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Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.

Orthopedic

Bunion & Pes Planovalgus Deformity

HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:, See Patient History sheet, which was reviewed with the patient and is signed in the chart. Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds. She has palpable pulses. Neurologic sensation is intact. Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy. There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement. She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right. Gait analysis: The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:, X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy. Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle. No evidence of arthrosis in the joint is noted. Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1. Recurrent bunion deformity, right forefoot.,2. Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal. Anticipated length of healing was noted for the patient as were potential risks and complications. The patient ultimately would probably require surgery on her left foot at a later date as well.,2. The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3. All questions were answered.

orthopedic, x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion

Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.

Orthopedic

Bunionectomy - Austin - Akin

PREOPERATIVE DIAGNOSIS:, Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:, Bunion, right foot.,PROCEDURE PERFORMED:, Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:, An IV was instituted by Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap. Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated to the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg. The foot was lowered to the operating field and the stockinet was reflected. The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot. An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint. The incision was then deepened with a #15 blade. All vessels encountered were ligated with hemostasis. The skin and subcutaneous tissue were then undermined off of the capsule medially. A dorsal linear capsular incision was then created over the first metatarsophalangeal joint. The periosteum and capsule were then reflected off of the first metatarsal. There was noted to be a prominent medial eminence. The articular cartilage was healthy for patient's age and race. Attention was then directed to the first interspace where a lateral release was performed.. A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified. The adductor tendons were transected as well as a lateral capsulotomy was performed. The extensor digitorum brevis tendon was identified and transected. Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum. Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon. Attention was then directed to medial eminence, which was resected with a sagittal saw. Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal. The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted. The head was intact. A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral. A second K-wire was then inserted from distal lateral to proximal plantar medial. Adequate fixation was noted at the osteotomy site. The K-wires were bent, cut, and pin caps were placed. Attention was then directed to the proximal phalanx of the hallux. The capsular periostem was reflected off of the base of the proximal phalanx. A sagittal was then used to create an akin osteotomy closing wedge. The apex was lateral and the base of the wedge was medial. The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression. Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site. Adequate fixation was noted at the osteotomy site and the osteotomy was closed. The toe was noted to be in a markedly more rectus position. Sagittal saw was then used to resect the remaining prominent medial eminence. The area was then smoothed with a reciprocating rasp. There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp. The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site. The capsule was closed with #3-0 Vicryl. Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl. Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot. A _______ cast was then applied postoperatively. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain. The patient is to follow up with Dr. X in his office as directed.

orthopedic, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy

A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The pain is located laterally as well as anteriorly into the groin.

Orthopedic

Bilateral Hip Pain

HISTORY OF PRESENT ILLNESS: ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.,PAST MEDICAL HISTORY: ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES: ,The patient has no known drug allergies.,SOCIAL HISTORY: ,The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:, X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:, After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed.

orthopedic, bilateral hip pain, femoroacetabular, impingement, hip,

Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.

Orthopedic

Back Pain - Discharge Summary

CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years. On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright. He was seen at ABCD Hospital Emergency Room, was evaluated and admitted. He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A. It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007. He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes. The patient reports that he has had a " bulging disk" for approximately 1 year. He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative. The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department. He is a nonsmoker. He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends. He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors. Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis. The patient reports that his last bowel movement was on 08/30/2007. No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties. The patient does report that he has occasional intermittent "numbness and tingling" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome. He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS: At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air. The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL: The patient appears to be comfortable, in no acute distress.,HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Tongue is at midline and no evidence of thrush.,NECK: Trachea is at the midline.,LYMPHATICS: No cervical or axillary nodes palpable.,LUNGS: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. Normal S1 and S2.,ABDOMEN: Obese, softly protuberant, and nontender.,EXTREMITIES: There is no clubbing, cyanosis or edema. There is no calf tenderness bilaterally. Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity. The right lower extremity is 4-5/5.,MENTAL STATUS: He is alert and oriented. He was pleasant and cooperative during the examination.,ASSESSMENT:,1. Acute on chronic back pain. The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy. He will be seen in consultation by Physical Therapy and Occupational Therapy. He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2. Status post right orchiectomy secondary to testicular cancer, stable at this time. We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3. Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis. Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4. Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5. Obesity. As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.

Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal. Excision of nerve lesion with implantation of the muscle belly of the left second interspace. Excision of nerve lesion in the left third interspace.

Orthopedic

Bbunionectomy & Metatarsal Osteotomy

PREOPERATIVE DIAGNOSIS: ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1. Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2. Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3. Excision of nerve lesion in the left third interspace.,ANESTHESIA: ,Monitored IV sedation with local.,HISTORY: ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal. The patient has attempted conservative correction and injections with minimal improvement. The patient desires surgical correction at this time. The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes. At this time, the patient desires surgical intervention and correction. The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position. A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia. The foot was then prepped and draped in the usual sterile orthopedic manner. The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage. The foot was then lowered down the operative field and sterile stockinet was draped. The stockinet was then reflected. Attention was then directed to the second intermetatarsal interspace. After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head. Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue. Care was taken to identify and avoid or to cauterize any local encountered vascular structures. Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade. The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated. The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly. These endings were dissected distally and cut at their most distal portions. Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space. Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue. This was also cut and removed. The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed. Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection. It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly. Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound. Attention was then directed to the third interspace where in a manner as mentioned before. A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head. Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal. The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified. These were once again dissected distally out and transected at their most distal portions. Care was then taken to dissect the nerve proximally into the proximal metatarsal region. No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed. The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace. Half of the nerve was transected proximally as was feasible and no exposed ending was noted. Incision was then flushed and irrigated using sterile saline. Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade. The incision was then deepened using #15 blade down to the level of the subcutaneous tissue. Care was taken to reflect any neurovascular structures which were encountered. Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region. After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially. Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone. OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position. Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally. Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture. Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit. The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage. The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact. The patient tolerated the procedure well without any complications. The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily. The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office. The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated. The patient also instructed to take her medications and prescriptions as directed. She was given the emergency contact numbers. Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.

orthopedic, tailor's bunion, neuroma, nerve lesion, interspace, metatarsal, osteotomy, metatarsal osteotomy, metatarsal head, foot, distally, head, incision, nerve, intermetatarsal, portions,

Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation.

Orthopedic

Back Injury IME

PAST MEDICAL CONDITION:, None.,ALLERGIES:, None.,CURRENT MEDICATION:, Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:, The patient is a 52-year-old male who is here for independent medical evaluation. The patient states that he works for ABC ABC as a temporary worker. He worked for ABCD too. The patient's main job was loading and unloading furniture and appliances for the home. The patient was approximately there for about two and a half weeks. Date of injury occurred back in October. The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load. Unfortunately at this particular event, the patient had sharp pain in his lower back. Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. This became progressively worse. He also states that some of his radiating pain went down to his left leg as well. He noticed increase in buttock spasm and also noticed spasm in his buttocks. He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe. The patient states that after this treatment, his symptoms still persisted. At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April. After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids. He was put on restricted duty. The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral. The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief. The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD. The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. He has difficulty sleeping at nighttime because of increase in pain. Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June. The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:, The patient was examined with the gown on. Lumbar flexion was moderately decreased. Extension was normal. Side bending to the right was decreased. Side bending to the left was within normal limits. Rotation and extension to the right side was causing increasing pain. Extension and side bending to the left was within normal limits without significant pain on the left side. While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°. There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position. In supine position, straight leg was negative in the LLE and also negative on the RLE. Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits. Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side. Medial hamstring reflex was 2+/4 on both hamstrings as well. On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side. Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:, I had the opportunity to review Dr. XYZ's medical records. Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December. Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal. The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:, The patient has an impairment based on AMA Guides Fifth Edition and it is permanent. The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck. Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left. The patient also has increase in back pain with lumbar flexion and rotational movement to the right side. With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function. Therefore, the patient is assigned 8% impairment of the whole person. We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide. Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury. In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy. The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI. In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back. His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain. The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management. The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,

orthopedic, rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology,

Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.

Orthopedic

Back & Leg Pain - Discharge Summary

ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:, Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain. He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability. He was admitted and underwent an uncomplicated surgical procedure as noted above. In the postoperative period, he was up and ambulatory. He was taking p.o. fluids and diet well. He was afebrile. His wounds were healing well. Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP: ,At this time, the patient will follow up with me in the office in six weeks' time. The patient understands discharge plans and is in agreement with the discharge plan. He will follow up as noted

orthopedic, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg

Ruptured distal biceps tendon, right elbow. Repair of distal biceps tendon, right elbow.

Orthopedic

Biceps Tendon Repair

PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:, Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE: ,The patient was taken to OR, Room #2 and administered a general anesthetic. The right upper extremity was then prepped and draped in the usual manner. A sterile tourniquet was placed on the proximal aspect of the right upper extremity. The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg. Tourniquet time was 74 minutes. A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin. Hemostasis was achieved utilizing electrocautery. Subcutaneous fat was separated and the skin flaps elevated. The _________ was identified. It was incised. The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found. There was some serosanguineous fluid from the previous rupture. This area was suctioned clean. The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface. At this point, the #2 fiber wire was then passed through the tendon. Two fiber wires were utilized in a Krackow-type suture. Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously. The radial tuberosity was palpated. Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow. A skin incision was made over this area. Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa. The tails of the fiber wire suture were grasped and pulled down through the second incision. At this point, they were placed to the side. Attention was directed at exposure of the radial tuberosity with a forearm fully pronated. The tuberosity came into view. The margins were cleared with periosteal elevator and sharp dissection. Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity. Three small drill holes were then placed along the margin for passage of the suture. The area was then copiously irrigated with gentamicin solution. A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole. The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated. The suture was tied over the bone islands. Both wounds were then copiously irrigated with gentamicin solution and suctioned dry. Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples. The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples. Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia. A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position. Tourniquet was inflated prior to application of the splint. Circulatory status returned to the extremity immediately. The patient was awakened. He was rather boisterous during his awakening, but care was taken to protect the right upper extremity. He was then transferred to the recovery room in apparent satisfactory condition.

orthopedic, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,

Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.

