PREOPERATIVE DIAGNOSIS: Bunion, right great toe.

POSTOPERATIVE DIAGNOSIS: Bunion, right great toe.

OPERATION: Chevron bunionectomy, right great toe.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, PA

ANESTHESIA: General.

POSTOPERATIVE CONDITION: Satisfactory.

INDICATIONS FOR SURGERY: This patient had chevron bunionectomy on her left foot last year, did very well, and the right foot was resistant to all conservative measures and surgery was indicated.

DESCRIPTION OF PROCEDURE: With the patient under satisfactory general anesthesia, supine on the operating table, the right foot was prepped with DuraPrep and draped into a sterile field for Chevron bunionectomy.

After the proper surgical consent form, surgical site marking, surgical time-out and infusion of preoperative antibiotics were performed and documented, the right leg was elevated. The tourniquet was applied to a pressure of 350 mmHg.

Medial incision was made over the MP joint. Dissection was carried out down to the capsule. The capsule was entered through a V incision based proximally and retracted distally as the capsule was dissected off the metatarsal head.

The saw was used to perform a bunionectomy and chevron cut was made. The metatarsal head was displaced laterally 4 mm and secured with an absorbable K-wire.

The remaining part of the shaft that was around medially was then removed with the saw and a drill hole was placed through the metatarsal shaft.

The wound was irrigated and the toe was held in a few degrees of varus and plantarflexion, and the capsule was reattached to the drill hole with interrupted PDS suture. The PDS was used on the superior and inferior capsule to reinforce the suture line. Vicryl was used to reinforce that. Vicryl was used on the subcutaneous, and the skin was closed with nylon suture.

A splint was applied. A dry, sterile dressing was applied. The tourniquet was released and normal circulation was noted to return to the toes.

The patient was taken to the recovery room in satisfactory condition after the completion of the Chevron bunionectomy.

PREOPERATIVE DIAGNOSES:
1. Right shoulder rotator cuff tear.
2. Right shoulder impingement.

POSTOPERATIVE DIAGNOSES:
1. Right shoulder rotator cuff tear.
2. Right shoulder impingement.
3. Degenerative tears of anterior and posterior glenoid labrum.

OPERATION PERFORMED:
1. Right shoulder arthroscopy with arthroscopic rotator cuff repair.
2. Right arthroscopic subacromial decompression.
3. Right limited glenohumeral debridement.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, PA

ANESTHESIA: General endotracheal plus scalene.

TOURNIQUET TIME: None.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

DRAINS: None.

IMPLANTS: Arthrex 6.5 metallic suture anchor.

INDICATIONS FOR OPERATION: This is a (XX)-year-old male who has had atraumatic shoulder pain for over eight months. He has had weakness and his pain has continued to bother him despite conservative management. MRI showed rotator cuff tear. Risks, benefits, and alternatives of right shoulder arthroscopy with arthroscopic rotator cuff repair, right arthroscopic subacromial decompression and right limited glenohumeral debridement were explained to him, and he is here for operative intervention.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the table in the supine position for the right shoulder arthroscopy with arthroscopic rotator cuff repair and procedures as mentioned above. An adequate level of general endotracheal and scalene block anesthesia was obtained. He was then placed in the beach-chair position, and all bony prominences were padded.

The right upper extremity was then prepped and draped in the normal sterile fashion. The site was verified prior to beginning the incision. A standard posterior portal was then made and diagnostic arthroscopy of the glenohumeral joint performed. There were no significant abnormalities of the biceps. There was a tear of the anterior lateral portion of the supraspinatus. The subscapularis had synovitis throughout its surface but appeared to be intact. The posterior rotator cuff was intact. The patient had degenerative tears of the superior and posterior labrum with free flaps. This was debrided through the anterior portal with motorized shaver. No significant chondromalacia and no loose bodies.

The arthroscope was then placed in the subacromial space and a thorough bursectomy was performed. Periosteum from the acromion undersurface was removed with cautery device. Motorized shaver was then placed through the lateral portal, and acromioplasty was performed arthroscopically until a smooth level surface was achieved. Distal clavicle was not violated. The rotator cuff tear was then visualized and noted to be a U-type tear of the supraspinatus along its lateral insertion.

The bony bed was then prepared to bleeding bone with the motorized shaver. The edges of the tear were debrided with a shaver as well. A single anchor was placed through an anterolateral portal, and the anchor had excellent purchase. Through the anterior and posterior portals, suture retrievers were then passed through the rotator cuff anteriorly and posteriorly and were retrieved. Simple sutures were then tied with the arm in slight abduction and external rotation with sliding knot followed by three half hitches through the anterior and posterior portals. It was excellent repair to the footprint.

Prior to tying the sutures, a side-to-side FiberWire stitch was then used to close the tear that went more medial. This was tied with sliding knot followed by half hitches. The repair was very secure at the end of the procedure with the arm at the side. The humeral head was completely covered.

The arthroscope was then removed. The portals were closed with subcu Monocryl followed by Steri-Strips. Sterile compressive dressings were then placed followed by an UltraSling. The patient was extubated and transferred to the recovery room in good stable condition. There were no complications.

PREOPERATIVE DIAGNOSIS: Degenerative joint disease with possible torn medial meniscus, right knee.

