DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right knee patellofemoral maltracking.
POSTOPERATIVE DIAGNOSES:
1. Right knee patellofemoral maltracking.
2. Grade 4 chondromalacia lesion, approximately 1 x 1.5 cm central portion of her trochlea.
OPERATIONS PERFORMED:
1. Right knee arthroscopy.
2. Abrasion chondroplasty of trochlear lesion.
3. Lateral release.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This patient is a (XX)-year-old female with a history of right anterior knee pain as evidenced by patellofemoral maltracking on physical examination. The patient was given treatment options, and she chose to proceed with right knee arthroscopy, lateral release and debridement as indicated.
DESCRIPTION OF OPERATION: Following informed consent, the patient was taken to the operating room and placed supine on the operating table. After adequate general anesthesia, the tourniquet was applied to the right lower extremity. It was not inflated during this case. The lower extremity was then placed into a leg holder. All bony prominences were well padded. The right lower extremity was then prepped and draped in the usual sterile fashion.
Standard inferolateral portal was made. Trocar was inserted into the knee. Diagnostic arthroscopy revealed the suprapatellar pouch without abnormalities. Examination of the patellofemoral joint showed she had grade 2 changes on the lateral side of her patella with no unstable chondral flap. She had a large central trochlear lesion measuring approximately 1 x 1.5 cm, grade 4, with exposed bone and unstable cartilage rim. Examination of her medial compartment showed no evidence of meniscal tear or chondral abnormalities. Examination of her notch showed her previous ACL reconstruction graft was intact. Examination of the lateral compartment showed she has very mild fraying of the body of her lateral meniscus, no evidence of any unstable tears.
Attention was then turned to the trochlea where a chondroplasty was performed back to stable margins with the use of a 4.5 mm shaver and open curettes. Abrasion chondroplasty was then performed with the use of an egg bur. This was done to bleeding subchondral bone. The patient had obvious lateral tilt of her patella and lateral subluxation. Decision was made to proceed on with lateral release. ArthroCare wand was used to perform a lateral release. This restored the normal alignment of the patellofemoral joint. Patella was able to be elevated to approximately 70 degrees upon the lateral release. Arthroscopic equipment was removed from the knee. Portal sites were closed with the use of simple nylon sutures. A sterile compressive dressing with a bolster over the lateral patella was placed as well as the Polar Care. The patient tolerated the procedure well.