Orthopedic

Austin-Moore Bipolar Hemiarthroplasty

PREOPERATIVE DIAGNOSIS:, Displace subcapital fracture, left hip.,POSTOPERATIVE DIAGNOSIS: , Displace subcapital fracture, left hip.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,PROCEDURE: , The patient was taken to OR #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table. The right lower extremity was protectively padded. The left leg was propped with multiple blankets. The hip was then prepped and draped in the usual manner. A posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues. Hemostasis was achieved utilizing electrocautery. Gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly. The external rotators were identified after removal of the trochanteric bursa. Hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line. They were then reflected distally. The capsule was then opened in a T-fashion utilizing the cutting cautery. Fraction hematoma exuded from the hip joint. The cork screw was then impacted into the femoral head and it was removed from the acetabulum. Bone fragments were removed from the neck and acetabulum. The acetabulum was then inspected and noted to be free from debris. The proximal femur was then delivered into the wound with the hip internally rotated.,A mortise chisel was then utilized to take the cancellous bone from the proximal femur. The T-handle broach was then passed down the canal. The canal was then sequentially broached up to a medium broach. The calcar was then plained with the hand plainer. The trial components were positioned into place. The medium component fit fairly well with the medium 28 mm femoral head. Once the trial reduction was performed, the hip was taken through range of motion. There was physiologic crystalling with longitudinal traction. There was no tendency towards dislocation with flexion of the hip past 90 degrees. The trial implants were then removed. The acetabulum was then copiously irrigated with gentamicin solution and suctioned dry. The medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit. The implant was then impacted into place. The 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup. The acetabulum was once again inspected, was free of debris. The hip was reduced. It was taken through full range of motion. There was no tendency for dislocation. The wound was copiously irrigated with gentamicin solution. The capsule was then repaired with interrupted #1 Ethibond suture. External rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 Ethibond in a modified Kessler type stitch. The wound was once again copiously irrigated with gentamicin solution and suctioned dry. Gluteus fascia was approximated with interrupted #1 Ethibond. Subcutaneous layers were approximated with interrupted #2-0 Vicryl and skin approximated with staples. A bulky dressing was applied to the wound. The patient was then transferred to the hospital bed, an abductor pillow was positioned into place. Circulatory status was intact to the extremity at completion of the case.

orthopedic, austin moore, bipolar hemiarthroplasty, femoral head, femoral, hip, hemiarthroplasty, ethibond, acetabulum,

Diagnostic arthroscopy exam under anesthesia, left shoulder. Debridement of chondral injury, left shoulder. Debridement, superior glenoid, left shoulder. Arthrotomy. Bankart lesion repair. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).

Orthopedic

Arthroscopy, Arthrotomy, Bankart lesion repair

TITLE OF OPERATION:,1. Diagnostic arthroscopy exam under anesthesia, left shoulder.,2. Debridement of chondral injury, left shoulder.,3. Debridement, superior glenoid, left shoulder.,4. Arthrotomy.,5. Bankart lesion repair.,6. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have chronic instability of her shoulder. Risks and benefits of the procedure had been discussed in length including but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, continued instability, recurrent instability, medical complications, surgical complications, and anesthesia complications. The patient understood and wishes to proceed.,PREOP DIAGNOSIS: , Anterior instability, left shoulder.,POSTOP DIAGNOSES:,1. Anterior instability, left shoulder.,2. Grade 4 chondromalacia, 10% humeral head, chondral defect 1 cm squared, left shoulder.,3. Type 1 superior labrum anterior and posterior lesion, left shoulder.,4. Anteroinferior glenoid erosions 10% bony surface, left shoulder.,5. Bankart lesion, left shoulder.,PROCEDURE: , The patient was placed in a supine position and both shoulders examined systematically. She had full range of motion with no joint adhesions. She had equal range of motion bilaterally. She had Hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders. This was the same when the arm was in neutral or in external rotation. The patient was then turned to right lateral decubitus position, axillary roll was placed, and beanbag was inflated. Peroneal nerve was well protected. All bony prominences were well protected.,The left upper extremity was then prepped and draped in the usual sterile fashion. The patient was given antibiotics well before the start of the procedure to decrease the risk of infection. The arm was placed in a arm holder with 10 pounds of traction. A posterior portal was created in the usual manner by isolating gently with the spinal needle, it was insufflated with 30 cubic centimeters of saline. A small incision was made after infiltrating the skin with Marcaine and epinephrine. The scope was introduced into the shoulder with no difficulty. It was then examined systematically. The patient did have diffuse synovitis throughout her shoulder. Her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head. She also had an area 1 cm in diameter, which was on more central portion of the head and more inferiorly which appeared to be more of an impaction-type injury. This had some portions of fibrillated and loose cartilage, hanging from the edges. These were later debrided, but the dissection was proximally 10 to 15% of the humeral surface.,The biceps tendon appeared to be normal. The supraspinatus, infraspinatus tendons were normal. The inferior pouch was normal with no capsular tearing and no HAGL lesions. The posteroinferior labrum was normal as well as the posterosuperior labrum. There was some fraying in the posterosuperior labrum, which was later debrided. It was found essentially to be a type 1 lesion anteriorly and superiorly. The anterosuperior labrum appeared to be detached, which appeared to be more consistent with a sublabral hole. The middle glenohumeral ligament was present as an entire sheath, but attach to the labrum. The labrum did appeared to be detached from the anterior glenoid from the 11 o'clock position all the way down to the 6 o'clock position. The biceps anchor itself was later probed and found to be stable and normal. The subscapularis tendon was normal. The anterior band of the glenohumeral ligament was present, but it was clearly avulsed off the glenoid. There was some suggestion of anteroinferior bony erosions, which was later substantiated when the shoulder was opened. The patient was missing about 10 to 15% of her anteroinferior glenoid rim. The patient had a positive drive-through sign.,The arm was then moved to lateral and placed through range of motion. There was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees, maximum flexion was 150 degrees. The arm abducted and externally rotated. There was contact to the rotator cuff with posterosuperior labrum. This occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation. It should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees, maximum external rotation was 95 degrees. The patient did have a positive relocation maneuver. The posterior labrum did appear to tilt-off, but did not appear to peel off.,The arm was then placed back in the arm holder. Anterior portal was created with Wissinger rod. A blue cannula was inserted into the shoulder without difficulty. Shaver was introduced in the labrum. Also the area of chondromalacia as mentioned above was debrided. The labrum was found to be stable with only a type 1 SLAP lesion, and there was no evidence as there was really a type 2 SLAP lesion. The instruments were then removed along with excess fluid. The posterior portals were closed with single 4-0 nylon suture. The anterior portal was left open. The patient was then placed in a supine position, and the extremity was reprepped and draped in anticipation of performing open capsular shift.,The patient's anterior incision made just lateral to the coracoid in the skin line. Mediolateral skin flaps were developed, and cephalic vein was identified and protected throughout the case. The interval was developed down the clavipectoral fascia. The conjoined tendon was retracted medially and the deltoid laterally. The patient's subscapularis was intact, and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers. The capsule could easily be detached from the muscle, and the interval developed very easily. A retractor was placed inferiorly to protect the axillary nerve. Then Gelpi retractor was used to hold the subscapularis split open.,Next, an arthrotomy was made down at the 9 o'clock position. The labrum was identified and found to be attached all the way down to 6 o'clock position. The inferior flap was then created in a usual manner and tied with a 0 Vicryl suture. The patient's glenoid rim did have some erosion as mentioned above with some bone loss and flattening. This was debrided with the soft tissue. Three Mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck. These were absorbable anchors with nonabsorbable sutures. They had excellent fixation once they had been placed.,Next, the capsular shift and Bankart repair were performed in the usual manner with the number 2 Ti-Cron sutures as an outside in and then inside out technique. This brought the capsule right up to the edge of the glenoid rim. With the arm in internal rotation and posterior pressure on the head, the capsule was then secured to the rim with no difficulty under direct visualization. The capsule did come right up into the joint as expected with this type of repair. The superior flap was then closed, the inferior flap over the superior anchor. The interval between two flaps was closed with multiple number 2 Ti-Cron sutures. Once this has been completed, there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached. The arm abducted 90 degrees. There was tension on the repair until 20 degrees of external rotation reached.,The wound was thoroughly irrigated throughout with antibiotic-impregnated irrigation. The subscapularis split was closed with interrupted 0 Vicryl sutures. The deep subcutaneous tissues were closed with interrupted 0 Vicryl sutures. The superficial subcutaneous tissues were closed with number 2-0 Vicryl sutures. The skin was closed with 4-0 subcuticular Prolene, reinforced with Steri-Strips. A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer. The patient was sent to the recovery room in stable and satisfactory condition.

orthopedic, diagnostic arthroscopy, chondral injury, debridement, superior glenoid, arthrotomy, bankart lesion, capsular shift, mitek suture, absorbable anchors, anterior instability, chondromalacia, superior labrum, glenoid erosion, glenoid rim, external rotation, glenoid, labrum, shoulder, arthroscopy,

Austin bunionectomy with internal screw fixation, first metatarsal, left foot.

Orthopedic

Austin Bunionectomy

TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:, Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:, The patient was brought to the operating room and placed on the operating table in a supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in normal sterile technique. The left ankle tourniquet was inflated. Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint. All the tendinous neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal. The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion. A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint. The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw. The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal. The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation. The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal. Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction. The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique. The wires were removed. Fixation on the table was found to be excellent. Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical. The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw. The area was copiously flushed with saline. The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues. The incision site was reinforced with Steri-Strips. At this time, the patient's left ankle tourniquet was deflated. The time was 45 minutes. Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage. The patient's left foot was then placed in a surgical shoe. The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medication and instructions on how to control her postoperative course. The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment.

orthopedic, internal screw fixation, first metatarsal, bunion deformity, osteomed, screw fixation system, subcutaneous tissues, metatarsal head, austin bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, austin, tourniquet, metatarsophalangeal, bunionectomy, foot, metatarsal,

Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure.

Orthopedic

Arthrotomy & I&D

PREOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,POSTOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,OPERATIONS:,1. Arthrotomy, left total knee.,2. Irrigation and debridement, left knee.,3. Polyethylene exchange, left knee.,COMPLICATION: , None.,TOURNIQUET TIME: ,58 minutes.,ESTIMATED BLOOD LOSS: , Minimal.,ANESTHESIA: ,General.,INDICATIONS: ,This patient underwent an uncomplicated left total knee replacement. Postoperatively, unfortunately did not follow up with PT/INR blood test and he was taking Coumadin. His INR was seemed to elevated and developed hemarthrosis. Initially, it did look very benign, although over the last 24 hours it did become irritable and inflamed, and he therefore was indicated with the above-noted procedure.,This procedure as well as alternatives was discussed in length with the patient and he understood them well. Risks and benefits were also discussed. Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of need for total knee revision, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. He understood them well. All questions were answered and he signed consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on operating table and general anesthesia was achieved. The left lower extremity was then prepped and draped in the usual sterile manner. The leg was elevated and the tourniquet was inflated to 325 mmHg. A longitudinal incision was then made and carried down through subcutaneous tissues. This was made through the prior incision site. There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site. Medial and lateral flaps were then made. The prior suture was identified, the suture removed and then a medial parapatellar arthrotomy was then performed. Effusion within the knee was noted. All hematoma was evacuated. I then did flex the knee and removed the polyethylene. Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution. Further debridement was performed of all inflamed tissue and thickened synovial tissue. A 6 x 16-mm Stryker polyethylene was then snapped back in position. The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee. Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline. The knee was placed in a flexed position and the extensor mechanism was reapproximated using #2 Ethibond suture in a figure-of-eight manner. The subcutaneous tissue was reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated using staples. Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint.,No complications were encountered throughout the procedure, and the patient tolerated the procedure well. The patient was taken to recovery room in stable condition.

orthopedic,

Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.