POSTOPERATIVE DIAGNOSIS: Degenerative joint disease of the right knee with grade 3 chondromalacia of the patella, femoral groove, and lateral femoral condyle and loose bodies.

OPERATION PERFORMED: Right knee arthroscopy with chondroplasty and removal of loose bodies.

SURGEON: John Doe, MD

ANESTHESIA: General.

IV FLUIDS: 1000 mL.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

SPECIMENS: None.

DESCRIPTION OF OPERATION: The patient was seen in the preoperative hall and correct operative site was identified. He was transported to the operating suite and placed supine on the operating table and given a general anesthetic without difficulty. A tourniquet was placed on the right thigh but not utilized during the case.

The right lower extremity was placed through an arthroscopy leg holder. The right lower extremity was then prepped with DuraPrep solution and draped in the usual sterile manner for this case.

Anteromedial and anterolateral portals were established initially. The arthroscope was placed into the suprapatellar pouch. There were some loose articular fragments noted in this region. These were removed with an arthroscopic shaver. There were also loose articular fragments in the medial gutter, and these were also removed with the arthroscopic shaver. The lateral gutter was clear.

The lateral compartment was entered. The lateral tibial plateau had grade 1 to 2 chondromalacia, but this was very mild. The lateral meniscus was probed in its entirety and was found to be intact. The lateral femoral condyle, however, had an area of grade 3 chondromalacia on the weightbearing surface. This was probed and found to have a delaminating flap.

An arthroscopic shaver was used to debride the edges of this flap and in the end it was approximately a 2 cm diameter defect with grade 3 cartilage loss on the weightbearing surface of the lateral femoral condyle. An arthroscopic thermal probe was used for thermal chondroplasty to stabilize the edges of this lesion.

The anterior cruciate ligament was visualized and was found to be intact. The medial compartment was then entered. The articular surfaces of the medial femoral condyle and medial tibial plateau were intact. The medial meniscus was probed in its entirety and found to be without evidence of tear. The patellofemoral articulation was then visualized.

There was significant grade 3 chondromalacia of the apex of the patella, extended to both lateral and medial facets. In addition, there was grade 3 chondromalacia involving the majority of the trochlea. An arthroscopic shaver was used to debride both areas taking articular edges to stable configuration. A thermal chondroplasty was performed in these regions as well.

After all intraarticular issues were addressed, excess fluid was drained from the knee. Marcaine 30 mL, 0.25%, with epinephrine was instilled into the knee and instruments were removed. Portal sites were closed with nylon sutures. A sterile dressing was then applied. An EBIce pad was placed over the dressing.

The patient was returned to the supine position and general anesthetic was reversed without difficulty. He was transferred supine on the operative gurney and transported to the postanesthesia care unit in stable condition.

PREOPERATIVE DIAGNOSES:

1. Left shoulder full-thickness rotator cuff tear.

2. Left shoulder subacromial impingement and rotator cuff tendonitis.

POSTOPERATIVE DIAGNOSES:

1. Left shoulder full-thickness rotator cuff tear.

2. Left shoulder subacromial impingement and rotator cuff tendonitis.

OPERATIONS PERFORMED:

1. Left shoulder arthroscopic rotator cuff repair.

2. Left shoulder arthroscopic subacromial decompression.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal anesthesia with regional interscalene nerve block.

ANESTHESIOLOGIST: Jane Doe, MD

INDICATIONS: The patient is a pleasant (XX)-year-old male who injured his left shoulder. Preoperative workup both clinically and radiographically including an MRI were consistent with a complete full-thickness tear of the rotator cuff along with excrescence of the acromion consistent with subacromial impingement and rotator cuff tendonitis. Given that it is a full-thickness rotator cuff tear with mild retraction, nonoperative and operative treatment options were discussed, but left shoulder arthroscopic rotator cuff repair, left shoulder arthroscopic subacromial decompression was recommended. The patient considered all of the options and elected to proceed with left shoulder arthroscopic rotator cuff repair, left shoulder arthroscopic subacromial decompression.

DESCRIPTION OF OPERATION: After obtaining informed consent and correctly identifying the patient, the patient was brought to the operating room and placed on the operating room table in a supine position for left shoulder arthroscopic rotator cuff repair, left shoulder arthroscopic subacromial decompression. After adequate anesthesia was obtained and intravenous antibiotics were given, the patient was then placed in a well-padded lateral decubitus position with the right upper extremity up. A time-out was then taken to confirm the identity of the patient, consented procedure and correct extremity. After this time-out, the left upper extremity was prepped and draped in the usual sterile fashion and placed in 10 pounds of balanced suspension traction.

The bony landmarks of the shoulder were then marked out in the skin, 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion, was injected with 0.5% bupivacaine. A small stab incision was then made. The arthroscopic camera was introduced into the joint. The joint was then distended and diagnostic arthroscopy then ensued. The most notable thing was a full-thickness tear of the rotator cuff with retraction of the rotator cuff midway to the level of the glenoid. The biceps tendon and the biceps root appeared to be intact with mild tenosynovitis surrounding the base of the biceps. The articular cartilage of the glenoid and humeral head was otherwise quite pristine. There was no evidence of a labral tear.

