DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right knee plica syndrome and hypertrophied fat pad/synovitis.
POSTOPERATIVE DIAGNOSIS: Right knee plica syndrome and hypertrophied fat pad/synovitis.
OPERATION PERFORMED: Right knee arthroscopic excision of plica and fat pad debridement.
SURGEON: John Doe, MD
ANESTHESIA: MAC/general anesthesia.
DESCRIPTION OF PROCEDURE: Prior to the procedures being performed, the procedures themselves, including all the risks, benefits, alternatives, and possible indication for future surgery, were explained. The patient completely understood and accepted the same. The patient was brought into the operating room and MAC/general anesthesia administered by the anesthesiology team. The left leg was elevated prior to and throughout the procedure, that is the nonoperative side. The operative side, the right lower extremity, was routinely prepped, draped, exsanguinated under MAC and tourniquet inflated to 300 mmHg. The limb was exsanguinated as noted, and the tourniquet was inflated.
The superomedial portal was incised and arthroscopic saline instilled in the knee through the anteromedial and anterolateral portals. All compartments of the knee were inspected. The knee was noted to reveal a significant plica medially that actually had been causing some inflammation and irritation along the medial undersurface of the patella. The plica was excised arthroscopically completely.
The undersurface of the patella and the patellofemoral joint were remarkably well preserved, and there was no evidence of actually any intra-articular subluxation of the patella. The menisci were noted to be intact as were the cruciates. The fat pad was noted to be quite hypertrophied, necessitating an arthroscopic debridement as it was felt to be impinging on the extensor mechanism. There was no evidence of any loose bodies, no osteochondral deficits or defects.
The knee was completely irrigated until clear. Hemostasis was noted to be quite intact, 15 mL of 0.5% plain Marcaine instilled in the knee for prolonged analgesia. The port was left open for drainage. Moderate compression dressing was applied. The patient tolerated all the procedures quite well.