Orthopedic

Arthrotomy & Ostectomy & Capsular Mass Excision

PREOPERATIVE DIAGNOSIS:, Soft tissue mass, right knee.,POSTOPERATIVE DIAGNOSES:,1. Soft tissue mass, right knee.,2. Osteophyte lateral femoral condyle, right knee.,PROCEDURES PERFORMED:, Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital. This was done under a local and IV sedation via the Anesthesia Department.,HISTORY AND GROSS FINDINGS:, This is a 37-year-old African-American male with a mass present at the posterolateral aspect of his right knee. On aspiration, it was originally attempted to no avail. There was a long-standing history of this including two different MRIs, one about a year ago and one very recently both of which did not delineate the mass present. During aspiration previously, the patient had experienced neuritic type symptoms down his calf, which have mostly resolved by the time that this had occurred. The patient continued to complain of pain and dysfunction to his calf. This was discussed with him at length. He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness, swelling, and peroneal nerve palsy. With this, he decided to proceed.,Upon observation preoperatively, the patient was noted to have a hard mass present to the posterolateral aspect of the right knee. It was noted to be tender. It was marked preoperatively prior to an anesthetic. Upon dissection, the patient was noted to have significant thickening of the posterior capsule. The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle. There was also noted to be prominence of the lateral femoral condyle ridge. The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present.,OPERATIVE PROCEDURE: ,The patient was laid supine upon the operating table. After receiving IV sedation, he was placed prone. Thigh tourniquet was placed. He was prepped and draped in the usual sterile manner. A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized. The nerve was identified and carefully retracted throughout the case. Both nerves were identified and carefully retracted throughout the case. There was noted to be no neuroma present. This was taken down until the gastroc was split. There was gross thickening of the joint capsule and after arthrotomy, a section of the capsule was excised. The lateral femoral condyle was then osteophied. We then smoothed off with a rongeur. After this, we could not palpate any mass whatsoever placing pressure upon the area of the nerve. Tourniquet was deflated. It was checked again. There was no excessive swelling. Swanson drain was placed to the depth of the wound and interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and #4-0 nylon was utilized for skin closure. Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing. Digits were warm _______ pulses distally at the end of the case. The tourniquet as stated has been deflated prior to closure and hemostasis was controlled. Expected surgical prognosis on this patient is guarded.

orthopedic, soft tissue mass, osteophyte, lateral femoral condyle, excision, capsular mass, arthrotomy, ostectomy, knee, soft tissue, femoral condyle, mass, subcutaneous, capsular, tourniquet, femoral, condyle,

Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint. Weil osteotomy with internal screw fixation, first right metatarsal. Arthroplasty, second right PIP joint.

Orthopedic

Austin-Akin Bunionectomy

TITLE OF OPERATION:,1. Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2. Weil osteotomy with internal screw fixation, first right metatarsal.,3. Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1. Bunion deformity, right foot.,2. Dislocated second right metatarsophalangeal joint.,3. Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1. Bunion deformity, right foot.,2. Dislocated second right metatarsophalangeal joint.,3. Hammertoe deformity, second right digit.,ANESTHESIA:, Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:, 60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES: ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size. One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in the supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites. The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg. The right foot was then prepped, scrubbed, and draped in a normal sterile technique. The right ankle tourniquet was then inflated. Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe. The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint. Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw. The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal. The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation. The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal. Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws. The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy. The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique. One screw measured 16 mm, second screw measured 18 mm in length. Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed. Fixation of the osteotomy was found to be excellent. The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw. To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally. Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system. Upon insertion of the screw, using AO technique, the wire was removed. The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe. Fixation of the osteotomy was found to be excellent. Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical. Range of motion of that joint was uninhibited. The area was flushed copiously with saline. Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision. Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped and cauterized. The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal. The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw. Upon insertion of the screw, using AO technique, the wire was then removed. Fixation of the osteotomy with 2.0 screw was found to be excellent. The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced. Range of motion of the second right metatarsophalangeal joint was found to be excellent. Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues. Then, 4-0 Vicryl was used to approximate the skin incision. Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint. The island of skin between the two semi-elliptical incisions was resected in toto. The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint. A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed. Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected. The area was copiously flushed with saline. The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe. A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions. Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical. At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's right ankle tourniquet was deflated, time was 60 minutes. Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels. The patient was given instructions and education on how to continue caring for her right foot surgery. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.

orthopedic, austin-akin bunionectomy, weil osteotomy, internal screw fixation, first right metatarsal, metatarsophalangeal joint, hammertoe deformity, extensor digitorum longus, austin akin bunionectomy, threaded cannulated screw, semi elliptical incisions, ankle tourniquet, surgical neck, cannulated screws, pip joint, proximal phalanx, fixation, metatarsophalangeal, proximal, screw, metatarsal, osteotomy, austin, joint, tourniquet, osteomed, phalanx, incision,

Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.

Orthopedic

Aspiration - Knee Joint

PREOPERATIVE DIAGNOSES: , Erythema of the right knee and leg, possible septic knee.,POSTOPERATIVE DIAGNOSES:, Erythema of the right knee superficial and leg, right septic knee ruled out.,INDICATIONS: , Mr. ABC is a 52-year-old male who has had approximately eight days of erythema over his knee. He has been to multiple institutions as an outpatient for this complaint. He has had what appears to be prepatellar bursa aspirated with little to no success. He has been treated with Kefzol and 1 g of Rocephin one point. He also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful. Orthopedic Surgery was consulted at this time. Considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee. After discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.,PROCEDURE: ,The patient's right anterolateral knee area was prepped with Betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella. The 20-gauge spinal needle was inserted and entered the knee joint. Approximately, 4 cc of clear yellow fluid was aspirated. The patient tolerated the procedure well.,DISPOSITION: , Based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint. We will send this fluid to the lab for cell count, crystal exam, as well as culture and Gram stain. We will follow these results. After discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics.

orthopedic, knee and leg, anterolateral portal, emergency department, spinal needle, septic knee, knee joint, knee, emergency, department, gauge, spinal, needle, aspiration, anterolateral, portal, aspirated, fluid, septic, erythema, joint, aspiraion,

Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well. Chondromalacia of medial femoral condyle. Medial meniscal tear, left knee.

Orthopedic

Arthroscopy, Meniscoplasty, & Chondroplasty

PREOPERATIVE DIAGNOSIS:, Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1. Arthroscopy of the left knee.,2. Left arthroscopic medial meniscoplasty of medial femoral condyle.,3. Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: , 80 cc.,TOTAL TOURNIQUET TIME: , 19 minutes.,DISPOSITION: , The patient was taken to PACU in stable condition.,HISTORY OF PRESENT ILLNESS: ,The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain. He has had a positive symptomology of locking and pain since then. He had no frank instability to it, however.,GROSS OPERATIVE FINDINGS: , We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,OPERATIVE PROCEDURE: ,The patient was taken to the operating room. The left lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was applied to the left thigh with adequate Webril padding, not inflated at this time. After the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an Esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes. We established the lateral port of the knee with #11 blade scalpel. We put in the arthroscopic trocar, instilled with water and inserted the camera.,On inspection of the patellofemoral joint, it was found to be quite smooth. Pictures were taken there. There was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage. The patella was well centered over the trochlear notch. We then directed the arthroscope to the medial compartment of the knee. It was felt that there was a tear to the medial meniscus. We also saw large area of chondromalacia with grade-IV changes to bone over the medial femoral condyle. This area was debrided with forceps and the arthroscopic shaver. The cartilage was also smoothened over the medial femoral condyle. This was curetted after the medial meniscus had been trimmed. We looked into the notch. We saw the ACL appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear. Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment. All instruments were removed. All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end. We removed all instruments. Marcaine was injected into the portal sites. We placed a sterile dressing and stockinet on the left lower extremity. He was transferred to the gurney and taken to PACU in stable condition.

orthopedic, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral

Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.

Orthopedic

Arthrotomy & Subscapularis Tendon Repair

TITLE OF OPERATION: ,1. Arthrotomy, removal humeral head implant, right shoulder.,2. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3. Debridement glenohumeral joint.,4. Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X. However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis. Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc. The patient understood and wished to proceed.,PREOP DIAGNOSIS: ,1. Torn subscapularis tendon, right shoulder.,2. Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS: ,1. Torn subscapularis tendon, right shoulder.,2. Right total shoulder arthroplasty (Biomet system).,3. Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position. A Foley catheter was placed in his bladder. He was then placed in a beach chair position. He was brought to the side of the table and the torso secured with towels and tape. His head was then placed in the neutral position with no lateral bending or extension. It was secured with paper tape over his forehead. Care was taken to stay off his auricular cartilages and his orbits. Right upper extremity was then prepped and draped in the usual sterile fashion. The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection. Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep. This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case. Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally. The patient had significant amount of scar already in this interval. Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar. This created a significant amount of bleeding. As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus. Care was taken to stay above the pectoralis minor and the conjoint tendon. The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus. Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component. It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin. The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity. The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released. The brachial plexus was identified as was the axillary nerve. Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later. This revealed sanguineous fluid inside the joint. We did not feel it was infected based upon the fluid that came from the joint. The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures. The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously. Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring. This was done also very meticulously. The upper one half of the latissimus dorsi tendon was also released. Once this was completed, the humerus could be subluxed enough laterally that we could remove the head. This was done with no difficulty. Fortunately, the humeral component stayed intact. There were some exudates beneath the humeral head, which were somewhat mucinous. However, these do not really appear to be infected, however, we sent them to pathology for a frozen section. This frozen section later returned as possible purulent material. I discussed this personally with the pathologist at that point. We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect. As a result, all the mucinous exudates were carefully removed. We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation. At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain. This came back as no organisms seen. We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid. The patient had significant amount of scar already. The subscapularis itself was significantly scarred down to the anterior rim. As a result, the adhesions along the anterior edge were released using a knife. Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus. Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis. The subscapularis was then tagged with multiple number 2 Tycron sutures. Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension. As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus. These all had excellent security in bone. Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus. Care was taken to remove fluid off the Morse taper. The head was then impacted. It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient. Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus. As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component. The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion. Also, it should be noted that the rotator cuff interval had to be released as part of the exposure. We started the repair by closing the rotator cuff interval. Anterior and posterior translation was then performed and was found to be very stable. The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained. This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon. After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side. Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation. It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation. The rotator cuff interval was closed with multiple number 2 Tycron sutures. It was reinforced with 0 Vicryl sutures. Two Hemovac drains were then placed inferiorly at the deltoid. The deltopectoral interval was then closed with 0 Vicryl sutures. A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections. This was sewn into place with the drain pulled out superiorly. Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered. There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures. Skin was closed with staples. A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer. The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case. This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement. Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant. This was being dictated for insurance purposes only and reflects no inherent difficulties with this case. The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair. This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker. This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.

orthopedic, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn,

Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.

Orthopedic

Arthroscopy - Shoulder

PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA: ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION: ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon. There was some softening and loss of the articular cartilage over the glenoid. The labrum was ________ attached permanently to the glenoid. The biceps tendon was nonsubluxable. Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side. Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space. There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:, This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder. MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position. After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion. The left extremity was prepped and draped in usual fashion. The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect. We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion. A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder. A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula. The operative findings found intra-articularly were as described previously gross operative findings. We did not see any evidence of acute pathology. We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline. The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal. All this was done and hemostasis was achieved. The rotator cuff was examined from the bursal side and showed no evidence of tears. There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver. We removed all of our instruments and suctioned the subacromial space dry. A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling. She was placed back on the gurney, extubated and taken to the PACU in stable condition.

orthopedic, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff,

Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.