Attention was then focused to the subacromial compartment. The arthroscopic camera was introduced posteriorly and pushed through the veil of tears in the subacromial compartment. Abundant hypertrophic bursitis was encountered. A spinal needle was inserted laterally at the junction of the anterior and middle thirds of the acromion for localization of the lateral portal. The skin was then injected with 0.5% bupivacaine and small stab incisions were then made.

Arthroscopic shaver was used to debride and excise the hypertrophic bursa to expose the underlying rotator cuff. The full-thickness rotator cuff tear was again visualized and confirmed medial retraction midway to the level of the glenoid. There is immediately overhanging the area of the rotator cuff tear a large subacromial spur and the soft tissue on the undersurface of the subacromial spur was abraded, consistent with a kissing lesion seen with chronic subacromial impingement. Given these findings, decision was made to proceed with an arthroscopic subacromial decompression.

The arthroscopic shaver was used to debride and excise the soft tissue and periosteum on the undersurface of the acromion, to expose the anterior and lateral borders of the acromion. The coracoacromial ligament was then released using Bovie cautery. The overhanging free edge of the ligament was excised. Then, using arthroscopic 6 mm bur, approximately 7 mm of the large subacromial spur was excised beginning anteriorly and laterally and progressing posteriorly and medially until the undersurface of the acromion was converted to a flat type I acromion. Upon completion of the subacromial decompression, attention was then re-focused back to the rotator cuff tear.

The arthroscopic shaver was used to debride and freshen the free edge of the rotator cuff in preparation for the repair. The articular margin was also debrided to create and prepare a bleeding bony bed for the rotator cuff repair. A spinal needle was then used as needle localization for the most optimal location of insertion of the suture anchor corresponding with the apex of the crescent tear.

A small stab incision was then made, and through this stab incision, the arthroscopic punch was used to create a pilot hole, followed by insertion of the Arthrex Bio-Corkscrew 5.5 suture anchor. Excellent bony purchase was noted. Strong longitudinal traction was applied on the sutures to confirm excellent fixation of the anchor. An Arthrex cannula was inserted via the lateral portal. Needle localization was used to create the anterior portal through which a second Arthrex cannula was inserted.

Then, using an Arthrex suture lasso instrument threaded in reverse as a suture shuttle, the four limbs of the #2 FiberWire sutures of the anchor were then passed through the rotator cuff in two horizontal mattress-type fashion. The sutures, once passed through the rotator cuff, were then re-grasped out of the lateral portal. Each suture pair was then tied using an arthroscopic sliding locking technique, each followed by 3-1/2 inches on alternating posts.

Upon completion of the rotator cuff repair, the repair site was probed to confirm excellent reduction and fixation back down to the articular margins of the greater tuberosity. The shoulder was then gently internally and externally rotated to confirm no gapping was noted of the rotator cuff. Inflow was then stopped to check for any bleeders and meticulous hemostasis obtained using Bovie cautery. The subacromial space was then copiously irrigated and then drained free of any fluid and debris. The portals were then closed using buried simple interrupted sutures of 4-0 Monocryl. Steri-Strips were applied. Sterile dressings were applied.

The patient tolerated the procedure well. There were no complications. All needle, sponge and instrument counts were correct and the patient was transported stable and extubated to the postanesthesia care unit.

PREOPERATIVE DIAGNOSIS: Left end-stage shoulder arthritis.

POSTOPERATIVE DIAGNOSIS: Left end-stage shoulder arthritis.

OPERATION PERFORMED: Left shoulder hemiarthroplasty with glenoid resurfacing.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General and local.

ANESTHESIOLOGIST: Bradford Doe, MD.

ESTIMATED BLOOD LOSS: 250 mL.

INDICATIONS: This is an (XX)-year-old lady with history of left shoulder pain and radiographic end-stage arthritis of the left shoulder. She has pain with daily activities and overhead activities. She is unable to elevate her shoulder past 90 degrees due to pain. She also has radiographic posterior glenoid wear. She also has large inferior humeral osteophytes. Because of the persistent pain and because she has failed conservative management, she wished for surgical intervention at this time. Risks and benefits of left shoulder hemiarthroplasty with glenoid resurfacing was explained to the patient by Dr. Doe. Consent was obtained. The patient wished to proceed with the left shoulder hemiarthroplasty with glenoid resurfacing as planned.

DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed supine on the operating room table for left shoulder hemiarthroplasty with glenoid resurfacing. She underwent general anesthesia by Dr. Doe. Her head was then supported in a head holder. She was then placed in a beach chair position. Pillows were placed under the knees. She also got a Foley inserted intraoperatively.

The patient’s head was then secured with a head strap. The left shoulder was examined. The patient does have limited forward flexion and external rotation. Forward flexion to about 100 degrees, external rotation to about 30 degrees. The patient’s left shoulder was then prepped and draped in a sterile fashion as usual. A time-out was taken. The patient was correctly identified, consent verified by the surgical team. She received 1 gram of Ancef prior to the skin incision. A marking pen was used to outline the coracoid and the incision for the deltopectoral approach. Ioban drapes were then used to cover the left shoulder.

A 10 cm incision was made just medial to the coracoid extending laterally down the upper arm. Dissection was then carried down bluntly to the deltopectoral fascia. Next, the deltopectoral interval was then identified bluntly with the finger, tracing it up towards the coracoid. This interval was entered and carried down to the deep fascia. Goelet retractor was then used to retract the deltoid, and the conjoined tendon was identified.

