DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Comminuted left pilon distal tibial fracture.
2. Right calcaneus fracture.
POSTOPERATIVE DIAGNOSES:
1. Comminuted left pilon distal tibial fracture.
2. Right calcaneus fracture.
OPERATIONS PERFORMED:
1. Open reduction and internal fixation, ORIF, of left pilon fracture using a Synthes anterolateral plate, nonlocking; also, using cancellous allograft.
2. Open reduction and internal fixation, ORIF, right calcaneus, using Norian 5 mL and Synthes locking calcaneus plate.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: 30 mL.
TOURNIQUET: Left pilon, inflated to 350 mmHg. Total Time: 105 minutes. Right calcaneus, inflated to 350 mmHg. Total Time: 102 minutes.
IMPLANTS:
1. Left pilon fracture using a Synthes anterolateral locking plate with a nonlocking screw placement with four proximal and four distal screws.
2. Right calcaneus using a Synthes locking calcaneus plate with three total screws, locking, and the rest cortical screws.
INDICATIONS FOR OPERATION: This is a (XX)-year-old Hispanic male who fell about 25 feet, landing on both lower extremities, about two weeks ago, and sustained a closed right calcaneus fracture and left pilon fracture that was treated at that time with a standing external fixator and open reduction and internal fixation of the left lateral distal fibula. The patient was staged and was scheduled for open reduction and internal fixation of the left pilon and right calcaneus. All the risks and benefits of the procedure were discussed with the patient, and informed consent was obtained.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. One gram of Ancef was given preoperatively. After satisfactory general endotracheal anesthesia was administered, a well-padded tourniquet was placed in the left upper thigh. The left pilon was addressed first. The left lower extremity was then prepped and draped in the routine sterile fashion after removal of the external fixator frame but leaving the pins in place. Through an anterolateral approach to the distal tibia, incision was made and the tibialis anterior tendon with the sheath was preserved and was reflected laterally. The fracture was exposed. There was a lot of comminution at the joint level. There was at least two large articular pieces that were impacted proximally. The anterior cortex was elevated, and we were able to disimpact the articular pieces to the appropriate levels. The pieces were stabilized provisionally with K-wires. The C-arm was used intraoperatively, which confirmed the good alignment and good restoration of the joint line.
At this point, the plate was placed and was found to be in good position. The plate was secured distally with a total of four screws and proximally initially with two screws. The very proximal two screws were placed percutaneously. The void, distal tibial bone, was filled with the cancellous allograft. Again, the C-arm confirmed good alignment and good placement of the screws and the plates. Intraoperative x-ray confirmed anatomic alignment and restoration of the joint line. The wound was then irrigated copiously with normal saline. The tourniquet was deflated. Total time was 105 minutes, and the deep fascia was then closed with 0 Vicryl, subcutaneous with 2-0 Vicryl, and skin with 2-0 nylon. We were able to close the skin without tension. Dressing was then applied in the form of Adaptic, 4 x 4, sterile Webril, and splint was placed at the end of the procedure. At this point, the drapes were all removed.
The right lower extremity was then addressed for the right calcaneus. The patient was then placed in the left lateral decubitus position with axillary roll in place. His right lower extremity was then prepped and draped in the regular sterile routine fashion after placement of well-padded tourniquet, right upper thigh. Through a lateral approach to the calcaneus, the incision was made, and the full-thickness flap was elevated off the lateral calcaneus. The cuboid as well as the talus was exposed and three K-wires, one in the cuboid, one in the talus, and one in the fibula, was placed and was used for retraction. We were able to clean the joint. The medial side of the joint appears to be intact. There were two large pieces of the posterior facet that was depressed. Also, the angle of Gissane was found to be distorted. We were able to reduce the posterior facet piece to anatomical position under direct visualization and was stabilized with two K-wires. Also, the angle of Gissane was restored. The lateral wall piece was kept on the back table.
The mini C-arm was used intraoperatively, which confirmed good alignment of the articular surface. The calcaneus Synthes locking plate was used and was recontoured to fit the right calcaneus. The plate was first secured with three cortical screws, and the mini C-arm again confirmed good placement of the plate and screws. A total of three locking screws and three cortical screws were used. There was bone loss, and we elected to use Norian tricalcium to fill the bone loss. After placement of the plate, Norian was mixed, 5 mL, and was placed in the void area which was completely filled. The Norian was set up and hardened.
At this point, an intraoperative x-ray was taken, which confirmed good anatomic alignment of the posterior facet and good placement of the plate and screws. The deep fascia with periosteum was then closed with 0 Vicryl, the subcutaneous with 3-0 Vicryl, and skin with 3-0 interrupted nylon. A small Hemovac was left in place to help in postop hematoma. The tourniquet was deflated. Dressing was then applied in the form of Adaptic, 4 x 4, and sterile Webril. A splint was then applied in both lower extremities. The patient tolerated the procedure well and was taken to recovery in stable condition.