Orthopedic

Arthroscopy Shoulder/Knee

PREOPERATIVE DIAGNOSES:,1. Medial meniscal tear, posterior horn of left knee.,2. Carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3. Impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,POSTOPERATIVE DIAGNOSES:,1. Carpal tunnel syndrome, right hand, severe.,2. Bursitis, tendonitis, impingement, and AC arthritis, right shoulder.,3. Medial and lateral meniscal tears, posterior horn old, left knee.,PROCEDURE:,1. Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection.,2. Right carpal tunnel release.,3. Left knee arthroscopy and partial medial and lateral meniscectomy.,ANESTHESIA: , General with regional.,COMPLICATIONS: ,None.,DISPOSITION: , To recovery room in awake, alert, and in stable condition.,OPERATIVE INDICATIONS: , A very active 50-year-old gentleman who had the above problems and workup revealed the above problems. He failed nonoperative management. We discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and he gave his fully informed consent to the following procedure.,OPERATIVE REPORT IN DETAIL: , The patient was brought to the operating room and placed in the supine position on the operating room table. After adequate induction of general anesthesia, he was placed in the left lateral decubitus position. All bony prominences were padded. The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep, entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar.,Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments, articular surfaces, and labrum. Subacromial space was entered. Visualization was poor due to the hemorrhagic bursitis, and this was resected back. It was essentially a type-3 acromion, which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur. Rotator cuff was little bit fray, but otherwise intact. Thus, the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed. The burr was then introduced to the anterior portal and the distal clavicle excision carried out. The width of burr about 6 mm being careful to preserve the ligaments in the capsule, but removing the spurs and the denuded arthritic joint.,The patient tolerated the procedure very well. The shoulder was then copiously irrigated, drained free of any residual debris. The wound was closed with 3-0 Prolene. Sterile compressive dressing applied.,The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep.,The attention was first turned to the right hand where it was elevated, exsanguinated using an Esmarch bandage, and the tourniquet was inflated to 250 mmHg for about 25 minutes. Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis. Tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures.,Cautery was used for hemostasis. The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament, and so a small amount of Celestone was dripped onto the nerve to help quite it down. The patient tolerated this portion of the procedure very well. The hand was then irrigated, closed with Monocryl and Prolene, and sterile compressive dressing was applied and the tourniquet deflated.,Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars. After entering the knee through inferomedial and inferolateral standard arthroscopic portals, examination of the knee showed a displaced bucket-handle tear in the medial meniscus and a radial tear at the lateral meniscus. These were resected back to the stable surface using a basket forceps and full-radius shaver. There was no evidence of any other significant arthritis in the knee. There was a lot of synovitis, and so after the knee was irrigated out and free of any residual debris, the knee was injected with Celestone and Marcaine with epinephrine.,The patient tolerated the procedure very well, and the wounds were closed with 3-0 Prolene and sterile compressive dressing was applied, and then the patient was taken to the recovery room, extubated, awake, alert, and in stable condition.

Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.

Orthopedic

Arthroscopy - Glenoid Labrum

PREOPERATIVE DIAGNOSIS:, Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Massive rotator cuff tear, right shoulder.,2. Near complete biceps tendon tear, right shoulder.,3. Chondromalacia of glenohumeral joint, right shoulder.,4. Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED: ,1. Arthroscopy of the arthroscopic glenoid labrum.,2. Rotator cuff debridement shaving glenoid and humeral head.,3. Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital. This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed. He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention. This was gradually done over a period of time. No specific accident or injury could be seen or pointed. He was refractory to conservative outpatient therapy. After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion. He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated. His rotator interval was resolved as well as his subscapularis with tearing. The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe. Glenoid labrum had degenerative tear in the inferior surface. Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table. After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position. He was prepped and draped in the usual sterile manner. The portals were created outside the end posteriorly and then anteriorly. A full and complete diagnostic arthroscopy was carried out with the above-noted findings. The shaver was placed anteriorly. Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed. Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out. Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity. No osteophytes were present. Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring. There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this. We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly. We took this back to the level of coracoid base. We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn. Because of this, further debridement was carried out. Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge. Care was taken to not to debride deeper than that. This was done prior to the above.,All instrumentation was removed. A Pain-Buster catheter was placed into a separate anterolateral portal cut to length. Interrupted #4-0 nylon was utilized for portal closures. Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling. He was transferred to his cart and to the PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology.

orthopedic, modified beachchair position, rotator cuff tear, glenoid labrum tear, glenohumeral joint, interscalene block, glenoid labrum, rotator cuff, rotator, debridement, glenoid, shoulder, tear, arthroscopy, arthroscopic, tenotomy, glenohumeral, supraspinatus, infraspinatus, subscapularis, chondromalacia, biceps, labrum, cuff,

Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.

Orthopedic

Arthroscopic Rotator Cuff Repair

PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:, This is a 42-year-old female. Refer to note in patient chart for documentation of history and physical. Due to the nature of the patient's increasing pain, surgery is recommended. The alternatives, risks and benefits of surgery were discussed with the patient. The patient verbalized understanding of the risks as well as the alternatives to surgery. The patient wished to proceed with operative intervention. A signed and witnessed informed consent was placed on the chart. Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:, Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1. There was a medium-sized (5 - 10 mm) anterior acromial spur.,2. The subacromial bursa was inflamed.,3. The subacromial bursa was thickened.,4. There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral. Muscles and Tendons: The biceps tendon is within normal limits.,JOINT:, Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table. All body parts were well padded and protected to make sure there were no pressure points. Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1. Scope Ports: Anterior Portal.,2. Scope Ports: Posterior Portal.,3. Scope Ports: Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1. The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2. The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3. The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4. The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr. Approximately 5 mm of bone was removed. The coracoacromial ligament was released with the bony resection. The shoulder joint was thoroughly irrigated.,5. The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6. The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures). The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7. The repair was stable to palpation with the probe and watertight.,8. The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:, The joint was thoroughly irrigated with 7 L of sterile saline. The portal sites were infiltrated with 1% Xylocaine. The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:, Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:, Final counts were correct.

Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.

Orthopedic

Arthroscopy & Chondroplasty

PREOPERATIVE DIAGNOSES:,1. Chondromalacia patella.,2. Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1. Grade-IV chondromalacia patella.,2. Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with partial chondroplasty of patella.,2. Lateral retinacular release.,3. Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:, General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella. There was a grade II to III chondral changes to the patellar groove. The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle. The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen. The articular surfaces and the remainder of the knee appeared intact. Cruciate ligaments also appeared intact to direct stress testing.,HISTORY: ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain. She has been diagnosed in the past with chondromalacia patella. She has failed conservative therapy. It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint. She elected to proceed with the surgical intervention. All risks and benefits of the surgery were discussed with her. She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital. She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department. Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion. A stab incision was made in inferolateral and parapatellar regions. Through this the cannula was placed and the knee was inflated with saline solution. Intraoperative pictures were obtained. The above findings were noted. Second portal site was initiated in the inferomedial parapatellar region. Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris. Next, the camera was placed through the inferomedial portal. An arthroscopic Bovie was placed through the inferolateral portal. A release of lateral retinaculum was then performed using the Bovie. Hemostasis was controlled with electrocautery. Next, the knee was suctioned dry. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. An oblique incision was made along the medial parapatellar region of the knee. The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery. The retinaculum was then incised in line with the incision. The patellar tendon was identified. The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris. Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact. The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle. It was then held in place with a Steinmann pin. Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle. There was excellent fixation noted. The Q-angle was noted to be decreased to approximately 15 degrees. She was transferred approximately 1 cm in length. The wound was copiously irrigated and suctioned dry. The medial retinaculum was then plicated causing further medialization of the patella. The retinaculum was reapproximated using #0 Vicryl. Subcuticular tissue were reapproximated with #2-0 Vicryl. Skin was closed with #4-0 Vicryl running PDS suture. Sterile dressing was applied to the lower extremities. She was placed in a Donjoy knee immobilizer locked in extension. It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet. She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint. She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.

orthopedic, diagnostic arthroscopy, patellofemoral malalignment syndrome, cannulated, partial chondroplasty, retinacular, chondromalacia patella, tibial tubercle, patella, tubercle, arthroscopy, tourniquet, chondroplasty, chondromalacia, patellofemoral,

Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.

Orthopedic

Arthroscopic Meniscoplasty

PREOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1. Torn lateral meniscus, right knee.,2. Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1. Arthroscopic lateral meniscoplasty.,2. Patellar shaving of the right knee.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:, Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE: ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position. Department of Anesthesia administered general anesthetic to the patient. All bony prominences were well padded at this time. The right lower extremity was then properly positioned in a Johnson knee holder. At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions. The right lower extremity was then sterilely prepped and draped in usual sterile fashion. Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon. The cannula and trocar were then inserted through this, putting the patellofemoral joint. An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch. Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella. There were no loose bodies noted in the either gutter. Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted. While in this area, attention was directed to establish the inferomedial instrument portal. This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line. A probe was then inserted through this portal and the meniscus was further probed. Again, there was noted to be no meniscal tear. The knee was taken through range of motion and there was no chondromalacia. Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign. PCL was also noted to be intact. Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns. It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle. An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus. It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee. Pictures were taken both pre-meniscal resection and post-meniscal resection. The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured. The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact. Next, attention was directed to the inner surface of the patella. This was debrided using the 2.5 arthroscopic shaver. It was noted to be quite smooth and postprocedure the patient was taken ________ well. The knee was then copiously irrigated and suctioned dry and all instrumentation was removed. 20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity. At this time, Department of Anesthesia reversed the anesthetic. The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit. The patient tolerated the procedure and there were no complications.

orthopedic, patella, chondromalacia, lateral meniscus, complex tear, torn lateral meniscus, femoral notch, meniscal tear, bucket handle, meniscal resection, arthroscopic shaver, patellofemoral joint, arthroscopic, knee, torn, meniscoplasty, meniscal, joint, meniscus,

Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.