Using the tenotomy scissors, the conjoined tendon fascia was exposed and the conjoined tendon was retracted medially. Distally, the pectoralis major insertion released off the humeral site about 1 cm. The long-headed biceps was also identified. Using a 90-degree clamp, the rotator interval was entered with the shoulder externally rotated and a Freer placed intra-articularly behind the subscapularis muscle.

Using Bovie electrocautery, the subscapularis tendon was then released in superior to anterior fashion. Retention sutures were then placed into the subscapularis tendon. After subscapularis tendon was released completely, it was reflected medially. This visualized the humeral head. There was significant arthritis of the humeral head with large osteophyte inferiorly.

By using a template for the humeral cut, the large broad oscillating saw was then used to make the humeral head cut at the anatomic neck. This was cut above 48 degrees. After completion of the cut, the inferior osteophytes were removed with osteotome. Care was taken to cut the neck at about 10-20 degrees of retroversion in order to prevent posterior instability to accommodate for the retrograded glenoid.

Using blunt dissection, the anterior aspect of the subscapularis was freed as well as the capsule, mainly posterior to the subscapularis muscle. Using the Mayo scissors, the capsule was released off the subscapularis. The anterior rotator interval was also released with Mayo scissors and allowed to bring the subscapularis out laterally. Using a Fukuda retractor, the glenoid space was visualized. The patient has a vertical ridge with posterior glenoid erosion. The glenoid itself was eburnated down to the subchondral bone. The anterior and posterior labrum was removed with a Bovie. The glenoid was retroverted about 20 degrees.

Using a hand reamer, the humeral canal was identified. A sequential reamer was taken up to size 10. A size 12 reamer did not get past the diaphysis. Thus, a 10 mm broach punch was used and placed with its fins in about 20 degrees of retroversion. Using a 10 mm broach, trial implant was placed and a 52 mm head was tried. The eccentric portion of the head was placed posteriorly to make up for the glenoid wear. The joint was then reduced and tested for stability. The patient had satisfactory inferior stability and anterior posteriorly translates about 50%.

At this point, the trial head implant was removed and a Fukuda retractor again placed behind the posterior glenoid. Using a glenoid reamer, the anterior half of the glenoid was then reamed to bring the glenoid surface out of retroversion into more neutral and also slightly anteverted position. After satisfactory reaming, a trial head with a +3 mm depth offset was tried with a 52 head. This gave excellent stability as for superior, inferior, anterior, and posterior. With humeral rotation and abduction, there was no impingement noted.

Next, the trial components were then removed. Autogenous bone graft from the humeral head was then placed into the intramedullary canal and the final porous-coated 10 mm prosthesis was then inserted. Prior to completely seating the implant, bone graft was packed around the implant proximally. The implant was seated by press-fit completely. A 52 x 21 mm head was then placed posteriorly to make up for the posterior defect. The shoulder was then reduced again. Range of motion checked and was satisfactory as well as the laxity.

The shoulder was then irrigated with the pulse lavage. The subscapularis tendon was then reapproximated to the lateral aspect with #2 Ethibond sutures in a figure-of-eight interrupted fashion. This brought the subscapularis tendon back nicely. The rotator hole was left unrepaired. Twenty mL of 0.5% ropivacaine was then injected into the skin and also into the shoulder joint. The subcutaneous was then closed with 2-0 Vicryl followed by 4-0 Monocryl for the skin. Steri-Strips were then applied. A sterile dressing was then placed with tape, and the arm was placed in a sling.

The patient was then placed supine, extubated and then transferred to the recovery room in stable condition. Sponge and needle counts were correct. Dr. Doe was present and scrubbed for the entire procedure and performed key portions of the surgery.

PREOPERATIVE DIAGNOSES:
1. Fracture of sustentaculum tali (right type II talar neck fracture with associated subtalar dislocation).
2. Closed dislocation of tarsal bone, joint unspecified (right subtalar dislocation).

POSTOPERATIVE DIAGNOSES:
1. Fracture of sustentaculum tali (right type II talar neck fracture with associated subtalar dislocation).
2. Closed dislocation of tarsal bone, joint unspecified (right subtalar dislocation).

OPERATIONS PERFORMED:
1. Open treatment of talus fracture with or without internal or external fixation.
2. Open treatment of talotarsal joint dislocation with or without internal or external fixation.

SURGEON: John Doe, MD

ANESTHESIA: General via endotracheal tube.

ESTIMATED BLOOD LOSS: Less than 200 mL.

TOURNIQUET TIME: Approximately 70 minutes.

COMPLICATIONS: None.

INDICATIONS FOR OPERATION: This approximately (XX)-year-old female patient was driving a motor vehicle when she sustained the above-stated injury in a crash. The patient was evaluated at the trauma center. She was cleared for surgical intervention. Because of the fracture, dislocation of the talar neck, it was felt to be a surgical emergency. The risks, benefits, and alternatives of the procedure were discussed with the patient, the patient’s family, and informed consent was signed and obtained. The patient was taken to surgery.

