Orthopedic (Ortho) Operative Procedure Medical Transcription Sample Reports / Examples


DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:

1.  Torn meniscus, right knee.
2.  Osteochondral fracture, distal femur, right knee.

POSTOPERATIVE DIAGNOSES:

1.  Torn medial meniscus, right knee.
2.  Torn lateral meniscus, right knee.
3.  Osteochondral fracture, intertrochlear groove, distal right femur.
4.  Multiple large loose bodies.

OPERATIONS PERFORMED:

1.  Arthroscopy, right knee, with partial medial meniscectomy and partial lateral meniscectomy.
2.  Patellar and femoral chondroplasty using microfracture technique.
3.  Removal of large loose bodies.
4.  Joint debridement and joint injection.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Jill Doe, CRNA

DESCRIPTION OF OPERATION:  After correct identification of the patient with satisfactory preoperative labs and appropriate medical clearances, the patient was taken to surgery.  We identified the correct operative site.  General anesthesia was induced by Ms. Jill Doe without complications.  The patient received Ancef 1 gram IV preoperatively.  The right knee was examined under anesthesia.  There was no ligamentous laxity noted.  Tourniquet was applied to the proximal right thigh area.  The right lower extremity was exsanguinated.  Tourniquet was inflated to 300 mmHg pressure.  Total tourniquet time was less than 1 hour.  The right leg was then placed in a well-padded leg holder.

After routine prep and drape, the inflow cannula was established superomedial to the patella and the joint infused with normal saline solution.  The arthroscope was then introduced through the lateral portal approach through medial portal.  On inspection of suprapatellar pouch area, there was some reactive synovitis that was debrided.  He had a large cartilaginous loose body that was removed.  He had a large medial plica, which was excised.  We then entered the medial gutter where he had a very large piece of bone measuring 1 x 1.5 cm.  We increased the size of the medial portal and then reached in with the grasper and removed this large loose body.

I then inspected the medial compartment where he had mild grade 1 and 2 changes of chondromalacia.  Chondroplasty was performed as necessary.  He had a small tear of the posterior horn of the medial meniscus, which was excised and some fraying and tearing of the anterior horn of the meniscus, which was incised.  We were then able to contour the meniscus using a meniscal shaver.  The mid portion of the meniscus was intact.

In the intercondylar notch area, we retrieved yet another loose body from the intercondylar notch area.  The anterior and posterior cruciate ligaments were visualized, probed, stressed and found to be intact.  We entered the lateral compartment.  No significant arthritic change was noted.  He had a flap tear of the anterior horn of the lateral meniscus, which was excised.  The remainder of the meniscus was probed and found to be intact.  We then balanced and contoured the meniscus using a meniscal shaver.

Once again, we turned our attention to the distal femur and intercondylar notch area.  He had a grade 4 area of erosion with exposed bone.  This was where the multiple loose bodies came from.  The undersurface of the patella showed grade 2 degenerative change but no full-thickness erosions.  We then completed our chondroplasty, beveling the edges of the defect, and with a microfracture technique, completed the chondroplasty.  All loose articular cartilage fragments were removed.

Inspecting the knee once further, no other pathology was noted.  All instrumentation was removed from the knee.  The knee was allowed to drain.  The wounds were closed in one layer with skin staples.  The knee was then injected with 1 mL of Decadron-LA and 20 mL of 0.25% Marcaine without epinephrine.  Appropriate Adaptic compression dressing was applied to the knee.  The tourniquet released, general anesthesia reversed and the patient was taken from the operating room to the recovery room in satisfactory condition with vital signs stable and circulatory status intact.

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Degenerative joint disease, left shoulder.

POSTOPERATIVE DIAGNOSIS:  Degenerative joint disease, left shoulder, with degenerative labral tear and chondral flap tear of glenoid.

OPERATION PERFORMED:  Arthroscopic exam of glenohumeral joint with arthroscopic debridement of labral tears, chondroplasty and microfracture of glenoid.