Orthopedic

Arthroscopic Rotator Cuff Repair - 1

PREOPERATIVE DIAGNOSIS: , Rotated cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Rotated cuff tear, right shoulder.,2. Glenoid labrum tear.,PROCEDURE PERFORMED:,1. Arthroscopy with arthroscopic glenoid labrum debridement.,2. Subacromial decompression.,3. Rotator cuff repair, right shoulder.,SPECIFICATIONS:, Intraoperative procedure was done at Inpatient Operative Suite, room #1 at ABCD Hospital. This was done under interscalene and subsequent general anesthetic in the modified beach chair position.,HISTORY AND GROSS FINDINGS: , The patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention. He was completely refractory to conservative outpatient therapy. After discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,Intraarticularly, the joint was observed. There was noted to be a degenerative glenoid labrum tear. The biceps complex was otherwise intact. There were minimal degenerative changes at the glenohumeral joint. Rotator cuff tear was appreciated on the inner surface. Subacromially, the same was true. This was an elliptical to V-type tear. The patient has a grossly positive type III acromion.,OPERATIVE PROCEDURE: , The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department. He was safely placed in modified beach chair position. He was prepped and draped in the usual sterile manner. Portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion. Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly. Debridement was carried out to the glenoid labrum. The biceps was probed and noted to be intact. Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,After this, instrumentation was removed. The scope was placed subacromially and a lateral portal created. Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters. An anterolateral portal was created. Sutures were placed via express silk as well as other sutures with a #2 fiber wire. With passing of the suture, they were tied with a slip-tight knot and then two half stitches. There was excellent reduction of the tear. Superolateral portal was then created. A #1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone. _______ suture was placed. The implant was put into place. The loop was grabbed and it was impacted in the previously drilled holes. There was excellent reduction of the tear.,Trial range of motion was carried out and seemed to be satisfactory.,Prior to this, a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie. A 4.8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion.,After all was done, copious irrigation was carried out throughout the joint. Gross bursectomy lightly was carried out to remove all bony elements. A pain buster catheter was placed through a separate portal and cut to length. 0.5% Marcaine was instilled after portals were closed with #4-0 nylon. Adaptic, 4 x 4s, ABDs, and Elastoplast tape placed for dressing. The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition. Expected surgical prognosis of this patient is fair.

orthopedic, subacromial decompression, rotator cuff repair, arthroscopic glenoid labrum debridement, arthroscopy, glenoid labrum tear, glenoid labrum, cuff, tear, arthroscopic, subacromial, decompression, debridement, rotator, glenoid, labrum, shoulder,

Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.

Orthopedic

Arthroscopic Rotator Cuff Repair - 2

PROCEDURES,1. Arthroscopic rotator cuff repair.,2. Arthroscopic subacromial decompression.,3. Arthroscopic extensive debridement, superior labrum anterior and posterior tear.,PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given general anesthetic. Once the patient was under general anesthetic, a careful examination of the shoulder was performed. It revealed no patholigamentous laxity. The patient was then carefully positioned into a beach-chair position. We maintained the natural alignment of the head, neck, and thorax at all times. The shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,Once we fully prepped and draped, we then began the surgery. We injected the glenohumeral joint with sterile saline with a spinal needle. This consisted of 60 cc of fluid. We then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Through this incision, a blunt trocar and cannula were placed in the glenohumeral joint. Through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed. We then carefully examined the glenohumeral joint.,We found the articular surface to be in good condition. There was a superior labral tear (SLAP). This was extensively debrided using a shaver through an anterior portal. We also found a full thickness rotator cuff tear. We then drained the glenohumeral joint. We redirected our camera into the subacromial space. An anterolateral portal was made, both superior and inferior.,We then proceeded to perform a subacromial decompression using high-speed shaver. The bursa was extensively debrided. We then abraded the bone over the footprint of where the rotator cuff is usually attached. The corkscrew anchors were used to perform a rotator cuff repair. Pictures were taken.,Through a separate incision, an indwelling pain catheter was then placed. It was carefully positioned. Pictures were taken. We then drained the joint. All instruments were removed. The patient did receive IV antibiotic preoperatively. All portals were closed using 4-0 nylon sutures.,Xeroform, 4 x 4s, and OpSite were applied over the pain pump. ABD, tape, and a sling were also applied. A Cryo/Cuff was also placed over the shoulder. The patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax. The patient was extubated and brought to the recovery room in stable condition. I then went out and spoke with the family, going over the case, postoperative instructions, and followup care.

orthopedic, debridement, superior labrum, patholigamentous, laxity, arthroscopic rotator cuff repair, subacromial decompression, glenohumeral joint, rotator cuff, arthroscopic, decompression, repair, glenohumeral, subacromial, rotator, cuff,

Rotator cuff tear, right shoulder. Superior labrum anterior and posterior lesion (peel-back), right shoulder. Arthroscopy with arthroscopic SLAP lesion. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.

Orthopedic

Arthroscopic SLAP lesion

PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSIS: , Superior labrum anterior and posterior lesion (peel-back), right shoulder.,PROCEDURE PERFORMED:,1. Arthroscopy with arthroscopic SLAP lesion.,2. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital. This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: ,This is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention. She had an injury to her right shoulder when she fell off a bike. She was diagnosed preoperatively with a rotated cuff tear.,Intra-articularly besides we noted a large SLAP lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30. This acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid. This was an obvious avulsion into subchondral bone with bone exposed. The anterior aspect had degenerative changes, but did not have evidence of avulsion. The subscapular was noted to be intact. On the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,This was confirmed subacromially. The patient had a type-I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the CA ligament in a releasing resection type fashion.,OPERATIVE PROCEDURE: , The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department. She was safely placed in a modified beachchair position. She was prepped and draped in the usual sterile manner. The portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally. She had at least two other portals appropriate for both repair mechanisms described above.,Attention was then turned to the SLAP lesion. The edges were debrided both on the bony side as well as soft tissue side. We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum. Further debridement was carried out here. A drill hole was made just on the articular surface superiorly for a knotless anchor. A pull-through suture of #2 fiber wire was utilized with the ________. This was pulled through. It was tied to the leader suture of the knotless anchor. This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet. There was excellent fixation of the superior labrum. It was noted to be solid and intact. The anchor was placed safely in the bone. There was no room for further knotless or other anchors. After probing was carried out, hard copy Polaroid was obtained.,Attention was then turned to the articular side for the rotator cuff. It was debrided. Subchondral debridement was carried out to the tuberosity also. Care was taken to go to the subchondral region but not beyond. The bone was satisfactory.,Scope was then placed in the subacromial region. Gross bursectomy was carried out with in the lateral portal. This was done throughout as well as in the gutters anterolaterally and posteriorly. Debridement was carried out further to the rotator cuff. Two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch. There was an excellent reduction of the tear posteriorly and then anteriorly. Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal. This was done with a sliding stitch and then two half stitches. There was excellent reduction of the tear.,Attention was then turned to the CA ligament. It was released along with periosteum and the undersurface of the anterior acromion. The CA ligament was not only released but resected. There was noted to be no evidence of significant spurring with only a mostly type-I acromion. Thus, it was not elected to perform subacromial decompression for bone with soft tissue only. A pain buster catheter was placed separately. It was cut to length. An interrupted #4-0 nylon was utilized for portal closure. A 0.5% Marcaine was instilled subacromially. Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing. The patient's arm was placed in a arm sling. She was transferred to PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is fair.

orthopedic, rotator cuff tear, shoulder, labrum, lesion, decompression, subacromial, arthroscopic slap lesion, slap lesion, rotator cuff, anterior, arthroscopy, arthroscopic, slap, cuff

Femoroacetabular impingement. Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.

Orthopedic

Arthroscopic Debridement & Labral Repair - Hip

PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1. Left hip arthroscopic debridement.,2. Left hip arthroscopic femoral neck osteoplasty.,3. Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic. His bilateral lower extremities were placed under traction on the Hana table. His right leg was placed first. The traction post was left line, and the left leg was placed in traction. Sterile Hibiclens and alcohol prep and drape were then undertaken. A fluoroscopic localization was undertaken. Gentle traction was applied. Narrow arthrographic effect was obtained. Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization. The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum. For this reason, the acetabular articular cartilage was taken down and stabilized. This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair. The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot. After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable. The remnant articular surface of the femoral artery and acetabulum was stable. The posterior leg was stable. The traction was left half off, and the anterolateral aspect of the head and neck junction was identified. A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly. This terminated with the hip coming out of traction and indeterminable flexion. A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression. The decompression was completed with thorough irrigation of the hip. The cannula was removed, and the portals were closed using interrupted nylon. The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room. He tolerated the procedure very well with no signs of complications.

orthopedic, labral repair, femoral neck osteoplasty, arthroscopic debridement, femoroacetabular impingement, arthroscopic, femoroacetabular, impingement, debridement, osteoplasty, acetabulum

Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.

Orthopedic

Arthroplasty - Hammertoe

PREOPERATIVE DIAGNOSIS:, Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe. The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe. The patient presents n.p.o. since mid night last night and consented to sign in the chart. H&P is complete.,PROCEDURE IN DETAIL:, After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position. Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time. Restraining, a lap belt was then placed around the patient's abdomen while laying on the table. After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia. The foot was then prepped and draped in the normal sterile orthopedic manner. The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg. The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed. A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup. Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue. Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin. This was performed with the combination of blunt and dull dissection. Care was taken to avoid proper digital arteries and neurovascular bundles as were identified. Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint. The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure. Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup. It was elevated with fresh #15 blade. The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally. Following this, the distal portion of the tendon was identified in a like manner. The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone. The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues. Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected. Care was taken to avoid the deep flexor tendon. The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology. The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment. The digit was also noted to be in rectus alignment. Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity. Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue. Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin. The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site. Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin. The toe was bandaged using 4 x 4s, Kling, and Coban. The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe. Total tourniquet time for the case was 30 minutes. While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot. The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain. The patient was also given prescription for cane to aid in ambulation. The patient will followup with Dr. X on Tuesday in his office for postoperative care. The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit. The patient tolerated the procedure well and the anesthesia with no complications.

orthopedic, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon

Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.

Orthopedic

Arthroscopic Debridement - Shoulder

PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:, Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:, Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE: ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area. The patient was positioned in the modified beachchair position utilizing the Mayfield headrest. The left shoulder was propped posteriorly with a rolled towel. His head was secured to the Mayfield headrest. The left shoulder and upper extremity were then prepped and draped in the usual manner. A posterior lateral port was made for _____ the arthroscopic cannula. The scope was introduced into the glenohumeral joint. There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock. The labrum was adherent to the underlying capsule. The margin of the glenoid was frayed in this area. The biceps tendon was noted to be intact. The articular surface of the glenoid was fairly well preserved. The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head. The rotator cuff was visualized and noted to be intact. The axillary pouch was visualized and it was free of injury. There were some cartilaginous fragments within the axillary pouch. Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum. Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position. A second tack was then placed at about the 8 o'clock position. The labrum was then probed and was noted to be stable. With some general ranging of the shoulder, the tissue was pulled out from the tacks. An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position. Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area. At this point, it was deemed that an open Bankart arthroplasty was necessary. The arthroscopic instruments were removed. An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold. The skin incision was taken down through the skin. Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis. The deltopectoral fascia was identified. It was split at the deltopectoral interval and the deltoid was reflected laterally. The subdeltoid bursa was then removed with rongeurs. The conjoint tendon was identified. The deltoid and conjoint tendons were then retracted with a self-retaining retractor. The subscapularis tendon was identified. It was separated about a centimeter from its insertion, leaving the tissue to do sew later. The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially. This allowed for visualization of the capsule. The capsule was split near the humeral head insertion leaving a tag for repair. It was then split longitudinally towards the glenoid at approximately 9 o'clock position. This provided visualization of the glenohumeral joint. The friable labral and capsular tissue was identified. The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock. The sutures were passed through the labral capsular tissue and tied securely. At this point, the anterior glenoid rim had been recreated. The joint was then copiously irrigated with gentamicin solution and suctioned dry. The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture. This later was then copiously irrigated with gentamicin solution and suctioned dry. Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture. This later was then copiously irrigated as well and suctioned dry. The deltoid fascia was approximated with running #2-0 Vicryl suture. Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips. 0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia. The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied. The patient was then transferred to the recovery room in apparent satisfactory condition.

orthopedic, dislocating, bankart, arthroplasty, bankart repair, arthroscopic debridement, anterior, arthroscopic, debridement, deltoid, glenoid, humeral, interrupted, shoulder, subscapularis

Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain.