DESCRIPTION OF OPERATION: The patient was taken to the operating room, and general anesthesia was induced via an endotracheal tube. The patient was given 1 g of IV cefazolin prior to initiation of the surgical procedure. The right lower extremity was prepped and draped in a sterile fashion. A thigh-high tourniquet was applied. The limb was elevated and exsanguinated with an Esmarch bandage. The tourniquet was elevated to 350 mmHg.

A provisional closed reduction of the subtalar joint was performed; however, it was reduced to a subluxation point. At that point, an open reduction of the dislocation and the fracture was performed. A standard extensile approach between the tibialis anterior and posterior tibial tendon was carried down through the skin and subcutaneous tissue over the medial border of the talus.

Dissection was taken down. Care was taken to avoid stripping off the insertion of the tibialis anterior tendon. The talar neck with some body fracture was demonstrated as well as the talonavicular joint. Lateral Bohler incision centered over the fourth ray was taken down through skin and subcutaneous tissue. The intermediate branch of the superficial peroneal nerve was identified and protected.

Retinaculum over the extensor tendon was opened. The extensor tendons retracted, including the peroneus tertius exposing the extensor digitorum brevis, which was elevated from proximal and distal thus exposing sinus tarsi to allow process with talus and accommodate the lateral talus body neck fracture to an open wound.

An open reduction of the subtalar joint was performed. The talar neck was then reduced by placing of Weber clamp in the distal head and neck segment to the medial and lateral wounds and reducing the fracture anatomically. Avulsive concomitant fracture of osteochondral fracture along the articular dome and head were revealed along the medial side. These osteochondral fractures that were so viable were placed back in the anatomic position.

Multiple 1.6 mm K-wires were used to provisionally stabilize the talus fracture. Reduction was confirmed on two plane image intensification, including lateral axial views as well as the Canale view demonstrating the reduction of the talar body and neck.

At that point, two 3.5 mm screws were placed, one placed lateral to posteromedial and a second screw was placed to the talar head from medial to posterolateral. Both screws were confirmed within body of talus and two plane image intensification demonstrated stabilization and neutralization across the fracture. With anatomic reduction stable, internal fixation of subtalar joint was anatomically reduced.

The wounds were copiously irrigated and closed in layers; the fascial layers with figure-of-eight 0 Vicryl suture, subcutaneous layer with inverted 2-0 Vicryl suture, and the skin with 3-0 nylon horizontal mattress suture. Sterile compressive dressings and a well-padded posterior splint were applied. The patient tolerated the procedure well and was taken to PACU in stable condition. There were no complications.

PREOPERATIVE DIAGNOSIS: Osteomyelitis to the distal aspect of right second metatarsal and base of right second proximal phalanx.

POSTOPERATIVE DIAGNOSIS: Osteomyelitis to the distal aspect of right second metatarsal and base of right second proximal phalanx.

OPERATION PERFORMED: Resection of head of right second metatarsal and base of right second proximal phalanx.

SURGEON: John Doe, MD

ANESTHESIA: MAC with local consisting of 12 mL of 1:1 mixture of 2% lidocaine plain and 0.5% Marcaine plain injected in an ankle block fashion.

PATHOLOGY: Bone from right second metatarsal head was sent for both culture and pathological analysis. Bone from right second proximal phalanx was sent for both culture and pathological analysis. Deep wound cultures were also obtained.

HEMOSTASIS: Right pneumatic ankle tourniquet set at 250 mmHg.

ESTIMATED BLOOD LOSS: Less than 5 mL.

MATERIALS: None.

INJECTABLES: None.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic male who is presenting today for resection of infected bone. The patient was previously hospitalized for infected ulcer to the right hallux, which was infected with MRSA. The patient underwent a right hallux amputation several months ago and had healed that amputation fine. However, upon subsequent visits, the patient had developed pain and swelling about the right second metatarsophalangeal joint. X-rays showed changes consistent with osteomyelitis of the head of the right second metatarsal and base of the right second proximal phalanx. The patient elected for surgical debridement of this infected bone and soft tissue. At this time, the patient is aware of the risks, benefits, and alternatives of the surgical correction offered. The patient has been n.p.o. for approximately 18 hours prior to surgery. The patient was medically cleared for surgery and has signed the consent.

DESCRIPTION OF OPERATION: Under mild IV sedation, the patient was wheeled back into the operating room and placed on the operating table in supine position. A well-padded right pneumatic ankle tourniquet was placed about the patient’s right ankle. The above-mentioned cocktail was injected in the above-mentioned fashion to achieve local anesthesia. The foot was then scrubbed, prepped, and draped in the usual aseptic manner. The right foot was elevated in Esmarch for exsanguination.

Attention was then directed to the dorsal aspect of the patient’s right foot where the patient had a contracture of the right second digit with hyperextension at the right second metatarsophalangeal joint and hyperflexion of the right second proximal interphalangeal joint. The incision was made overlying the right second metatarsophalangeal joint extending distally to the right second proximal interphalangeal joint, and extending approximately one third proximal to the right second metatarsal head. The incision was deepened down in a layered fashion using combination of sharp and blunt dissection. Care was taken to carefully retract all vital neurovascular structures. All bleeders were cauterized or ligated as necessary.

