DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left femoral neck fracture, impacted valgus position.
POSTOPERATIVE DIAGNOSIS: Left femoral neck fracture, impacted valgus position.
OPERATION PERFORMED: Open reduction and internal fixation, left femoral neck fracture.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: Spinal anesthesia
COMPLICATIONS: None.
DRAINS: None.
BLOOD LOSS: 50.
INDICATION FOR OPERATION: This is a (XX)-year-old female with multiple medical problems who suffered a fall a week ago resulting in an impacted left femoral neck fracture. The patient was taken to the operating room for a left hip hemiarthroplasty.
DESCRIPTION OF OPERATION: The patient was given 1 gram of Rocephin IV piggyback prior to coming back to the operating room. Once the patient was back, she was transferred from the OR stretcher to the operating table without complications. The patient was placed in a lateral decubitus position. Spinal anesthesia was induced without complication. Once this was completed, she was placed in the supine position on the fracture table. The left lower extremity was placed in gentle traction and internal rotation. The entire left hip region was prepped and draped in a sterile fashion with a double DuraPrep scrub. Routine sterile draping technique was used.
A lateral incision was made over the left hip measuring about 2 inches. Dissection was continued down to the fascia. The fascia lata was opened and reflected anteriorly. The vastus lateralis was also dissected through and reflected anteriorly. An osteotome and a periosteal elevator were used to remove all muscle attachments from the proximal lateral femur. C-arm fluoroscopy showed appropriate placement of the guidewire. Three guidewires were placed in a triangular pattern, two inferior and one superior. Each of them were measured and checked in the AP and lateral planes. Cannulated drills were then used to open up the lateral cortex, and the appropriate size screws were then placed in a cannulated fashion. The two inferior screws were 85 mm in length, partial thread, 60 mm 7.0 screws, and the superior one was 80 mm in length. Final C-arm fluoroscopy views were taken. The fracture was reduced nicely in an appropriate position and the hardware appeared stable.
Copious amounts of normal saline were used to irrigate off the wound. Deep fascia was closed with interrupted 0-Vicryl figure-of-eight sutures. Subcutaneous tissue was closed with interrupted inverted 2-0 Vicryl sutures. Skin was reapproximated with staples. Dressing was placed of Xeroform, 4 x 4, ABD, soft bulky dressing, and a sponge, tape dressing. This case was done under spinal anesthesia. At the end of the surgery, the blood loss was 50 mL, and she was transferred to the recovery room in stable condition. The patient tolerated the procedure well without complications.
