DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left tibial plateau fracture.
POSTOPERATIVE DIAGNOSIS: Left tibial plateau fracture.
OPERATION PERFORMED: Open reduction and internal fixation of left tibial plateau.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 100 mL.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who was struck by a car. He sustained the above-stated injury. Informed consent was obtained for operative procedure after CT scan and plain films were reviewed.
DESCRIPTION OF OPERATION: The patient was brought to the OR and laid supine on the OR table. After general anesthesia was induced, the left lower extremity was prepped and draped in usual sterile fashion. This was done after a tourniquet was placed high up on his left thigh. Esmarch bandage was used to exsanguinate the left lower extremity, and the tourniquet was inflated to 300 mmHg.
Next, a standard lateral approach to the lateral tibial plateau was performed. A submeniscal arthrotomy was performed. Prolene suture was placed into the meniscus elevating the meniscus, allowing visualization of the joint surface. A depressed posterolateral piece of the articular surface was encountered. Next, the fracture was opened up, wedged like a book using a Cobb elevator. Next, using a combination of elevators and bone tamps, the depressed articular segment was elevated to line it up with the remaining articular surface. This was done from below. Once the articular surface was disimpacted and elevated to its anatomic position, 15 mL of allograft bone chips were impacted into the defect underneath.
Next, two K-wires were placed to provisionally hold the reduction of the articular surface. A Synthes 3.5 proximal tibial nonlocking plate was fashioned to the lateral aspect of the tibial plateau. Three screws were placed distal and four screws into the proximal fragment. All screws were placed in standard AO fashion. Next, K-wires that were initially placed were removed. C-arm fluoroscopy was used to confirm excellent position of the articular surface on both the AP and lateral fluoroscopic images, as well as positioning of all screws and hardware.
Next, the wound was thoroughly irrigated with normal saline. Plain films were obtained in the OR. The submeniscal arthrotomy was closed using Prolene suture and tied down to the plate. The IT band was closed with 0 Vicryl suture in figure-of-eight fashion followed by subcutaneous layer of 2-0 Vicryl sutures and staples for the skin. Sterile dressings were applied. The patient was placed into a knee immobilizer. Prior to closure, the tourniquet was deflated and hemostasis was obtained. There were no complications.
