DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right knee medial meniscal tear.
POSTOPERATIVE DIAGNOSIS: Right knee medial meniscal tear.
OPERATION PERFORMED: Right knee arthroscopy, partial medial meniscectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: Less than 45 minutes.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who has been having medial-sided right knee pain, which has been refractory to conservative management. The patient had an MRI, which revealed a degenerative posterior horn medial meniscal tear. She understands the risks and benefits of a right knee arthroscopy and wishes to proceed.
DESCRIPTION OF OPERATION: After the patient was identified in the preop holding area and 600 mg of clindamycin was administered, she was then transferred back to the operating room and placed supine on the operating room table. After adequate general anesthesia was administered and all bony prominences were padded, a right upper thigh tourniquet was then placed. The right lower extremity was then prepped and draped in a standard sterile fashion.
Standard superomedial, anterolateral, and anteromedial arthroscopic portals were then made. The suprapatellar pouch was explored initially and revealed small areas of outer bridge grade I and II changes to the undersurface of the patella. The trochlear groove was without defect. The medial and lateral gutters were also without pathology. The notch was explored and revealed an intact ACL and PCL. The lateral compartment was explored and revealed outer bridge grade II and III changes to the lateral tibial plateau. The lateral femoral condyle was pristine.
The lateral meniscus was probed and was found to be intact. The medial compartment was then explored and revealed some areas of outer bridge grade II changes to the medial femoral condyle and medial tibial plateau. There was a degenerative posterior horn medial meniscal tear, which was saucerized to a stable rim using basket forceps and a 4.0 full-radius resector.
At this point, all instruments were removed, and 20 mL of 0.5% Marcaine with epinephrine was then placed in the joint. Staples were then used for skin followed by a sterile dressing. The patient was then awakened from general anesthesia and transferred to the recovery room in good condition. There were no complications.
