ORTHOPEDIC MEDICAL TRANSCRIPTION OPERATIVE EXAMPLE REPORT
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left knee lateral compartment degenerative joint disease.
POSTOPERATIVE DIAGNOSIS: Left knee lateral compartment degenerative joint disease.
OPERATION PERFORMED: Left lateral unicondylar knee arthroplasty.
BLOOD LOSS: 50 mL.
ANESTHESIA: Epidural/general LMA.
COMPONENTS USED: DePuy size 4 femoral component and a DePuy mobile-bearing size 3 tibial component with a 9.5 mm mobile-bearing polyethylene insert.
DESCRIPTION OF OPERATION: The patient was taken to the operating room where she was placed on the operating room table after epidural anesthesia was performed in the preoperative holding area. The patient was given vancomycin 1 gram preoperatively. She was prepped and draped in standard fashion after a tourniquet was applied to the left upper thigh.
After exsanguinating the left lower extremity and inflating the tourniquet to 250 mmHg, initial incision was made over the midline of the anterior knee and dissection was carried down to the lateral aspect of the patellar tendon and the patella. A lateral arthrotomy was performed. The undersurface of the patella and medial compartment were then both visualized and both appeared to have excellent maintenance of cartilage components without any evidence of any deformities or abnormalities. The lateral meniscus was then cleared from around the lateral side. Exposure to the lateral compartment was accomplished by removal of many of the osteophytes in the lateral aspect of her distal femur.
A lateral arthrotomy was performed. The undersurface of the patella and medial compartment were then both visualized and both appeared to have excellent maintenance of cartilage components without any evidence of any deformities or abnormalities. The lateral meniscus was then cleared from around the lateral side. Exposure to the lateral compartment was accomplished by removal of many of the osteophytes in the lateral aspect of her distal femur.
An initial sagittal cut was made in the notch, and using an extramedullary cutting jig, an appropriate proximal tibial cut was made on the lateral side. Placing the knee in extension and using a size 9 mm trial, the patient had excellent fit and fill with this implant. The knee was then kept in flexion, and using a cutting jig, the distal femur was cut appropriately. The knee was then flexed up, and using the distal femoral cutting jig, the distal femoral cutting jig was cut to accommodate a size 4 tibial femoral component. After the distal femoral cuts were performed, trials were then inserted again and the patient had excellent balance with this construct with a 9 mm insert. Final preparation of both distal femur and proximal tibia was accomplished using appropriate burs.
The knee was then flexed up, and using the distal femoral cutting jig, the distal femoral cutting jig was cut to accommodate a size 4 tibial femoral component. After the distal femoral cuts were performed, trials were then inserted again and the patient had excellent balance with this construct with a 9 mm insert. Final preparation of both distal femur and proximal tibia was accomplished using appropriate burs.
The knee was then flexed up, and using the distal femoral cutting jig, the distal femoral cutting jig was cut to accommodate a size 4 tibial femoral component. After the distal femoral cuts were performed, trials were then inserted again and the patient had excellent balance with this construct with a 9 mm insert. Final preparation of both distal femur and proximal tibia was accomplished using appropriate burs.
One bag of DePuy #3 cement was mixed on the back table, and a size 3 mobile-bearing tibial tray was placed in the lateral aspect of the femur. The 9.5 mm insert was then inserted partially into the mobile-bearing tray followed by cementation of a size 4 femoral unicondylar component.
The knee was then placed in extension. Any excess cement was removed around the implant and the cement was allowed to cure. Any cement was removed from around the implants. The patient again, with this construct, had excellent balance.
The wound was then thoroughly irrigated and drain was placed at the medical aspect of the knee. The arthrotomy was closed using 0 Vicryl, the subcutaneous tissues using 2-0 Vicryl, and the skin using staples. At the time of dressing, the drain accidentally was pulled out. The patient was then dressed with Xeroform, 4 x 4’s, ABDs, Webril, cooling pad, and an Ace wrap. The patient was transferred to the PACU in good condition.
