Removal of External Fixator Surgery Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left open segmental tibia/fibula fracture.
POSTOPERATIVE DIAGNOSIS: Left open segmental tibia/fibula fracture.
OPERATION PERFORMED:
1. Removal of external fixator, left leg.
2. Open reduction internal fixation, left segmental tibia fracture.
3. Application of a VAC sponge to open wound.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 300 mL.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male involved in a motor vehicle accident three days ago. He was initially taken to the operating room for irrigation and debridement as well as application of an external fixator for provisional stability. The patient was brought back to the operating room today for definitive fixation.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and laid supine on the OR table. General anesthesia was induced. The left lower extremity was then prepped and draped in the usual sterile fashion. The external fixator was then removed. Standard lateral approach to the proximal tibia was performed. Dissection was carried down elevating the anterior compartment muscles of the tibia. The tibial plateau was brought into visualization.
Next, attempts were made to reduce the fracture under C-arm fluoroscopy. Reduction was not obtained. Therefore, the open wound on the medial and lateral side of the leg, which was at the level of the distal segmental piece, was extended allowing for direct reduction. Once acceptable reduction was obtained on both the AP and lateral planes, a 12-hole LISS plate was passed down through the proximal wound along the lateral aspect of the tibial shaft. Screws were then placed in the proximal segment followed by placement of cortical screws distal to the fracture site. The remaining holes in the LISS plate were then filled using standard AO technique with the LISS plate. Excellent reduction was obtained on both the AP and lateral fluoroscopic images. Overall anatomic alignment of the tibia was restored.
Next, plain films were obtained in the OR. The wounds were all thoroughly irrigated with normal saline. All wounds were closed with 2-0 Vicryl suture in the subcutaneous layer, except for the medial and lateral traumatic wounds. The medial wound was able to be closed using 2-0 nylon suture using trauma stitches. The lateral leg wound was unable to be closed due to excessive tension. Therefore, a VAC sponge was placed on this wound. Adhesive drapes were then placed around the VAC sponge obtaining a vacuum tight closure. Staples were placed for the skin closures. Sterile dressings were applied. The patient was placed into an AO splint. The VAC sponge was then hooked up to the canister and was functioning postoperatively. The patient was awakened from anesthesia and transferred back onto a stretcher and taken to the SICU for further care.