An incision was then made utilizing the #15 blade overlying the periosteum of the distal one third of the right second metatarsal, the right second metatarsophalangeal joint capsule, and the proximal aspect of the right second proximal phalanx. Utilizing the #15 blade, the periosteum was reflected off those bony structures. It was immediately noticeable that the right second metatarsal head was fragmented into many small pieces, was yellowish in consistency along with the cartilaginous cap being yellowish and loosely adhered to the subchondral bone. All of these changes were consistent with the osteomyelitis diagnosis as seen on x-ray.

Once the bones were freed up from their soft tissue attachments, and with the second extensor tendon carefully retracted laterally, a sagittal saw was utilized to make a bone cut from dorsal to plantar through the base of the proximal phalanx of the second metatarsal and at a 45 degree angle from dorsal distal to proximal plantar through the distal one third of the right second metatarsal head. When marking out the osteotomy site, care was taken to carefully note that the bone was deemed hard and showed no intraoperative signs of infection at the levels of the osteotomy sites.

Once the osteotomies were made, a #15 blade was used to free up the bone from its plantar soft tissue attachments and the head of the second metatarsal and base of the second proximal phalanx were then removed from the operative field and set aside to be halved and sent for both culture and pathological analysis. At this point, deep cultures were then obtained from the space remaining from the resected bone. Utilizing a hand rasp, all the prominent bony edges were smoothed down. The remaining bone was once again inspected for intraoperative signs of bone infection, of which none were seen. The space was then copiously flushed with normal sterile saline.

Next, biodegradable OsteoSet implantable beads were mixed utilizing vancomycin as the antibiotic and these small beads were packed filling the empty space left from the resected bone. Care was also taken to pack the beads into the medullary canal of the proximal phalanx of the right second digit. Once the beads were packed in place, the periosteum and capsule of the former joint was closed utilizing 3-0 Vicryl. The extensor tendon was then plicated proximally to regain tension and subsequently counteract the shortening and loss of tension caused by resection of the bone. This was done utilizing horizontal sutures both medially and laterally along the extensor tendon to the underlying periosteum while tensioning the extensor tendon proximally and distally.

Next, subcutaneous closure was obtained utilizing 4-0 Vicryl in a simple interrupted suture fashion. Skin was then closed utilizing 4-0 nylon in a simple interrupted suture fashion. The incision was then dressed with Betadine-soaked Adaptic, 4 x 4s, Kling, and an Ace bandage. The tourniquet was deflated and a prompt hyperemia response was noted to the right foot as mentioned earlier. The patient was then transferred to recovery and will be discharged home with postoperative instructions.

PREOPERATIVE DIAGNOSES:
1.  Chronic anterior cruciate ligament deficient left knee.
2.  Possible chondromalacia, left knee.

POSTOPERATIVE DIAGNOSES:
1.  Chronic anterior cruciate ligament deficient left knee.
2.  Posterior horn medial meniscus tear, left knee.
3.  Nondisplaced superior surface posterior horn lateral meniscus tear, left knee.
4.  Grade 1 to 2 chondromalacia, medial patellar facet, left knee.
5.  Fissuring, chondromalacia, lateral portion, medial femoral condyle, left knee.

OPERATION PERFORMED:
1.  Anterior cruciate ligament reconstruction with central one-third patellar tendon autograft, left knee.
2.  Repair of posterior horn medial meniscus tear with Polysorb meniscal staple, left knee.

SURGEON:  John Doe, MD

ANESTHESIA:  General LMA anesthesia.

TOURNIQUET TIME:  100 minutes.

DRAINS:  One intra-articular Hemovac drain.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed on the operating room table in the supine position. After adequate general LMA anesthesia was obtained, the patient’s left knee was examined. She has 2 to 3+ Lachman and 1 to 2+ pivot shift. She did have a popping with McMurray testing. She had full range of motion of proximal left lower extremity. A well-padded tourniquet was placed at 275 mmHg. The left extremity was elevated and exsanguinated with an Esmarch. The tourniquet was then inflated, and the left lower extremity was placed in a well-padded arthroscopic leg holder. The right lower extremity was also well padded, bottom of the bed was dropped. The left lower extremity was sterilely prepped from toes to leg holder with DuraPrep solution x2 and sterilely draped in standard fashion with waterproof extremity drape and waterproof stockinette. A circumferential adhesive Ioban draped about the left knee.

At this time, attention was turned to the anterior aspect of the left knee, where an incision was made just slightly medial to the center of the patellar tendon, taken down through skin and subcutaneous tissue. The paratenon was split in line with the incision. The medial and lateral borders of the patellar tendon were identified and it measured 33 mm. An 11 mm DePuy graft knife was used to take the central third of the patellar tendon with associated tibial and patellar bone plugs. This was fashioned on the back table. It was fit through a 10 mm spacer and sutures were passed through the bone plugs to aid in passage of the graft.

Attention was then turned to the knee with the skin retracted. Then anteromedial and anterolateral portals were established. The arthroscope was introduced with blunt trocar in the suprapatellar pouch. The anterolateral portal and the knee was distended with lactated Ringer’s and copiously irrigated. The suprapatellar pouch was within normal limits. The undersurface of the patella did have chondromalacia in the medial patellar facet, that was probed and felt to stable, and it was grade 1 to 2.

