DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Left pilon fracture.
POSTOPERATIVE DIAGNOSIS:
Left pilon fracture.
PROCEDURES PERFORMED:
1. Open reduction and internal fixation of left pilon.
2. Removal of an external fixator, left ankle.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 200 mL.
DESCRIPTION OF OPERATION: The patient was brought to the OR and laid supine on the OR table. General anesthesia was induced. Tourniquet was placed high up on the left thigh. The external fixator was removed. The left lower quadrant was then prepped and draped in the usual sterile fashion. Esmarch bandage was used to exsanguinate the left lower extremity and the tourniquet was inflated to 300 mmHg.
Next, a standard anteromedial approach to the pilon fracture was performed. The tibialis anterior muscle was retracted laterally. The fracture was exposed and an arthrotomy was performed to visualize the joint surface. Fracture fragments were noted to be primarily located in the anterior and anterolateral portions of the tibial metaphysis. A reduction was performed and the reduction was held with K-wires provisionally. C-arm fluoroscopy was used to confirm good reduction of the articular surface on both the AP and lateral images.
Next, two lag screws were placed from anterior to posterior holding the reduction. Next, an anterolateral plate from the Zimmer set was selected and fashioned to the distal tibial metaphysis. The plate was nine-hole length. Fixation was performed holding the plate to the bone using four screws in the distal fragments and three screws in the proximal fragment. Excellent fixation was obtained and C-arm fluoroscopy was used to confirm good reduction of the articular surface on both the AP and lateral fluoroscopic images.
The wound was then thoroughly irrigated with normal saline. The wound was closed with 2-0 Vicryl suture in the subcutaneous layer followed by staples for the skin. Sterile dressings were applied and the patient was placed into an AO splint. The patient was then awakened from anesthesia, transferred back onto the stretcher and taken to the PACU for recovery. There were no complications.
