Orthopedic Medical Transcription Sample Reports for Medical Transcriptionists:
OPERATION PERFORMED: Complex right total hip arthroplasty.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine fashion on the operating room table. General anesthesia was induced. A Foley catheter was placed and the patient was turned on the patient's left side and was well padded in position with a Stulberg hip positioner. The right hip and leg were prepped and draped in sterile fashion. Ioban sheet was used and gloves were changed. We first excised the prior 20 cm lateral hip scar and then extended it 5 cm distally and 10 cm proximally in order to make our approach to the hip in the posterolateral position. We put the iliotibial band and gluteus maximus in line with their fibers. We then proceeded to dissect through all the previous scar tissue very meticulously and tediously, protecting the sciatic nerve carefully throughout the case. Once we created the subfascial planes, we placed a Charnley retractor over antibiotic-soaked sponges. We identified the tendon of the gluteus medius and placed a blunt Hohmann retractor under it to protect it. We then proceeded to take down the external rotators and the capsule as one layer from the posterior greater trochanter while we internally rotated the hip. We also released the gluteal sling 1 cm from this insertion of the posterolateral femur to facilitate exposure and protect the nerve. We then dissected the external rotators away from the capsule and tagged the ends of the capsule after we T'ed it to use for later repair. There was no sign of any infection and there was a normal amount of fluid within the joint. We dislocated the hip by carefully flexing and internally rotating in adduction. We measured the lesser trochanter to the center of head. This is to be 46 mm. We made a neck 10 mm above the top of the lesser trochanter with a reciprocating saw and noted the patient's anteversion to be approximately 15 degrees. The patient's major deformity was of the greater trochanter itself, which was hypertrophic anteriorly and moderately overhanging and then distal to our neck cut, the bone is very sclerotic for a distance of 8 cm down the femoral canal. We then placed retractors around all four quadrants of the acetabulum and excised the labrum with a transverse acetabular ligament and we did very conservative reaming in 25 degrees of anteversion and 45 degrees adduction with progressive reamers up to a 49 mm size in order to preserve as much of the patient's native bone stock as possible due to the patient's young age. We then carefully impacted in a DePuy Pinnacle acetabular shell 50 mm in size and this fit very securely. We however elected to augment it with a single screw 25 mm in length at the 12 o'clock position, achieving a good bite with this. We grasped the edge of the cup, but a Kocher clamp could not budge it. We then impacted in a 32 mm plus 4 offset 0 degree Marathon liner and checked it for security. We protected this with a sponge and turned our attention to the femur. At this point, the case became more complex than standard, as we expected. We internally rotated the femur to 90 degrees, placed a proximal femoral neck retractor. We noted that a standard canal finding rod could not pass the healed sclerotic and neocortical bone in the proximal 10 cm of the femur. We therefore used the Midas Rex very carefully, under direct vision, and created a passage into the proximal femur. Into this, we inserted our guide rod under direct vision and then we sucked out the canal. We then used an 8, then a 9, then a 10 reamer, and at this point, given the unusual geometry of the patient’s proximal femur, I was concerned that we had somehow penetrated the femoral canal, and therefore, we just split the incision down another 10 cm distally in the skin and the IT band and exposed the femur further down, and noted that underneath the lesser trochanter, there was a well corticated track from previous fixation hardware and on the exact opposite side of the femur where one would except a lag screw to be put, and this is where our reamers had gone through but not made a new channel in and of themselves. Therefore, we kept this area exposed and then we re-reamed the proximal femur using the Midas Rex to bypass the segment under direct visualization. There was a 5 x 8 cm defect in this region of the posteromedial femur. We planned on strut grafting this at the end of the case. We next progressively reamed with reamers up to a size of 11 and had a good bite with this reamer and then used a 16B conical reamer and then used the ZTT sleeve reamer. I chose a small ZTT sleeve size matching the patient's anteversion between 15 and 20 degrees. We then placed an allograft strut around the medial side of the femur, just below the lesser trochanter, where the previous defect had been and cabled it, but did not crimp the cable sleeves and placed a trial 16B small ZTT sleeve followed by a 16 x 11 x 150 S-ROM stem matching the patient's anteversion between 15 and 20 degrees. We used a neutral neck length and a 32 trial head. We reduced the hip and it reduced very nicely and stability was excellent with flexion, 90 internal rotation, 60 external rotation, 45 abduction, 45 adduction across the midline. At this point, we elected to take an x-ray of the patient, given the patient’s distorted femoral anatomy, and found our stem was in varus and needed to be redirected and resized. We therefore dislocated the hip and removed our trial femoral component. We then used the Midas Rex to lateralize our opening on the proximal femur into the greater trochanter and then reamed up from 16 proximal to 18 proximal after having reamed distally to a 13 mm distal diameter. We re-did our ZTT sleeve reaming and this time showed 18 x 13 x 160 plus 6 lateral offset with an 18B large ZTT sleeve. We obtained another x-ray and this x-ray showed excellent position of our trial components. We then dislocated the hip and removed all of the trial components. We then proceeded