EXAMPLE
Barry Tuch, M.D.
OPERATIVE REPORT
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ANESTHESIOLOGIST: Mohammad Qadeer, M.D.
ANESTHESIA: General.
PREOPERATIVE DIAGNOSES: Displaced lateral malleolus fracture,
left ankle, with disruption of the distal tibia fibular
syndesmosis.
POSTOPERATIVE DIAGNOSES: Displaced lateral malleolus fracture,
left ankle, with disruption of the distal tibia fibular
syndesmosis.
PLANNED PROCEDURE: Open reduction internal fixation lateral
malleolus fracture with insertion of tibia fibular syndesmosis
screw.
HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old male who
sustained trauma to his left ankle on 04/08/2006 when he was
thrown out of a nightclub. He was seen in the emergency room at
Saint Louise. X-rays were obtained. He was immobilized in a
splint and referred to my office. He is taken to surgery at this
time, primarily because of the tibia fibular syndesmosis
disruption and lateral displacement of the distal fibula relative
to the ankle mortis.
OPERATIVE PROCEDURE: The patient was given a general anesthetic
and placed supine on the operating table. The left leg and foot
were prepped sterilely and draped free in the usual sterile
manner. The limb was exsanguinated with an Esmarch bandage and a
pneumatic tourniquet was inflated to 300 mm/Hg. A lateral skin
incision was made over the distal fibula. This was deepened by
sharp and blunt dissection and bleeders were coagulated with a
Bovie as encountered. The fibula was stripped subperiosteally at
the fracture site. The fracture was approximately 2-3 inches
proximal to the syndesmosis and was oblique in orientation and
somewhat displaced. The hematoma was irrigated with bacitracin
antibiotic solution. The fracture was then reduced and held in
place with a bone clamp in an anatomic position. A 7-hole, 1/3
tubular AO Synthes plate was then attached to the fibula with
three screw holes distal to the fracture and four proximal. All
seven screws were 3.5 mm cortical screws and all had excellent
purchase in both cortices. The fracture was stable and its
position was confirmed anatomic with the mini C-Arm which also
confirmed that the plate and screws were in perfect position.
Because of the distal tibia fibular syndesmosis, it was elected
to insert a 4.5 partially threaded cannulated Synthes screw. A
guide pin was inserted through the fibula and into the tibia,
parallel to the joint, and just slightly proximal to the
syndesmosis. The position of the guide pin was confirmed in all
planes to be satisfactory with the mini C-Arm. A cannulated
reamer was used to ream over the guide pin and then a 15 mm
partially threaded 4.5 mm AO self-tapping screw was inserted over
the guide pin. As it was tightened against the fibula, the foot
was held in maximum dorsiflexion. There was excellent of the
screw in the tibia. The mini C-Arm was then used to confirm that
the syndesmosis was anatomically reduced and that the screw was
in perfect position in all planes. Finally, permanent films were
taken off the mini C-Arm for documentation purposes. This was
done throughout the procedure, both before and after insertion of
the hardware.
At this point, the wound was irrigated thoroughly with bacitracin
antibiotic solution and then closed in layers. The deep fascia
was closed with interrupted figure of eight with 0 Vicryl. The
subcutaneous fatty tissue was closed with interrupted 2-0 Vicryl.
The skin was closed with staples. The skin and subcutaneous
tissue were infiltrated with 20 mL of 0.5% Marcaine with
epinephrine. A sterile bulky compressive dressing was applied.
The leg was immobilized in a short-leg fiberglass cast with the
ankle in neutral position. The mini C-Arm was used to take x-rays
through the cast of the ankle and this confirmed that the ankle
remained in anatomic position. The tourniquet was deflated after
being up a total of 57 minutes and there was prompt return of
circulation distally. The patient was then awakened and taken to
the recovery room in satisfactory condition where the cast was
univalved and split and spread. The patient received 1 gm of
Ancef intravenously just prior to onset of surgery.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.