The remainder of the patellar articular cartilage and the trochlear groove articular cartilage were within normal limits. The medial gutter was without plica synovitis and loose body. Medial compartment was entered. The probe was used through the anteromedial portal to probe the extent of the posterior horn medial meniscus tear measuring approximately 1 cm and superior surface of the posterior horn. A decision was made to repair. The tear was in the red zone. Decision was made to repair this tear. That was repaired with one Polysorb meniscal suture and it was felt to be stable.

The articular cartilage, medial tibial plateau, was within normal limits. The medial femoral condyle had fissuring, chondromalacia, lateral portion, which was stable. The intercondylar notch was entered. The ACL was lax. There did appear to be some fibers that had scarred down more medially. The lateral compartment and lateral meniscus were probed in its entirety and it was stable. There was a superior surface 5 mm tear of the posterior horn, which was stable. The articular cartilage, lateral femoral condyle, and lateral tibial plateau were within normal limits. The lateral gutter was without plica synovitis and loose body.

Attention was turned to the intercondylar notch where the remnant of previous anterior cruciate ligament was debrided using the 5.5 mm shaver in the oscillating fashion. A quarter-inch osteotome was used to enlarge the notch anteriorly and a 5 mm round bur was used to enter posteriorly to complete the notchplasty. At this time, the tibial guide was used to enter the medial portal placed to the center of the footprint on previous ACL and a guidewire was run from distal and proximal at that site and reamed with a 10 mm reamer. The intra-articular portions of the tunnel were rasped. All fluid was removed from the knee.

Attention was then turned to the lateral aspect of the left thigh where a 3 cm incision was made just proximal to lateral femoral condyle taking down through the skin and subcutaneous tissue. The iliotibial band was split in line with the incision. The vastus lateralis was elevated and held anteriorly with a Z-retractor. The knee was again distended with fluid with the scope through the anteromedial portal and femoral guide through the anterolateral portal was placed just over the top position at approximately 1 o’clock in a clock phase. The guidewire was running from proximal to distal without difficulty and reamed with a 10 mm reamer. The intra-articular portions of the tunnel were rasped. A 9.5 mm graft passer was passed from distal to proximal and the graft was passed from proximal and distal without difficulty. The bone plug was fixed in the femoral tunnel with a 8 x 20 mm Stryker screw with attention on the graft. The knee was taken through range of motion several times. There was no evidence of pistoning, it was examined arthroscopically, and there was no evidence of anterolateral impingement. At this time, tension on the graft and knee, approximately 10 to 15 degrees of flexion, mild posterior pressure on the tibia. The distal bone plug was fixed with 9 x 20 mm Stryker wedge screw.

The graft was again examined arthroscopically. It was probed and felt to be stable. The Lachman’s was felt to be obliterated. There was no evidence of anterolateral impingement. The knee was copiously irrigated. A drain was placed in the suprapatellar pouch exiting laterally through the anterolateral portal. The drain was injected with 30 mL of 0.5% Marcaine with epinephrine without preservative. The excess bone from the bone plugs was packed into the patellar defect. The patellar tendon was loosely approximated with two interrupted sutures of 0 Vicryl. The paratenon was loosely approximated with 2-0 Vicryl.

The subcutaneous tissue was irrigated and closed with interrupted sutures of 2-0 Vicryl and the skin was closed with running 4-0 subcuticular Vicryl. Benzoin and Steri-Strips were applied laterally. The wound was irrigated. The iliotibial band was closed with interrupted sutures of 1 Vicryl. The subcutaneous tissue was irrigated and closed with interrupted 2-0 Vicryl sutures. The skin was closed with a running 4-0 subcuticular Vicryl. Benzoin and Steri-Strips were applied. Sterile 4 x 4, ABD, Protouch, a cool temp pad, and Ace wrap dressing from the toes to the groin were applied. Tourniquet was released at the completion of dressing. Tourniquet time was 100 minutes. The patient tolerated the procedure well and was stable in the recovery room.

PREOPERATIVE DIAGNOSES:
1. Chronic tendonitis of the rotator cuff with possible tear of the cuff.
2. Degenerative arthritis of the acromioclavicular joint.

POSTOPERATIVE DIAGNOSES:
1. Chronic tendonitis of the rotator cuff with impingement.
2. Synovial cyst, acromioclavicular joint, right.

OPERATION PERFORMED:
1. Arthroscopy of the right shoulder with debridement and lavage.
2. Bursoscopy, right shoulder.
3. Subacromial decompression.
4. Acromioplasty, partial excision of the lateral end of the clavicle.
5. Excision of large synovial cyst, right shoulder.

SURGEON: Jane Doe, MD

ANESTHESIA: General.

DESCRIPTION OF OPERATION: Under general anesthesia, following endotracheal intubation, the patient was placed in a beach chair position. The right shoulder was then isolated with isolation drape and then prepped and draped in a routine manner for arthroscopy. Posterior portal was used to enter the joint from posterior aspect through a small incision. Joints were checked out. There were degenerative changes in the joint but no major damage noted. There was some fibrillation at the attachment of the biceps tendon. The second portal was created anteriorly and a plastic cannula inserted into the joint for continuous irrigation of the joint. The labrum was noted to be intact, although some fibrillation was noted. The rotator cuff did not appear torn checking from underneath. Debridement of the fibrillated areas was done and then this procedure was terminated and we decided to go to the next phase of the operation, which was a bursoscopy.

