DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left elbow heterotopic ossification with ankylosis of left elbow joint.
POSTOPERATIVE DIAGNOSIS: Left elbow heterotopic ossification with ankylosis of left elbow joint.
PROCEDURES PERFORMED:
1. Excision of heterotopic bone, left elbow joint.
2. Repair of lateral collateral ligament, left elbow.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 200 mL.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and laid supine on the OR table. After general anesthesia was induced, the left upper extremity was prepped and draped in the usual sterile fashion. A sterile tourniquet was used. The Esmarch bandage was used to exsanguinate the left upper extremity, and the tourniquet was inflated to 275 mmHg. Next, a standard lateral approach was performed through the previous surgical incision. Dissection was carried out to the level of the fascia, which was opened. Significant amount of heterotopic bone was found bridging the humerus to the radius. This bone was excised using a combination of rongeurs and osteotomes. The radial head replacement implant was identified. Next, the incision was extended proximally and distally. The extensor tendon origin off the supracondylar ridge was then elevated using an elevator. The anterior surface of the distal humerus was exposed. The capsule was removed. Next, dissection was carried out elevating the muscle and capsule all the way to the medial side of the joint. Significant amount of bone was found medially as well. Osteotome was used to excise this bone, including the capsule over the anterior aspect of the joint. At this point, we were able to get approximately 30 degree arc of motion. Next, dissection was carried out posteriorly along the lateral aspect of the proximal radius. Bone was also excised from this region. Next, with manipulation, we were able to break free some of the scar posteriorly as well as more scar anteriorly and medially. At this point, we were 20 degrees short of full extension and up to 120 degrees of flexion motion. He still had no rotation. We attempted to remove some of the heterotopic bone, which had formed between the radius and the ulna, which was essentially synostosis; however, his elbow was becoming unstable with further bone resection, and therefore, we elected to keep him at this range in order to hopefully give him a stable elbow. Next, the wound was thoroughly irrigated with normal saline. The lateral collateral ligament was repaired using suture anchors into the lateral epicondyle of the humerus. These sutures were tied down and next the elbow was again ranged. The elbow was stable between approximately 40 degrees short of full extension to about 120 degrees of flexion. Extension of the elbow further than 40 to 45 degrees led to posterolateral dislocation of the forearm as there was still a synostosis between the radius and the ulna. Next, the deep fascia was closed with 0 Vicryl suture in figure-of-eight fashion. The tourniquet was deflated prior to closure and hemostasis was obtained. The subcutaneous layer was closed with 3-0 Vicryl suture in inverted fashion followed by staples for the skin. Sterile dressings were applied. The patient was placed into an elbow splint with his elbow at about 90 degrees of flexion. The patient was then awakened from anesthesia, transferred back onto his stretcher and taken to the PACU for recovery.
POSTOPERATIVE PLAN: The patient will remain in his elbow splint for one week. After the first week, we will put him in a hinged Bledsoe elbow brace with range from 45 degrees short of full extension with unlimited amount of flexion. At that point, we can start physical therapy in his brace within that range. After approximately two weeks, we can proceed with more aggressive physical therapy. As mentioned, the patient essentially had no rotation following our procedure and further excision of bone we felt would lead to further instability. As long as we can give him a functional range of motion in flexion and extension, we felt this would be adequate for him.
