DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Lateral meniscus tear, right knee.
2. Possible chondromalacia, right knee.
POSTOPERATIVE DIAGNOSES:
1. Radial tear, mid portion discoid variant lateral meniscus, right knee.
2. Grade 2 chondromalacia, lateral portion of medial femoral condyle, right knee.
3. Grade 2 chondromalacia, medial patellar facet, right knee.
OPERATION PERFORMED: Partial lateral meniscectomy, right knee.
SURGEON: John Doe, MD
ANESTHESIA: General LMA.
ANESTHESIOLOGIST: Jane Doe, MD
TOURNIQUET TIME: 30 minutes.
DRAINS: No drains.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is an active (XX)-year-old female who presents with history of anterior and lateral right knee pain, unimproved with conservative measure. MRI demonstrated lateral meniscus tear. The risks and benefits of diagnostic arthroscopy versus the risks and benefits and alternatives were reviewed in detail with the patient. The patient desired to proceed with arthroscopy. The patient’s MRI also suggested some underlying chondromalacia, and she fully understood she may or may not have improvement of pain following surgery, depending on the findings at the time of surgery.
DESCRIPTION OF OPERATION: Preoperatively, the patient identified her operative leg by writing “yes” on her operative thigh. She underwent a 10-minute Betadine scrub of her right knee and received 1 gram of IV Ancef in the preoperative holding area. The patient was then taken to the operating room and placed on the operating room table in the supine position. After adequate general LMA anesthesia was obtained, the patient’s right knee was examined. She had full range of motion, good endpoint on Lachman. No medial or lateral instability. Her proximal right lower extremity was well padded, and tourniquet was placed and set at 275 mmHg. The right lower extremity was elevated and exsanguinated with an Esmarch. The tourniquet was then inflated, and the right lower extremity was placed in a well-padded arthroscopic leg holder. The left lower extremity was also well padded. The right lower extremity was sterilely prepped from toes to leg holder with DuraPrep solution x2 and sterilely draped in standard fashion using waterproof extremity draping and waterproof stockinette. There was no overgrowth.
The patient was identified as the correct patient, and her signed consent identified the procedure as a right knee arthroscopy. Attention was turned to the anterior aspect of the right knee where a standard anterolateral portal was established. The arthroscope was introduced with blunt trocar in the suprapatellar pouch. The knee was distended with lactated Ringer’s and copiously irrigated. The suprapatellar pouch was within normal limits. The undersurface of the patella had mild chondromalacia on the medial facet. The medial gutter was without plica, synovitis and loose body.
Medial compartments were then seen, and anteromedial portal was established under direct visualization. A probe was used in the anteromedial portal, probed the medial meniscus in its entirety. There was grade 2 chondromalacia of the posterolateral portion of the weightbearing surface of medial femoral condyle. That was widely debrided with the shaver in a fast forward position. The articular cartilage of the medial tibial plateau was within normal limits. The intercondylar notch was entered. The ACL was firm and stable. PCL was firm and stable. The lateral compartment was entered. The patient did have a discoid variant of her meniscus with a radial tear through the center portion of the meniscus. The tear was debrided back to a stable rim using the broad straight punch and 4.0 shaver in an oscillating fashion. The remainder of the meniscus was probed and felt to be stable. The articular cartilage of the lateral femoral condyle and lateral tibial plateau were within normal limits. Lateral gutter was without plica, synovitis or loose body.
Attention was again turned to the patellofemoral joint. Articular cartilage of the patella and the trochlear groove were probed and stable. There was mild chondromalacia diffusely on the medial patellar facet, which was stable. The knee was copiously irrigated and all instruments were removed. The portals were closed with simple sutures of 4-0 nylon. The knee was injected with 30 mL of 0.25% Marcaine without epinephrine and without preservatives. Sterile Xeroform, 4 x 4s, ABD, compressive Ace wrap dressing, and ice wrap were applied. The patient tolerated the procedure well.