SURGEON:  John Doe, MD

ASSISTANT SURGEON:  Jane Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, placed in a supine position on the operating room table.  A general anesthetic was administered.  The left shoulder was prepped and draped in a sterile orthopedic fashion after he was placed in a beach-chair position.  A time-out was performed confirming left shoulder pathology, and he also had 1 gram of Ancef administered intravenously.  After the sterile orthopedic prep and drape, a posterior stab wound was created and the arthroscope was introduced into the glenohumeral joint.  The joint was inspected.  There were degenerative changes of the labrum circumferentially.  Through an anterior portal, a full-radius resector was inserted and these areas debrided back to stable tissue and this was supplemented with use of the ArthroCare wand on a setting of one.  There was a flap tear of the anterior portion of the mid glenoid region.  This was easily displaceable.  Using a 4.2 full-radius resector, this was debrided back to stable tissue and then an awl was used to microfracture the bone.  The inflow pump was then stopped and bloody fluid could be seen coming from the microfracture area.  The undersurface of the rotator cuff was inspected and found to be without pathology.  The arthroscope was then placed into the anterior portal, and through the posterior portal, the ArthroCare wand and a full-radius resector was inserted and the most inferior aspect and posterior aspect of the glenoid and labrum debrided.  There were no frank tears of the posterior labrum.  The arthroscope was then placed in the subacromial space, which did appear to be pristine.  There was no evidence of impingement.  All instruments were then removed and the stab wounds were closed with a single Monocryl suture and Steri-Strips.  Dry sterile dressings were placed over the wound.  The patient was placed in a shoulder sling and then sent to the recovery room in stable condition

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Laceration, right wrist, with extensor tendon injury.

POSTOPERATIVE DIAGNOSIS:  Laceration, right wrist, with extensor tendon injury.

OPERATIONS PERFORMED:
1.  Exploration of right wrist laceration.
2.  Extensor tenosynovectomy of the sixth extensor compartment with tenolysis.
3.  Secondary repair of extensor carpi ulnaris tendon laceration.
4.  External neurolysis and decompression of dorsal ulnar sensory nerve.

SURGEON:  John Doe, MD

ANESTHESIA:  Axillary block.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMENS:  None.

COMPLICATIONS:  None.

DRAINS:  None.

DESCRIPTION OF OPERATION:  The patient was identified in the holding area.  Appropriate surgical limb and site were confirmed and marked.  Axillary block anesthetic was administered.  He was brought to the operating room and placed in supine position on the operating room table.  The right upper limb was prepped and draped in routine fashion.  The upper limb was exsanguinated with an Esmarch bandage and a previously placed well-padded pneumatic tourniquet was inflated to 250 mmHg.  A 3.5 loupe magnification was used throughout.  Longitudinal exposure was used.  An incision was made through the previous scar, extended proximally and distally through the zone of injury.  Skin flaps were raised at the subcutaneous level.  The dorsal branch of the ulnar nerve was identified.  It was encased in scar tissue.  External neurolysis and decompression were carried out as it was within the zone of injury.  Further dissection revealed an active tenosynovitis involving the sixth extensor compartment.  This was found to have injury to the distal portion of the extensor retinaculum.  The retinaculum was completely opened.  There was a partial injury to the extensor carpi ulnaris tendon.  There was a high grade tenosynovitis present.  Tenosynovectomy was carried out with tenolysis of the tendon from scar tissue bed.  Secondary tenorrhaphy was performed with running over-and-over 6-0 Prolene.  There was no violation of the joint capsule.  The fifth extensor compartment containing the extensor digiti minimi was outside the zone of injury.  The wounds were irrigated with saline.  The sixth extensor compartment retinaculum was repaired with interrupted 4-0 Supramid sutures.  The wrist and forearm were put through range of motion to confirm that the tendon was not entrapped.  The tourniquet was deflated.  Hemostasis of small bleeding points using bipolar cautery.  The skin wound was closed in layers with buried deep dermal 6-0 Vicryl and running over-and-over 5-0 nylon.  The wound was dressed with antibiotic ointment and Adaptic.  A bulky dressing was applied and reinforced with a long-arm fiberglass splint maintaining the wrist and forearm in neutral position.  The patient tolerated the procedure well, was awakened in the operating room and transported to the recovery room in stable condition.


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DATE OF OPERATION: MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Torn anterior cruciate ligament with possible medial meniscal tear, left knee.
 
POSTOPERATIVE DIAGNOSIS:  Torn anterior cruciate ligament with chondromalacia, left knee.
 
OPERATION PERFORMED:  Diagnostic and operative right knee arthroscopy with debridement.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Jane Doe, MD
 
ANESTHESIA:  General.
 
ANESTHESIOLOGIST:  Jill Doe, MD
 
IV FLUIDS:  750 mL.
 