to impact in an 18B large ZTT sleeve. This fit very nicely. We then went to impact our 18 x 13 x 160 S-ROM stem in between 15 and 20 degrees of anteversion, as we had done on the trial, and we got it down with 2 cm of fully seating on the ZTT sleeve and it incarcerated at this point. Reviewing the patient's x-rays, it seemed that the tip of the stem had been impinging somewhat on the anterolateral cortex of the femur distally and that the patient's very hard diaphyseal bone was not accepting this, and so to avoid breaking the patient’s femur, we attempted to extract the stem with a slap hammer. This was not successful. We therefore performed first a monovalving of the proximal femur down to almost the level where the tip of the stem was, using the previous posteromedial cortical defect as a center line guide for this. We used the oscillating saw for this monovalving and this still would not let us extract the femur safely. We therefore used a drill bit to round off the tip of this monovalving at the mid portion of the femur after extending our incision down another 10 cm and then we used the Midas Rex R10 bur to connect these drill holes and bring them up proximally from the tip of the sliding osteotomy for 4 cm. This allowed us to extract the stem tip easily and without causing damage to the femur. We then placed 2.0 Dall-Miles cables around the femur distal to where a sliding trochanteric osteotomy had been made and tightened this up and crimped it. This was to prevent a splitting of the femur we actually put the stem down. We then temporally cabled the distal osteotomy with two 2.0 Dall-Miles cables tightened down but not crimped, and then we crimped the most distal one, and then we put in 2.0 Dall-Miles cables around the greater trochanteric region just above the lesser trochanter on the femoral neck and then tightened this down but did not crimp it. This gave us stability for an implantation of our stem and we elected to over-ream the distal canal by 0.5 cm. We used a 13.5 reamer distally and then inserted our stem after suctioning out the canal and this inserted very nicely and very securely in 20 degrees of anteversion with excellent seating. We then did a trial reduction with the neutral neck length. We were very pleased with this. An identical range of motion as we had with the previous trial. We then tightened and crimped the Dall-Miles cable sleeves and then we used two 1.5 Dall-Miles cables and sleeve with a shaped strut femoral allograft over the lateral posteromedial defect as prior and tightened these cables and crimped them. Our overall construct was very solid at this point and range of motion of the patient's hip was excellent as well as the stability. We then thoroughly irrigated and then placed the deep 10 mm JP drain above through a separate anterolateral stab wound and we closed the vastus lateralis with a running locking 0 Vicryl. We closed the capsule in capsular noose fashion with #1 figure-of-eight Ethibond sutures. Re-attached the external rotators to the greater trochanter with #1 Ethibond and closed the rotator interval. We closed the fascia and the gluteal sling with #1 figure-of-eight Ethibond sutures. We closed the subcutaneous tissue with two layers of 2-0 Vicryl and the skin with staples. We infiltrated the wound with 0.25% Marcaine and applied sterile dressing followed by an abduction pillow and transported the patient to the recovery room in satisfactory condition. Sponge and needle counts were verified correct x2.
DATE OF OPERATION: MM/DD/YYYY
1. Gunshot wound with open fracture, left mid shaft of ulna with comminution.
2. Retained foreign body, bullet, in the left forearm.
1. Gunshot wound with open fracture, left mid shaft of ulna with comminution.
2. Retained foreign body, bullet, in the left forearm.
1. Irrigation and debridement of bullet entry wound, left forearm.
2. Bridging ORIF, left ulna, with LC-DCP.
3. Removal of retained foreign body, bullet, in the left forearm.
John Doe, MD
ESTIMATED BLOOD LOSS:
To left upper arm.
TOTAL TOURNIQUET TIME:
LC-DCP 14-hole with 4 screws proximal and 3 screws distal.
INDICATION FOR PROCEDURE:
The patient is a (XX)-year-old female who sustained a gunshot wound to the left forearm this evening. The patient sustained a comminuted mid shaft ulnar fracture. All risks and benefits of the procedure were discussed with the patient and informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed in the supine position. One gram of Ancef was given in the preop area. After satisfactory general endotracheal anesthesia was administered, the tourniquet was placed on the left upper arm, which was well padded. The left upper extremity was then prepped and draped in the routine sterile fashion. The entry wound was incised sharply and the wound was irrigated copiously with normal saline and closed with 3-0 nylon. The bullet was palpable in the distal volar aspect of the left forearm subcutaneously. Esmarch was then used at this point for exsanguination and the tourniquet inflated to 150 mmHg. The bullet was removed through the distal incision. The volar border of the ulna was dissected with a periosteal elevator. The 14-hole LC-DCP, which was recontoured to fit in the volar aspect of the ulna, was advanced from the proximal incision bridging the fracture into the distal shaft. The forearm was placed in neutral position and the plate was secured provisionally with approximately one screw distal. The mini C-arm was used to confirm anatomic alignment and placement of the plate. After that, the plate was secured with a total of 4 screws proximal and 3 screws distally, bypassing the fracture site. Intraoperative x-ray was taken which showed good anatomic alignment of the fracture, as well as good placement of the plate. The patient tolerated the procedure well. The subcutaneous tissues were closed with 3-0 Vicryl and the skin with staples. Adaptic was used for the dressing along with 4 x 4s and sterile Webril. A splint was applied. The patient was taken to recovery in stable condition.
