DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Internal derangement of the right knee with meniscus tear.
POSTOPERATIVE DIAGNOSES:
1. Lateral meniscus tear.
2. Chondromalacia, patellae and trochlea.
3. Synovitis, chronic, reactive.
OPERATION PERFORMED:
1. Arthroscopic surgery with partial lateral meniscectomy of lateral meniscus tear.
2. Chondroplasty of trochlea and patella with removal of loose bodies and floaters.
3. Synovectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in a supine position. After induction of anesthesia, the right lower extremity was prepped and draped in the sterile field in the usual fashion. Anterolateral portal was used for scope and inflow. Anteromedial portal was used for probe and motorized instruments.
Findings were as follows: The patient had decent patellofemoral tracking. There was, however, a significant degree of chondromalacia involving the trochlear groove and the undersurface of the patella with some edges of loose articular cartilage and fissuring. This was noted both in the trochlear groove as well as in the undersurface of the patella. The medial compartment was relatively smooth with a normal medial meniscus. The ACL was intact. Pertinent pathology was noted over the lateral meniscus, where the patient was noted to have a degenerative lateral meniscal tear involving the posterior to mid body portion of the meniscus. There were large amounts of reactive synovitis as well.
Following visualization, a chondroplasty was first carried out on the trochlea and patella, smoothing it down to a stable edge. A lot of cartilaginous floaters were removed by suction and shaving. Following this, a relatively stable cartilage bed was noted involving the trochlea. The synovial and chondromalacia crab meat fronds over the patella were shaved down as well.
After this was done, the lateral meniscus was trimmed back to a stable meniscal rim using the basket and full radius shaver. The transition zone was noted to be smooth. Intraoperative photographs were taken to show the before and after pictures.
After the above, a final synovectomy was carried out of the joint. Copiously irrigation of the knee was then done until the return flow was clear, following which 0.25% Marcaine was used for the portals, which were then closed with 4-0 nylon. The patient was brought to the recovery room with a compression dressing, Ace wrap, and ice compression in stable condition.