TOTAL TOURNIQUET TIME:  10 minutes.
 
ESTIMATED BLOOD LOSS:  Minimal.
 
SPECIMENS:  None.
 
COMPLICATIONS:  None.
 
GROSS FINDINGS:  Completely torn anterior cruciate ligament with redundant anterior fat pad and synovium with grade 2 chondromalacia of lateral femoral condyle and femoral groove.
 
DISPOSITION:  The patient was discharged to the postanesthesia care unit in stable condition.
 
BRIEF HISTORY:  The patient is a (XX)-year-old male with a history of left knee trauma many years ago.  In addition, he had an injury to his left knee several months ago and he has had persistent pain.  He was seen previously and had symptoms of medial joint line tenderness indicating a possible medial meniscal tear.  Examination initially with the patient awake did not demonstrate any ligamentous laxity, however, guarding was present.  In addition, according to the medical record, there was a diagnosis of anterior cruciate ligament tear.  However, I do not have any MRI reports or MRI films to confirm that.  Because of the persistent nature of this patient's symptoms, it was decided that the above procedure was necessary.
 
DESCRIPTION OF OPERATION:  The patient was seen in the preoperative holding area and the correct operative site was identified.  He was transported to the operative suite by department of anesthesia.  He was then transferred supine to the operating table.  Department of anesthesia administered a general anesthetic without difficulty.  A well-padded tourniquet was placed in the proximal left thigh.  The left lower extremity was then placed into an arthroscopic leg holder and a pad was placed under the right thigh.  The bottom of the operating table was dropped.  He was then prepped and draped in the usual sterile manner for this case.
 
Prior to prepping and draping, the knee was taken through an examination under anesthesia, and there was obvious anterior laxity as well as a pivot shift indicating an anterior cruciate ligament tear.  Initially, superomedial portal was established at the level of the previous portal site and an inflow cannula was placed into the suprapatellar pouch.  In addition, the anterolateral and anteromedial portals were made.  Arthroscopic cannula was placed into the anterolateral portal and into the knee.  Arthroscope was placed into the cannula and into the suprapatellar pouch.  The inflow cannula was visualized and found to be in good position.  There was some grade 2 chondromalacia noted at the femoral groove.  This was essentially a linear pattern at the deepest portion of the groove.  There were no significant loose portions of cartilage noted.  The undersurface of the patella did not demonstrate any significant chondromalacia.  Hypertrophic anterior fat pad was noted at this time.  Medial and lateral gutters were visualized, and there were no loose bodies noted in these areas or evidence of degenerative joint disease.  The lateral compartment was visualized initially.  There was some grade 2 chondromalacia noted on the lateral femoral condyle in an area of approximately 10 mm in diameter on the weightbearing surface.  The tibial plateau articular surface appeared to be intact.  The lateral meniscus did not have any evidence of tear.  A probe was placed into the compartment and did confirm lack of lateral meniscal tear.  At that point, the femoral notch was visualized.  There was a frayed torn anterior cruciate ligament stump noted on the tibia.  There was no evidence of any anterior cruciate ligament attachment to the lateral femoral condyle.  There was a fairly loose lateral meniscofemoral ligament of Humphry which was noted, and posterior cruciate ligament appeared behind a synovial covering.  The medial compartment was then visualized.  There was no evidence of chondromalacia of the medial femoral condyle or the medial tibial plateau.  A probe was placed to manipulate at the medial meniscus, and there was no evidence of a medial meniscal tear.
 
At that point, arthroscopic shaver was used to debride the anterior cruciate ligament stump.  In addition, some of the redundant anterior synovium and hypertrophic fat pad were débrided as well.  Tourniquet was inflated at this point secondary to bleeding.  It was inflated to 300 mmHg.  After the debridement was complete, the compartments were visualized once again and no other pathology was noted.  At that time, instruments were removed from the medial portal as well as the cannula from the superomedial portal.  The arthroscope was placed into the suprapatellar pouch.  It was removed, and excess fluid was drained from the knee through the arthroscopic cannula in the anterolateral portal.  At that point, 20 mL of 0.5% Marcaine with epinephrine was instilled into the knee and the cannula was removed from the anterolateral portal.
 
