DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right femoral shaft fracture.
2. Right lateral femoral condyle fracture, intra-articular.
3. Right pantalar dislocation.
4. Right lateral malleolus fracture.
5. Left navicular fracture.
6. Left humeral shaft fracture.
POSTOPERATIVE DIAGNOSES:
1. Right femoral shaft fracture.
2. Right lateral femoral condyle fracture, intra-articular.
3. Right pantalar dislocation.
4. Right lateral malleolus fracture.
5. Left navicular fracture.
6. Left humeral shaft fracture.
PROCEDURES PERFORMED:
1. Open reduction internal fixation of right pantalar dislocation.
2. Irrigation and debridement of right open ankle joint.
3. Intramedullary nail, right femoral shaft.
4. Closed reduction and percutaneous screw fixation of right lateral femoral condyle.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 700 mL.
DESCRIPTION OF OPERATION: The patient was brought to the OR and laid supine on the fracture table for open reduction internal fixation and procedures described above. After general anesthesia was induced, attention was directed towards closed reduction of the right pantalar dislocation. Attempts at closed reduction were unsuccessful; therefore, the decision was made to proceed with open reduction of the dislocation. The right lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was placed on the right ankle. Esmarch bandage was used to exsanguinate the right lower extremity and tourniquet was inflated to 250 mmHg. Next, a medial approach to the talus was performed along the course of the posterior tibialis tendon. Dissection was carried down to the level of the dislocation. The talus was completely dislocated from the navicula as well as from the tibia. The posterior tibialis tendon was noted to be a block to reduction. Army-Navy was used to pull on the posterior tibial tendon, and using a combination of traction and inversion of the ankle joint, the talus was reduced into the ankle joint as well as to the navicula. After reduction was performed, C-arm fluoroscopy was used to confirm excellent reduction of both the talonavicular and the ankle joints. Next, 2 K-wires, each 2.0 mm in size, were inserted, one through the calcaneal tuberosity up into the subtalar joint and one across the navicular and into the talus across the talonavicular joint. After placement of these 2 K-wires, the dislocation was noted to be stable. Next, attention was directed towards debriding the open wound, which measured less than a centimeter over the anterior aspect of the ankle joint. Thorough irrigation and debridement was performed using 9 liters of normal saline, the middle 3 liters of which contained 100,000 units of bacitracin. Next, the tourniquet was deflated and the medial wound was closed with 4-0 Vicryl suture in an inverted fashion followed by staples for the skin. Sterile dressings were applied. The K-wires were cut short and bent at their tips. Next, the patient was placed into an AO splint. Attention was then directed towards performing the intramedullary nail of the right femur. Therefore, the right lower extremity was placed into boot traction. The left lower extremity was also placed in the boot in a scissor-like orientation. Next, the right lower extremity was prepped and draped in the usual sterile fashion. A piriformis starting point was used and the guidewire was advanced into the proximal femur. Next, a starting reamer was used to open up the femoral canal. The guidewire was then passed into the medullary shaft at the level of the fracture. The fracture was reduced using a femoral wrench under C-arm fluoroscopy. The guidewire was passed into the distal femur. Next, reaming was initiated, starting with an 8.0 mm reamer, advancing up to a size 12 mm reamer in 0.5 mm increments. Next, measurements were taken and a size 360 x 11 mm Synthes Nail-EX was selected. The nail was purposefully selected to be of a shorter size because we planned to perform reduction and fixation of the lateral femoral condyle fracture. Therefore, the nail extended to just above the metaphyseal-diaphyseal junction of the distal femur. The nail was then impacted into the femur and across the fracture site obtaining excellent reduction of the fracture. The nail was impacted completely in. Next, 2 proximal locking screws were placed using the proximal locking jig. Next, 2 distal locking screws were placed using perfect circle technique. One distal locking screw was placed in the AP direction and another one in the lateral to medial direction. Next, after completion of the femoral nail procedure, attention was directed towards reducing the lateral femoral condyle fracture, which was minimally displaced. Under direct C-arm fluoroscopy, a large periarticular clamp was applied to the lateral and medial aspects of the distal femur. This was done through stab wounds. Reduction of the lateral femoral condyle was performed. Next, two 6.5 mm partially-threaded cancellous screws were placed from lateral to medial across the fracture site, one measuring 75 mm and the other measuring 70 mm in length. Excellent fixation and reduction of the lateral femoral condyle fracture was obtained. All wounds were thoroughly irrigated with normal saline and closed with 2-0 Vicryl suture followed by staples for the skin. Sterile dressings were applied. The patient was then taken out of boot traction and transferred over to his stretcher and taken to the SICU for further recovery. The patient remained hemodynamically stable throughout this procedure.