Orthopedic

Anterior Lumbar Fusion

PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:, None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:, Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body. This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug. At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:, The patient was placed under general endotracheal anesthesia. The abdomen was prepped and draped in the usual fashion. Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters. I was able to remove additional disk space and score the vertebral bodies. The rest of the disk removal was done with the curette, scraping the endplates. I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug. Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place. We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side. This was filled with bone and BMP as well. Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws. Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness. He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc. MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5. A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic. An anterior lumbar interbody fusion was suggested. Procedure, risks, and complications were explained.

orthopedic, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion,

Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.

Orthopedic

Arthroplasty

PREOPERATIVE DIAGNOSES:,1. Hammertoe deformity, left fifth digit.,2. Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1. Hammertoe deformity, left fifth toe.,2. Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2. Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe. The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area. The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position. After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc. Following this, the patient was draped and prepped in a normal sterile orthopedic manner. An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot. The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table. The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined. The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit. Then using a fresh #15 blade, skin incision was made. Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue. Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion. The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety. The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within. The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum. Remaining tissues were inspected and appeared healthy. The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth. Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx. The capsule was also reflected to expose the prominent lateral osseous portion of this joint. Using a sagittal saw and #139 blade, the lateral osseous prominence was resected. This was removed in entirety. Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition. Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin. Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin. Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion. The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot. The patient was then escorted from the operative table into the Postanesthesia Care Unit. The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact. In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation. The patient was also given instructions as to signs of infection and to monitor her operative site. The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.

orthopedic, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion

Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.

Orthopedic

Anterior Cervical Discectomy & Interbody Fusion - 1

PREOPERATIVE DIAGNOSES: ,1. Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2. Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES: ,1. Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2. Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2. Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3. Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:, General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces. Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner. Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided. The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status. The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed. The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away. Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion. At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.

orthopedic, herniated nucleus pulposus, radiculopathy, cervical stenosis, anterior instrumentation, stabilization, slim-loc, neural decompression, anterior cervical discectomy, cord compression, interbody fusion, bengal cages, interbody, compression, anterior, fusion, decompression, discectomy, cervical

Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.

Orthopedic

Arthrodesis

PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia. The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME: ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:, None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL: ,The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening. This was explained to the mother in detail. This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered. The patient received Ancef preoperatively. Bilateral nonsterile tourniquets were placed on each thigh. A bump was placed underneath the left buttock. Both the extremities were then prepped and draped in standard surgical fashion. Attention was first turned towards the left side. Intended incision was marked on the skin. The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view. The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg. Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint. The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally. Once the foot was reduced a Steinman pin was used to hold it in position. This position was first checked on the fluoroscopy. The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction. This was also checked with fluoroscopy. The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half. This was sutured using 2-0 Ethibond and that was also oversewn. The wound was irrigated with normal saline. The periosteal flap was sutured over the staple using 2-0 Vicryl. Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl. The area was injected with 6 mL of 0.25% Marcaine local anesthetic. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril. Tourniquet was released after 53 minutes. The exact same procedure was repeated on the right side with no changes or complications. Tourniquet time on the right side was 45 minutes. The patient tolerated the procedure well. Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch. The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request. The patient is to be strict nonweightbearing for at least 6 weeks. He is to follow up in the next 10 days for a check. We will plan of changing to short-leg casts in about 4 weeks postop.

orthopedic, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, surgery, subtalar, achilles, anesthesia, planovalgus, foot, bilateral,

Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.

Orthopedic

Antibiotic-Impregnated Beads Placement

PREOPERATIVE DIAGNOSIS:, Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:, Open calcaneus fracture on the right.,PROCEDURES:, ,1. Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2. Placement of antibiotic-impregnated beads.,ANESTHESIA:, General.,BLOOD LOSS:, Minimal.,COMPLICATIONS:, None.,FINDINGS:, Healing skin with no gross purulence identified, some fibrinous material around the beads.,SUMMARY:, After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion. The tourniquet was inflated and the previous wound was opened. Dr. X came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound. The wound margins were healthy with the exception of very central triangular incision area. The edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,The skin edges were approximated under minimal tension. The soft dressing was placed. An Ace was placed. She was awakened from the anesthesia and taken to recovery room in a stable condition. Final needle, instrument, and sponge counts were correct.

orthopedic, open calcaneus fracture, irrigation and debridement, antibiotic impregnated beads, irrigation, subcutaneous, placement, debridement, calcaneus, fracture, wound, beads, antibiotic

Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.

Orthopedic

Anterior Cruciate Ligament Reconstruction

PREOPERATIVE DIAGNOSIS: , Anterior cruciate ligament rupture.,POSTOPERATIVE DIAGNOSES:,1. Anterior cruciate ligament rupture.,2. Medial meniscal tear.,3. Medial femoral chondromalacia.,4. Intraarticular loose bodies.,PROCEDURE PERFORMED:,1. Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2. Removal of loose bodies.,3. Medial femoral chondroplasty.,4. Medial meniscoplasty.,OPERATIVE PROCEDURE: ,The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia. Following this, the knee was sterilely prepped and draped as discussed for this procedure. The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region. After the notch was identified, then ACL was confirmed and ruptured. There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface. The snare was smoothed out. Entire area was thoroughly irrigated. Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage. The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing. There were multiple loose bodies noted in the knee and these were then __________ and then removed. The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed. The knee was taken through a full range of motion without any impingement. An Endobutton was used for proximal fixation. Distal fixation was obtained with an independent screw and a staple. The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.,

orthopedic, femoral chondroplasty, intraarticular loose bodies, anterior cruciate ligament reconstruction, anterior, arthroscopy, meniscoplasty, fixation, reconstruction, chondroplasty, ligament, femoral, intraarticular, medial

Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.

Orthopedic

Anterior Cervical Discectomy & Interbody Fusion - 3

PREOPERATIVE DIAGNOSES:, ,1. Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2. Neck pain with left radiculopathy, progressive (723.1/723.4).,3. Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:, ,1. Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2. Neck pain with left radiculopathy, progressive (723.1/723.4).,3. Headaches, progressive (784.0).,PROCEDURES:, ,1. Anterior cervical discectomy at C5-C6 for neural decompression (63075).,2. Anterior interbody fusion C5-C6 (22554) utilizing Bengal cage (22851).,3. Anterior cervical instrumentation at C5-C6 for stabilization by Uniplate construction at C5-C6 (22845); with intraoperative x-ray x2.,SERVICE: , Neurosurgery,ANESTHESIA:,

orthopedic, spondylosis, neck pain, headaches, decompression, uniplate, anterior cervical discectomy, neural decompression, cervical stenosis, prevertebral space, antibiotic solution, cervical discectomy, interbody fusion, bengal cage, interbody, anterior, cervical, discectomy,

Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.

Orthopedic

Anterior Cervical Discectomy & Interbody Fusion - 2

PREOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1. Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2. Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3. Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION: ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case. A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved. This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section. Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well. A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status. At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation. Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied. Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner. The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner. Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.

orthopedic, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,

C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.

Orthopedic

Anterior Cervical Discectomy & Fusion - 8

PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain. We decided go ahead with anterior cervical discectomy at C5-C6 and fusion. The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication. The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut. He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded. The tape was placed and his arms were well padded. He was prepped and draped in a sterile fashion. A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle. We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle. We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region. We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space. We then marked the disc space. We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space. We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates. We took down posterior longitudinal ligament as well. We incised the 6-mm cornerstone bone. We placed a 6-mm parallel medium bone nicely into the disc space. We then sized a 23-mm plate. We inserted the screws nicely above and below. We tightened down the lock-nuts. We irrigated the wound. We assured hemostasis using bone wax prior to placing the plate. We then assured hemostasis once again. We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion. The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion. The skin was closed with 3-0 Monocryl in a running subcuticular stitch. Steri-Strips were applied. Dry sterile dressing with Telfa was applied over this. We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs. I was present as a primary surgeon throughout the entire case.

orthopedic, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft

C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.

Orthopedic

Anterior Cervical Discectomy & Fusion - 7

PREOPERATIVE DIAGNOSIS:, C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6. I discussed the procedure as well as risks and complications. She wishes to proceed with surgery. Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE: ,The patient was taken to the operating room on 10/02/2007. She was intubated for anesthesia. TEDS and boots as well as Foley catheter were placed. She was placed in a supine position with her neck in neutral position. Appropriate pads were also used. The area was prepped and draped in usual sterile fashion. Preoperative localization was taken. _____ not changed. Incision was made on the right side in transverse fashion over C5 vertebral body level. This was made with a #10 blade knife and further taken down with pickups and scissors. The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine. Intraoperative x-ray was taken. Longus colli muscles were retracted laterally. Caspar retractors were used. Intraoperative x-ray was taken. I first turned by attention at C5-C6 interspace. This was opened with #15 blade knife. Disc material was taken out using pituitary as well as Kerrison rongeur. Anterior aspects were taken down. End plates were arthrodesed using curettes. This was done under distraction. Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur. Bilateral foraminotomies were done. At this point, I felt that there was a good decompression. The foramen appeared to be opened. Medtronic cage was then encountered and sent few millimeters. This was packed with demineralized bone matrix. The distraction was then taken down. The cage appeared to be strong. This procedure was then repeated at C4-C5. A 42-mm AcuFix plate was then placed between C4 and C6. This was carefully screwed and locked. The instrumentation appeared to be strong. Intraoperative x-ray was taken. Irrigation was used. Hemostasis was achieved. The platysmas was closed with 3-0 Vicryl stitches. The subcutaneous was closed with 4-0 Vicryl stitches. The skin was closed with Steri-strips. The area was clean and dry and dressed with Telfa and Tegaderm. Soft cervical collar was placed for the patient. She was extubated per anesthesia and brought to the recovery in stable condition.

orthopedic, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,

Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.

Orthopedic

Anterior Cervical Discectomy & Interbody Fusion

PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2. Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2. Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression, C5-C6.,2. Arthrodesis with anterior interbody fusion, C5-C6.,3. Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4. Implant using PEEK 7 mm.,5. Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:, This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist. The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants. The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome. The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6. The patient understood the risks and benefits of the surgery. Risks include but not exclusive of bleeding and infection. Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function. This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele. Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele. There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level. There is also the possibility of nonimprovement of her symptoms in about 10% of cases. The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery. There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation. The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, awake, alert and not in any form of distress. After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut. A marker was placed. This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle. The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10. Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion. Dissection was then carried underneath the platysma superiorly inferiorly. The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle. The prevertebral fascia was noted to be taken her case with a lot of fat deposition. Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4. After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level. We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6. Self-retaining retractor was then laid down. An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur. This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm. The herniation was noted on the right. However, there was significant neuroforaminal stenosis on the left. Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage. The area was then irrigated with saline with bacitracin solution. A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium. X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution. A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly. The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond. Dressing was placed only at the exit site of the catheter. C-collar was placed. The patient was extubated and transferred to recovery.

Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.

Orthopedic

Anterior Cervical Discectomy & Fusion - 9

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:, Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position. The neck was prepped and draped in the usual fashion for anterior discectomy and fusion. An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level. The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally. Trachea and esophagus were retracted medially. After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis. We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally. With this having been done, we then turned our attention with the operating microscope to the osteophytes. We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes. This was removed along with the posterior longitudinal ligament. After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed. The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion. We observed that there was a ____________ in the posterior longitudinal ligament. There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size. That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws. After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips. Blood loss during the operation was less than 10 mL. No complications of the surgery. Needle count, sponge count, and cottonoid count were correct.,

orthopedic, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium

Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.

Orthopedic

Anterior Cervical Discectomy & Fusion - Discharge Summary

FINAL DIAGNOSES:,1. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2. Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches." In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right. He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful. More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7. In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief. The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty. Blood loss was about 125 cc. Postop x-ray showed good alignment and positioning of the cages, plate, and screws. After surgery, he was able to slowly increase his activity level with assistance from physical therapy. He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck. He also had some nausea with the PCA. He had a low-grade fever to 100.2 and was started on incentive spirometry. Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home. He has been counseled regarding wound care and has received a neck sheet for instruction. He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks. He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg. He is to call if there are any problems.

orthopedic, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,

Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation

Orthopedic

Anterior Cervical Discectomy & Osteophytectomy

PREOPERATIVE DIAGNOSES,1. Cervical radiculopathy, C5-C6 and C6-C7.,2. Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3. Symptomatic cervical stenosis, C5-C6 and C6-C7.,4. Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Cervical radiculopathy, C5-C6 and C6-C7.,2. Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3. Symptomatic cervical stenosis, C5-C6 and C6-C7.,4. Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1. CPT code 63075: Anterior cervical discectomy and osteophytectomy, C5-C6.,2. CPT code 63076: Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3. CPT code 22851: Application of prosthetic interbody fusion device, C5-C6.,4. CPT code 22851-59: Application of prosthetic interbody fusion device, C6-C7, additional level.,5. CPT code 22554-51: Anterior cervical interbody arthrodesis, C5-C6.,6. CPT code 22585: Anterior cervical interbody arthrodesis, C6-C7, additional level.,7. CPT code 22845: Anterior cervical instrumentation, C5-C7.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL:, The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area. The patient was transported to the operative suite and on to the operative table in the supine position. General endotracheal anesthesia was induced. The head was placed on a well-padded head holder. The eyes and face were protected from pressure. A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis. The arms were tucked and draped to the sides. All bony prominences were well padded. An x-ray was taken to confirm the correct level of the skin incision. The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery. The superficial and deep layers of the deep cervical fascia were divided. The midline structures were reflected to the right side. Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected. The carotid sheath was palpated and protected laterally. An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection. Hemostasis was obtained using the electrocautery. The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally. At C5-C6, the anterior longitudinal ligament was divided transversely. Straight pituitary rongeurs and a curette were used to remove the contents of the disc space. All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6. The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints. The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur. Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs. The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies. Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete. A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression. Both nerve roots were visualized and noted to be free of encroachment. The same procedure was then carried out at C6-C7 with similar findings. The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling. The disc spaces were then measured to the nearest millimeter. Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone. The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space. The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis. The grafts were impacted into the disc spaces. There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7. A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position. Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling. An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis. The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6. Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures. The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal. The wound was irrigated with irrigant solution containing antibiotics. The wound was inspected and judged to be dry. The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips. The sponge and needle count were correct. A sterile dressing was applied to the wound. The neck was placed in a cervical orthosis. The patient tolerated the procedure and was transferred to the recovery room in stable condition.

Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.

Orthopedic

Anterior Cervical Discectomy & Fusion - 6

PREOPERATIVE DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1. Anterior cervical discectomy with decompression of spinal cord C7-T1.,2. Anterior cervical fusion, C7-T1.,3. Anterior cervical instrumentation, anterior C7-T1.,4. Insertion of intervertebral device, C7-T1.,5. Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS: ,A 30 mL.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service. He was placed in the supine position on an OR table. His arms were carefully taped down. He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck. Subcutaneous tissue was dissected down to the level of the platysma. The platysma was incised using electrocautery. Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle. This allowed us to get right down on to the anterior cervical spine. Blunt dissection was done to sweep off the longus colli. We isolated the C7-T1 interspace. An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins. This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur. At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr. The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur. Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur. At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace. Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1. An x-ray was taken. It showed good placement of the plate and screws.,A deep drain was placed. The platysma layer was closed in running fashion using #1 Vicryl. Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl. Skin was closed in a running fashion using 4-0 Monocryl. Steri-Strips and dressings were applied. All counts were correct. There were no complications.

orthopedic, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation,

Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.

Orthopedic

Anterior Cervical Discectomy & Fusion - 5

PREOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2. Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3. Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA: ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues. Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7. Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen. This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well. This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed. At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam. Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7. These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size. The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc. The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition. At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct. There were no intraoperative complications of any type.

orthopedic, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy

Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).

Orthopedic

Anterior Cervical Discectomy & Fusion - 4

PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression, C3-4.,2. Arthrodesis with anterior interbody fusion, C3-4.,3. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4. Implant using PEEK 7 mm.,5. Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT: ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS: ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: ,Less than 100 mL.,CONDITION: ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION: ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop. Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening. About two days ago, he started noticing weakness on the left arm. The patient also noted shuffling gait. The patient presented to a family physician and was referred to Dr. X for further evaluation. Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine. MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes. Based on these findings, I recommended decompression. The patient was started on Decadron at 10 mg IV q.6h. Operation, expected outcome, risks, and benefits were discussed with him. Risks to include but not exclusive of bleeding and infection. Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma. The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function. Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient. There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics. However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation. This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed. There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele. This too can compromise airway and may require return to the operating room for repair of the dural tear. There is also potential risk of injury to the esophagus, the trachea, as well as the carotid. The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation. The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, awake, alert and not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. No monitoring leads were placed. The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders. Localizing x-ray verified the marker to be right at the C3-4 interspace. Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length. The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion. The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath. The prevertebral fascia was identified. Localizing x-ray verified another marker to be at the C3-4 interspace. Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out. There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur. The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur. The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4. There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side. By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed. Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder. With this completed, the Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant with its interior packed with Vitoss was then tapped into place. An 18-mm plate was then screwed down with four 14 x 4.0 mm screws. The area was irrigated with saline, with bacitracin solution. Postoperative x-ray showed excellent placement of the graft and spinal instrumentation. A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond. The catheter was anchored to the skin with a nylon 3-0 stitch. Dressing was placed only on the exit site of the drain. C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.

Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.

Orthopedic

Anterior Cervical Discectomy & Fusion - 3

PREOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-c4 and C4-C5.,2. Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-C4 and C4-C5.,2. Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1. Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2. Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3. Anterior cervical fusion, C3-C4 (CPT 22554),4. Anterior cervical fusion, C4-C5 (CPT 22585).,5. Utilization of allograft for purposes of spinal fusion (CPT 20931).,6. Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:, General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE INDICATIONS: ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness. His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness. We discussed the diagnosis and the treatment options. Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections. I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5. We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal. Furthermore I explained that the fusion may not become solid or that the hardware could break. We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation. I explained the rationale for this as well as the options of using his own bone. Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications. He was then positioned supine on the operating table, and all bony prominences were padded. Pulse oximetry was maintained on both feet throughout the case. The arms were carefully padded and tucked at his sides. A roll was placed between the shoulder blades. The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion. Ten pounds of traction was applied. A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision. The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle. This was then split in line with its fibers. Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized. A needle was placed into a disc and an x-ray was done to determine its location. The longus colli muscles were then elevated bilaterally with the electrocautery unit. Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5. This included complete removal of the anterior annulus, nucleus, and posterior annulus. The posterior longitudinal ligament was removed as were the posterior osteophytes. Foraminotomies were then accomplished bilaterally. Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression. The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace. Bleeding cancellous bone was exposed. The disc spaces were measured and appropriate size allografts were placed sterilely onto the field. After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position. There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace. All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis. Two screws were then placed into each of the vertebral bodies at C3, C4, and C5. There was excellent purchase. A final x-ray was done confirming good position of the hardware and grafts. The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks. The carotid pulse was strong. A drain was placed deep to the level of the platysma muscle and left at the level of the hardware. The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure. Steri-Strips were placed followed by application of a sterile dressing. The drain was hooked to bulb suction. A Philadelphia collar was applied.,The cranial tongs were carefully removed. The soft tissue overlying the puncture site was massaged to free it up from the underlying bone. There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.

Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.

Orthopedic

Anterior Cervical Discectomy & Fusion - 2

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position. The neck was prepped and draped in the usual fashion. An incision was made from midline to the anterior border of the sternocleidomastoid in the right side. Skin and subcutaneous tissue were divided sharply. Trachea and esophagus were retracted medially. Carotid sheath was retracted laterally. Longus colli muscles were dissected away from the vertebral bodies of C5-C6. We confirmed our position by taking intraoperative x-rays. We then used the operating microscope and cleaned out the disk completely. We then sized the interspace and then tapped in a #7 mm cortical cancellous graft. We then used the DePuy Dynamic plate with 14-mm screws. Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed in layers using 2-0 Vicryl for muscle and fascia. The blood loss was less than 10-20 mL. No complication. Needle count, sponge count, and cottonoid count was correct.

orthopedic, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior

Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5.

Orthopedic

Anterior Cervical Discectomy & Arthrodesis - 2

PREOPERATIVE DIAGNOSIS: ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:, Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:, Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position. Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position. A preoperative x-ray was obtained to identify the operative level and neck position. An incision was marked at the C4-C5 level on the right side. The incision was opened with #10 blade knife. Dissection was carried down through subcutaneous tissues using Bovie electrocautery. The platysma muscle was divided with the cautery and mobilized rostrally and caudally. The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection. The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia. This was opened with scissors and dissected rostrally and caudally with the peanut dissectors. The operative level was confirmed with an intraoperative x-ray. The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator. The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5. Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted. We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes. Operating microscope was draped and brought into play. Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went. We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally. Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch. There was a transligamentous disc herniation, which was removed during this process. We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent. Cord was seen to be pulsating freely behind the dura. There appeared to be no complications and the decompression appeared adequate. We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body. An 8 mm lordotic trial was used and appeared perfect. We then used a corticocancellous 8 mm lordotic graft. This was tapped into position. Distraction was released, appeared to be in excellent position. We then positioned an 18 mm Vector plate over the inner space. Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position. We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion. All of the screws locked to the plate and this was confirmed on visual inspection. Intraoperative x-ray was again obtained. Construct appeared satisfactory. Attention was then directed to closure. The wound was copiously irrigated. All of the self-retaining retractors were removed. Bleeding points were controlled with bone wax and bipolar electrocautery. The platysma layer was now closed with interrupted 3-0 Vicryl sutures. The skin was closed with running 3-0 Vicryl subcuticular stitch. Steri-Strips were applied. A sterile bandage was applied. All sponge, needle, and cottonoid counts were reported as correct. The patient tolerated the procedure well. He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.

orthopedic, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy,

Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.

