DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Comminuted intertrochanteric fracture of the right hip.
POSTOPERATIVE DIAGNOSIS: Comminuted intertrochanteric fracture of the right hip.
OPERATION PERFORMED: Open reduction and internal fixation of right hip.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: This patient sustained a comminuted intertrochanteric fracture of the right hip with some varus angulation and deformity. The patient was felt to be an operative candidate since he was ambulatory and in severe pain. It was felt best to rehabilitate him with the hip pinning using the intramedullary nail. The patient’s family was advised of possibility of complications, including but not limited to infection, poor healing, blood clots, failure of the surgery in terms of not providing patient’s needed relief in terms of pain control and other unspecified complications.
DESCRIPTION OF OPERATION: Under satisfactory general anesthesia, the patient was placed on the fracture table. Traction was applied to the right lower extremity. The left lower extremity was placed in the lithotomy-type position. Traction was longitudinal traction with some slight internal rotation. Image intensifier C-arm showed good position of the fracture. Lateral thigh was then prepped with Betadine scrub and solution and draped in the usual fashion with isolation draping.
Longitudinal incision was made above the greater trochanter, and guides were passed into the head and neck under image intensifier control. The area was then reamed in the standard fashion, and the intramedullary nail was first placed and guide pins placed into the head and neck under image intensifier control. The patient had then placement of the lag screw as well as compression screw, as well as the static distal locking screw through two additional distal incisions. The final position appeared to be quite satisfactory. It was felt that approximately 10 mm of compression was obtained with reaming to 105 and lag screw at 95. The final construct appeared to be quite stable, and the wounds were thoroughly irrigated with bacitracin irrigation.
Then, 0 Vicryl was used to close the fascia, 2-0 Vicryl for the subcu, wide staples to the skin, Xeroform gauze, and dry sterile gauze. The patient was then carefully taken from the fracture table to the recovery room in satisfactory condition.
