DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right shoulder sepsis.
POSTOPERATIVE DIAGNOSIS:
Right shoulder sepsis.
OPERATION PERFORMED:
Arthroscopic irrigation, debridement and synovectomy, right shoulder.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal tube.
ANESTHESIOLOGIST: Jane Doe, MD
BLOOD LOSS: Minimal.
FLUIDS RECEIVED: Approximately 1 liter crystalloid.
DRAINS: Hemovac drain placed.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old woman with rheumatoid arthritis who had been admitted with signs and symptoms of a septic left total knee arthroplasty. The patient had undergone irrigation, debridement and removal of components and placement of an antibiotic-impregnated spacer block three days ago. The patient was having less knee discomfort but was complaining of right shoulder discomfort, which actually had been going on for more than a week. It was apparent on physical examination that she had swelling in the right shoulder. The shoulder was aspirated of approximately 25 mL of grossly purulent-appearing fluid, which returned from the lab with gram positive cocci in it. The patient elected to undergo arthroscopic irrigation and debridement, was examined on day of the procedure, and deemed appropriate to proceed.
DESCRIPTION OF OPERATION: The patient was identified in the operating room, and after adequate anesthesia, with the patient in the supine position, she was gently positioned in a beach chair fashion. All bony prominences were well padded. The area about the right shoulder, arm, and forearm was scrubbed, prepped, and draped in sterile fashion. The joint was infiltrated with saline via posterior portal.
A #11 blade was used to create a standard posterior arthroscopic portal through which the arthroscopic cannula was inserted. Diagnosis for arthroscopy revealed marked synovitis and hyperemia within the shoulder joint with complete eburnation of the articular surfaces of the glenoid and the humerus. Further visualization was poor.
A #11 blade used to create a standard superior arthroscopic portal. Shaver was used to perform synovectomy and cautery used to cauterize synovial vessels, and when this had been done, it was apparent that she as well had a massive rotator cuff tear. As much synovial tissue as possible was removed using the shaver.
The joint was copiously irrigated with sterile irrigant and impregnated with antibiotics and epinephrine. The joint was drained. Hemovac drain was placed to the anterior portal. A 4-0 nylon suture was used to approximate skin. Sterile dressing and sling applied.
The patient tolerated the procedure well, was extubated, transported to the recovery room in stable condition.