Arthroscope was withdrawn from the joint and into the subacromial bursa. A lateral portal was created and then a 4 mm aggressive meniscal cutter was introduced into the subacromial space. The cobweb of synovial tissues was excised as much as necessary to get a clear visualization of the subacromial area. The rotator cuff was found to be intact. There was hypertrophy at the end of the clavicle that was noted after the posterior capsule was debrided and removed. The soft tissue underneath the anterior acromion was denuded with the 4 mm meniscus cutter and then a 5 mm bur was introduced and undersurface of the acromion was shaved and smoothed out. Next, the outer end of the clavicle was partially excised using the bur. ArthroCare instrument was also introduced to coagulate any bleeding points. After thorough irrigation and after the subacromial decompression was satisfactorily completed, instruments were withdrawn and then we went to the next phase of the procedure.

The last phase of the procedure was to excise the cystic lesion that was discovered at the top of the AC joint. Initially, we introduced the needle and mucinous thick fluid came out proving the point that there was in fact a big synovial cyst. Incision was made over the cyst. Incision was slightly curved. It was about 2 inches long. The incision was taken down through the skin, subcutaneous tissue, fascia down to the synovial tissue, which was dissected. It was quite tense, and we decided to go ahead and open the cyst, which we did and evacuated all the contents. We identified the wall of the cyst, and it was in close association with the superior part of the acromioclavicular joint. The capsule and the ligaments were all found to be intact. We just simply removed the wall of the cyst in piecemeal. Thorough irrigation was done and then the closure was completed. We are leaving a Penrose drain in place. The deep tissues were approximated with interrupted 2-0 Vicryl sutures. The subcutaneous tissues were approximated with 2-0 Vicryl sutures and skin closed with skin clips. Dressing was applied. The patient went through the procedure without complication and was taken to recovery.

PREOPERATIVE DIAGNOSIS: Right knee medial compartment degenerative arthritis.

POSTOPERATIVE DIAGNOSIS: Right knee medial compartment degenerative arthritis.

OPERATION PERFORMED:
1. Right knee medial compartment hemiarthroplasty.
2. Partial patella excision.

SURGEON: John Doe, MD

ANESTHESIA: General.

DESCRIPTION OF OPERATION: The patient was brought into the room and anesthetized with general anesthesia. The right lower extremity was prepared with a tourniquet. The leg was prepped with DuraPrep and draped in a sterile fashion. The limb was exsanguinated. Thigh tourniquet was inflated to 300 mm of pressure.

The patient had an oblique incision over the medial aspect of the knee. We were able to use most of this incision distally. It was curved slightly anterior so that we could gain a full access of the medial compartment. Dissection was carried down through the subcutaneous tissue. The medial retinaculum of the patella was incised, and the incision was carried proximally along the vastus medialis oblique for 2 cm. This revealed the medial compartment with extensive osteoarthritis, medial compartment with eburnated bone on both femur and tibia, large bone spurs on both sides. The patella was thickened and overgrowing medially. We thought that we had to do a partial patella excision so that the patella would not impinge on the implant, so we subperiosteally elevated the medial facet of the patella, and using the oscillating saw, we osteotomized approximately 30% of the medial facet of the patella. The rongeur was used to smooth out the remainder of the patella. At the end of the case, this defect was closed by pulling the periosteal tissues and retinacular tissues over the defect and suturing from medial to lateral.

Next, we approached the proximal tibia and exposed it. We used a tibial cutting guide attached to the proximal tibia. We made the sagittal cut with the reciprocating saw and the transverse cut with the oscillating saw. We sized the flexor space. We used the intramedullary alignment guide. We made the pilot hole for the intramedullary alignment guide. We put the first cutting jig in position using the intramedullary rod for alignment. We anchored the cutting jig in position and we cut the posterior femoral condyle.

Then, we used a second jig. We measured the flexion space and extension space and used the progressively larger spigots. We were able to ream the extension space to match the flexion space. Along the way, we removed the bone spurs circumferentially. Once we had the flexion space and extension spaces matched up, we put the trial components in place.

Once we were happy with the alignment and positioning, we then marked the position for the tibial tray, and we cut the slot for the tibial stem in the usual fashion with the punches and curette. Since the distal femur was eburnated, we made several drill holes in the distal femur. We irrigated the bone. We irrigated the joint. We infiltrated the posterior capsule, PCL, medial capsular structures, and subcutaneous tissues with 0.025% Marcaine. The cement, antibiotics, tobramycin cement was mixed, and we cemented the components in place, first the tibia, then the femur.

Once the cement hardened, we did another trial reduction with 6 mm bearing. This gave us excellent stability. Soft tissue tension was equal in both flexion and extension. The actual bearing was selected. The area was irrigated.

At the beginning of the case, we removed 55 mL of blood from the patient, spun it down to platelet growth factors, and this was applied around the cut tendinous and bony surfaces. A drain was left in place.

The medial retinacular structures were closed with interrupted Vicryl suture closing the defect that was left by removing part of the patella. The deep fascia was closed with interrupted Vicryl suture. The subcutaneous closure was obtained with Vicryl. Skin was closed with staples. Sterile dressing was applied. The patient was awoken and taken to the recovery room in stable condition.