The skin was then closed with #3-0 nylon suture.  The skin was then cleansed and dried.  Xeroform was placed over the portal sites followed by 4 x 4s and ABD dressing.  This was then wrapped loosely with a wrap roll.  The drapes were removed from the patient.  Remainder of the skin was cleansed and dried.  A 6-inch Ace bandage was then used to loosely wrap the dressing.  The patient was returned to a normal supine position.  The tourniquet was let down with a total time of 10 minutes.  Department of anesthesia reversed the general anesthetic without difficulty.  The patient was then transferred supine to the operative gurney.  He was transported to the postanesthesia care unit in a stable condition.
 
Prognosis for this patient is fair.  He is cruciate deficient and is at risk for further episodes of instability with activity.  Postoperatively, an anterior cruciate ligament brace was ordered as well as physical therapy for range of motion and strengthening.  Sutures will be removed in 5-7 days postoperatively.  He may shower on postoperative day #3 with absolutely no tub soaks or other soaks for 2 weeks.  We will see him for followup in the clinic at approximately 6 weeks' time and manage his condition further from there depending on how he is doing.  The patient may require anterior cruciate ligament reconstruction in the future.

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left chronic anterior cruciate ligament tear.

POSTOPERATIVE DIAGNOSES:
1.  Left chronic anterior cruciate ligament tear.
2.  Grade III chondromalacia of the patella.

OPERATION PERFORMED:
1.  Left knee arthroscopy with arthroscopic anterior cruciate ligament reconstruction using autologous hamstring tendon.
2.  Left patellar chondroplasty.

SURGEON:  John Doe MD

ANESTHESIA:  LMA.

TOURNIQUET TIME: 110 minutes.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

DRAINS:  None.

INDICATIONS FOR OPERATION:  This is a (XX)-year-old female with chronic problems of the knee including instability. MRI showed evidence of a near complete ACL tear. The patient continues to have functional impairment and has not improved with conservative treatment. Risks, benefits and alternatives of the surgery were explained to the patient, and the patient 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. An adequate level of LMA anesthesia was obtained. Preoperative IV Ancef was given. Tourniquet was applied to the left lower extremity and was then verified, prepped and draped in the normal sterile fashion. An incision was made overlying the hamstring tendons and dissection carried down sharply through the subcutaneous. Superficial vein running transversely was preserved. The hamstring tendon was then identified and the periosteum resected. The semitendinosus and gracilis were localized and #2 Ethibond stitch was placed through the tendons. These were then harvested completely with a tendon stripper and both had excellent length and bulk. They were prepared on the back table. Previously, the sites of incisions were all injected with Marcaine. An anterolateral port was then made and diagnostic arthroscopy performed. There was grade III chondromalacia of some unstable flaps of the patella. A chondroplasty was performed with motorized shaver. Trochlea had minimal chondromalacia. The patient had a small medial plica, which was left intact. No evidence of medial meniscal tear. The ACL had scarred to the PCL but had minimal attachment onto the lateral portion of the femur. The lateral meniscus and compartment showed no significant chondromalacia or meniscal tears. At this time, the ACL was debrided with motorized shaver. There was significant thickening and yellowish discoloration in the proximal segment. Notch plasty was performed with a bur. The tibial guide was then used to make the tibial tunnel in the posterior footprint of the ACL, just anterior to the PCL. The tunnel was 58 degrees. The graft measured 8.5 mm in diameter and the 8.5 mm reamer was placed over the guidepin. The guidepin was then placed onto the femoral condyle at about the 1 o'clock position. This was drilled. This was then reamed with an 8.5 reamer, preserving about 2 mm of posterior bone. Mitek guide was then placed into the tunnel and 2 cannulas were drilled just posterior to the IT band through small stab incisions. The guide was then removed and beefed in place into the femur and graft pulled up through the tunnels. The graft was then secured and two of the Rigidfix pins were placed with excellent purchase. The graft was very stable at this point. There was no impingement of the graft in full extension. Distally, the graft was secured with the Intrafix system with a sleeve and a bioabsorbable screw with the knee in 20 degrees of flexion and posterior drawer force applied. There was negative Lachman exam at the conclusion of the procedure. The knee was then thoroughly irrigated and drained. Marcaine injected into the knee. Deep tissue closed with 0 Vicryl and subcutaneous closed with Monocryl, followed by a subcuticular stitch and Steri-Strips. All small incisions were closed with Steri-Strips. Sterile compressive dressings were then applied, followed by cold packing and a brace. The patient was extubated and transferred to the recovery room in good, stable condition. There were no complications



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