OPERATION PERFORMED: Open reduction and internal fixation of right proximal humerus.
DESCRIPTION OF OPERATION: The patient was brought to the OR and laid supine on the OR table. After general anesthesia was induced, the patient was placed in a semi-beach chair position in the McConnell headrest. The right upper extremity was prepped and draped in the usual sterile fashion. Standard deltopectoral approach was performed exposing the proximal humerus. The biceps tendon was identified. The fracture was noted to be at the surgical neck with the head completely dislocated posteriorly. There was also a lesser and greater tuberosity fracture fragment. The rotator interval was developed further exposing the humeral head, which was again dislocated posteriorly. With significant amount of difficulty, the humeral head was finally reduced back onto the humeral shaft using a combination of traction and Hohmann retractors. Once the fracture was reduced, the medial cortex was noted to be still intact. Although this fracture was a four-part fracture, due to the patient's history of repeat seizure episodes, decision was made to proceed with open reduction and internal fixation rather than a hemiarthroplasty. With hemiarthroplasty, the patient is at risk of dislocating again, and due to the continuity of the medial cortex, there is perhaps an adequate blood flow to the head and we made the decision to preserve the head and fix it. Therefore, once the humeral head was reduced to the shaft, Ti-Cron sutures were placed into the lesser and greater tuberosities along the tendinous portions. These were used as joysticks for reduction over the plate. Next, a 5-hole, 3.5 mm LCP proximal humerus locking plate was fashioned to the lateral aspect of the humerus. Five 3.5 mm locking screws were placed into the humeral head followed by two 3.5 m cortical screws into the shaft fragment. The greater and lesser tuberosities were then sutured over on top of the plates using the #2 Ti-Cron sutures. A 0 Vicryl suture was then used to further close the rotator interval that had been previously opened for exposure of the humeral head. Next, the wound was thoroughly irrigated with normal saline. C-arm fluoroscopy was used to confirm good position of all screws on both the AP and axillary fluoroscopic images. None of the screws penetrated the joint. All hardware was in good position and the fracture was noted to be well reduced. Next, the wound was thoroughly irrigated with normal saline. The fascia was closed with 0 Vicryl suture followed by 2-0 Vicryl inverted sutures for the subcutaneous layer and staples for the skin. Sterile dressings were applied. Once the right upper extremity was dressed, attention was turned toward the left proximal humerus. The C-arm fluoroscopy was used to confirm reduction of the left shoulder on the axillary view. This arm was then placed into the external rotation brace. The patient was then awakened from anesthesia, transferred back onto the stretcher and taken to PACU for recovery.
OPERATION PERFORMED: Open reduction and internal fixation of bilateral tibial plateau fractures.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and laid supine on the operating room table. After general anesthesia was induced, both lower extremities were prepped and draped in the usual sterile fashion. The external fixators were removed. Attention was first directed towards the left tibial plateau. A standard lateral procedure to the lateral tibial plateau was performed. A submeniscal arthrotomy was performed. Next, the joint was visualized through this lateral approach. The posterolateral fragments were reduced and the lateral tibial plateau was elevated, restoring the articular surface. Next, K-wires were placed to provisionally hold this reduction. C-arm fluoroscopy was used to confirm good reduction of the joint surface. Next, a 6-hole lateral plateau locking plate from the Stryker sets was selected. This locking plate was advanced down the tibial shaft. Next, screws were placed holding the plate to the bone. Four screws were placed in the distal shaft fragments and 4 locking screws in the proximal fragment. A kickstand screw was also placed in the locking mode. After all screws were placed, the x-rays were used to confirm good reduction of the fracture, as well as good placement of all hardware. Next, the wound was thoroughly irrigated with normal saline. The meniscal arthrotomy was closed with the 0 PDS suture, including the capsule. Next, the IT band was closed with 0 Vicryl suture, followed by 2-0 Vicryl sutures for the skin and staples. Attention was then directed toward the right tibial plateau. A similar procedure was performed. Then, the lateral approach to the lateral tibial plateau was performed, exposing the fracture. The articular surface on the right side was well reduced and we did not perform an arthrotomy on the right side. The incision was approximately 4 cm on the right side. A 6-hole LISS plate was advanced down the tibial shaft. Four screws were placed in the distal fragments followed by four screws in the locking mode and proximal metaphyseal fragment. Excellent fixation was obtained. The C-arm fluoroscopy was used to confirm excellent reduction of the fracture on both the AP and lateral fluoroscopic images. Next, the wound was thoroughly irrigated and closed in layers. Sterile dressings were applied. Ex-fix pins were then removed and the pin sites were irrigated. All wounds were dressed with sterile dressing and the patient was placed into a knee immobilizer. The patient was then awakened from anesthesia, transferred back onto a stretcher and taken to the PACU for recovery. The patient will be nonweightbearing for approximately three months on bilateral lower extremities. The patient will receive DVT prophylaxis during this time.
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