DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right calcaneal wound dehiscence, lateral side.
POSTOPERATIVE DIAGNOSIS: Right calcaneal wound dehiscence, lateral side.
PROCEDURES PERFORMED:
1. Irrigation and debridement, lateral calcaneal wound.
2. Closure of the wound dehiscence, right lateral calcaneal wound.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 50 mL.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old Hispanic male who was involved in a fall in early August and sustained a fracture of the left tibial plateau, as well as comminuted fracture of the right calcaneus. The patient underwent ORIF of the right calcaneus in mid August. The patient developed wound dehiscence on the medial part of the lateral incision. Risks and benefits of the procedure were discussed with the patient, and informed consent was obtained for I&D and wound closure.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. After satisfactory general endotracheal anesthesia was administered, a tourniquet was placed on the right upper thigh but never inflated. The right lower extremity was then prepped and draped in the regular sterile routine fashion. The patient was placed with a slight bump underneath the head.
The wound was measuring about 4-5 cm with a necrotic edge, but there was no drainage. The necrotic tissue was sharply excised. A swab was taken for culture and sensitivity, and at this point, the patient was given 1 gram of vancomycin. There was no pus that could be seen. All the necrotic edges were sharply excised with a #15 blade. The base of the wound is healthy. The wound was irrigated copiously with normal saline, about 1 liter. A flap was elevated on either side of the incision, full thickness, to facilitate wound closure.
The wound, at this point, was irrigated with another liter of normal saline. The skin was then closed with 3-0 nylon and the closure was under no tension. Dressing was then applied in the form of Adaptic, 4 x 4s, sterile Ace wrap. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
