blade. 
2.  Dispense digital separator.
3.  Refer to Urgent Care for treatment of possible ear infection. 
4.  Follow up with scheduled clinic appointment in Podiatry.