Orthopedic

Anterior Cervical Discectomy & Fusion

PREOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis. In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion. Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4. Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially. The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5. It appeared that the C5-C6 disk area had fused spontaneously. We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation. We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments. This was then removed with 2-mm Kerrison rongeur. After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely. We did foraminotomies at C3-C4 as well as C4-C5 as well. After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place. The distraction was removed and the grafts were now within. We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws. X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia. Meticulous hemostasis was obtained. The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue. Steri-Strips were used for skin closure. Blood loss less than about 200 mL. No complications of the surgery. Needle counts, sponge count, and cottonoid count was correct.

orthopedic, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior

C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.

Orthopedic

Anterior Cervical Discectomy - 4

PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS: ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1. C5-C6 anterior cervical discectomy.,2. Bone bank allograft.,3. Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain. He had multiple levels of disease, but clinically, it was C6 radiculopathy. We tested him in the office and he had weakness referable to that nerve. The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed. General endotracheal anesthesia was obtained. He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner. An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes. We patiently drilled through them to the posterior ligament. We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side. The C6 foramen was narrowed by uncovertebral joint overgrowth. The foramen was open widely.,An allograft was placed. An anterior Steffee plate was placed. Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin. A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.

orthopedic, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,

Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.

Orthopedic

Anterior Cervical Discectomy & Decompression - 1

PREOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,PROCEDURES,1. Anterior cervical discectomy with decompression, C5-C6.,2. Anterior cervical fusion, C5-C6.,3. Anterior cervical instrumentation, C5-C6.,4. Allograft C5-C6.,ANESTHESIA: ,General endotracheal.,COMPLICATIONS:, None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months. Nonoperative measures failed to relieve her symptoms and surgical intervention was requested. We discussed reasonable risks, benefits, and alternatives of various treatment options. Continuation of nonoperative care versus the risks associated with surgery were discussed. She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery. Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite. General anesthetic was administered. The patient was placed in the supine position. All prominences and neurovascular structures were well accommodated. The patient was noted to have pulse in this position. Preoperative x-rays revealed appropriate levels for skin incision. Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed. The patient was then prepped and draped in sterile fashion. Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease. Subcutaneous tissue was dissected down to the level of the omohyoid which was transected. Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally. This was taken down to the prevertebral fascia which was bluntly split. Intraoperative x-ray was taken to ensure proper levels. Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures. Inferior spondylosis was removed with high-speed bur. A scalpel and curette was used to remove the disc. Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally. Disc herniation was removed from the right posterolateral aspect of the interspace. High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion. Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura. No further evidence of compression was identified. Hemostasis was achieved with thrombin-soaked Gelfoam. Interspace was then distracted with Caspar pin distractions set gently. Interspace was then gently retracted with the Caspar pin distraction set. An 8-mm allograft was deemed in appropriate fit. This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit. The graft was stable to pull-out forces. Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws. Plate and screws were then locked to the plate. Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft. Wounds were copiously irrigated with normal saline. Omohyoid was approximated with 3-0 Vicryl. Running 3-0 Vicryl was used to close the platysma. Subcuticular Monocryl and Steri-Strips were used to close the skin. A deep drain was placed prior to wound closure. The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition. There were no intraoperative complications. All needle and sponge counts were correct. Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.

orthopedic, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy

Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.

Orthopedic

Anterior Cervical Discectomy & Fusion - 1

PREOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus C2-C3.,2. Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus C2-C3.,2. Spinal stenosis C3-C4.,PROCEDURES,1. Anterior cervical discectomy, C3-C4, C2-C3.,2. Anterior cervical fusion, C2-C3, C3-C4.,3. Removal of old instrumentation, C4-C5.,4. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position. The neck was prepped and draped in the usual fashion for anterior cervical discectomy. A high incision was made to allow access to C2-C3. Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially. This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate. We placed in self-retaining retractors. With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5. After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal. In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit. It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis. With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4. We then placed the ABC 55-mm plate from C2 down to C4. These were secured with 16-mm titanium screws after excellent purchase. We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves. The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin. Blood loss was about 50 mL. No complication of the surgery. Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb. At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation. At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain. He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.

orthopedic, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion

Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant. Disc herniation with right arm radiculopathy.

Orthopedic

Anterior Cervical Discectomy & Arthrodesis - 1

PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1. C5-C6 arthrodesis, anterior interbody technique.,2. C5-C6 anterior cervical discectomy.,3. C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4. Implantation of machine bone implant.,5. Microsurgical technique.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS: ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain. The pain has become more and more severe. It runs to the thumb and index finger of the right hand and it is accompanied by numbness. If he tilts his neck backwards, the pain shoots down the arm. If he is working with the computer, it is very difficult to use his mouse. He tried conservative measures and failed to respond, so he sought out surgery. Surgery was discussed with him in detail. A C5-C6 anterior cervical discectomy and fusion was recommended. He understood and wished to proceed with surgery. Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR. There general endotracheal anesthesia was induced. He was positioned on the OR table with an IV bag between the scapulae. The neck was slightly extended and taped into position. A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle. The incision was extended through skin, subcutaneous fat, and platysma. Hemostasis was assured with Bovie cautery. The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath. The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine. A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space. An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure. A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space. The operating microscope was then brought into the field and used throughout the case except for the closure. Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible. Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body. A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament. A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina. A small amount of disk material was found at the right neural foramen. After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated. A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate. So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk. The wound was thoroughly irrigated and inspected for hemostasis. A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated. The patient was valsalved. There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers. The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin. The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins. Sterile dressing was placed on the patient's neck. He was extubated in the OR and transported to the recovery room in stable condition. There were no complications.

orthopedic, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,

Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr. 7. Microscopic dissection.

Orthopedic

Anterior Cervical Discectomy & Arthrodesis

PREOPERATIVE DIAGNOSIS:, Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1. Anterior cervical discectomy, C4-C5 and C5-C6.,2. Arthrodesis, C4-C5 and C5-C6.,3. Partial corpectomy, C5.,4. Machine bone allograft, C4-C5 and C5-C6.,5. Placement of anterior cervical plate with a Zephyr C4 to C6.,6. Fluoroscopic guidance.,7. Microscopic dissection.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:, This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance. He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6. Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed. He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position. Preoperative antibiotics were given. The patient was placed in the supine position with all pressure points noted and well padded. The patient was prepped and draped in standard fashion. An incision was made approximately above the level of the cricoid. Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially. We then placed needle into the disc spaces and was found to be at C5-C6. Distracting pins were placed in the body of C4 and in to the body of C6. The disc was then completely removed at C4-C5. There was very significant compression of the cord. This was carefully removed to avoid any type of pressure on the cord. This was very severe and multiple free fragments were noted. This was taken down to the level of ligamentum. Both foramen were then also opened. Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed. The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area. Again part of the body at C5 was removed to make sure that there was no additional constriction. Both nerve roots were then widely decompressed. Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5. Excellent purchase was obtained. Fluoroscopy showed good placement and meticulous hemostasis was obtained. Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin. The patient tolerated the procedure well and went to recovery in good condition.

orthopedic, fluoroscopic guidance, microscopic dissectio, cervical plate, zephyr, corpectomy, arthrodesis, anterior cervical discectomy, machine bone allograft, cervical discectomy, bone allograft, disc herniations, anterior, cervical, discectomy,

Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.

Orthopedic

Anterior Cervical Discectomy & Decompression

PREOPERATIVE DIAGNOSES,1. Left neck pain with left upper extremity radiculopathy.,2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1. Left neck pain with left upper extremity radiculopathy.,2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1. Anterior cervical discectomy with decompression C6-C7.,2. Arthrodesis with anterior interbody fusion C6-C7.,3. Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4. PEEK implant 7 mm.,5. Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS: ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS: ,Round French 10 JP drain.,SPECIMENS,: None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:, This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped. The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07. This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow. She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear. She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level. Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level. Operation, expected outcome, risks, and benefits were discussed with her. Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma. There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function. Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics. However, the patient may develop deeper-seated infection, which may require return to the operating room. Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft. There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery. There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid. There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. There is also the risk of pseudoarthrosis and hardware failure. She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress. After smooth induction and intubation, a Foley catheter was inserted. Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case. The EMGs were silent and there was no evidence of any stimulation. After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension. The head was supported on a foam doughnut. The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side. A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm. The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision. The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles. Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath. The prevertebral fascia was identified and cut sharply. A localizing x-ray verified the marker to be at the C6-C7 interspace. Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7. Self-retaining retractor was then laid out. The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr. The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7. There was note of a new osteophyte on the left C6-C7 foramen. This was carefully drilled down. After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders. They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam. After this was completed, Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant was then tapped into placed after its interior was packed with Vitoss. The plate was then applied and secured in place with four 12 x 4.7 mm screws. Irrigation of the area was done. A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis. The wound was reinforced with Dermabond. The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site. C-collar was placed and the patient was transferred to Recovery after extubation.

Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.

Orthopedic

Anterior Cervical Discectomy - 3

PREOPERATIVE DIAGNOSES: , Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,POSTOPERATIVE DIAGNOSES:, Cervical disk protrusions at C5-C6 and C6-C7, cervical radiculopathy, and cervical pain.,PROCEDURES:, C5-C6 and C6-C7 anterior cervical discectomy (two levels) C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,INDICATION FOR THE PROCEDURE: , This lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with MRI showing significant disk protrusions with the associate complexes at C5-C6 and C6-C7 with associated cervical radiculopathy. After failure of conservative treatment, this patient elected to undergo surgery.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR and after adequate general endotracheal anesthesia, she was placed supine on the OR table with the head of the bed about 10 degrees. A shoulder roll was placed and the head supported on a donut support. The cervical region was prepped and draped in the standard fashion. A transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle. In a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done. Then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly. Spinal needles were placed into the displaced C5-C6 and C6-C7 to confirm these disk levels using lateral fluoroscopy. Following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between C5-C7 and then the Trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly. A #15 scalpel was used to do a discectomy at C5-C6 from endplate-to-endplate and uncovertebral joint. On the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect. This was done under the microscope. A high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus. A blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then Kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the C5-C6 level. This was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen. Then, at the C6-C7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released. Then using the Kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right. This was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots. With this done, the wound was irrigated. Hemostasis was ensured with bipolar coagulation. Vertebral body distraction pins were then placed to the vertebral body of C5 and C7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below C5-C6 and C6-C7 discectomy sites. Then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (Danek windows titanium plates) was then taken and sized and placed. A temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of C5, two in the vertebral body of C6, and two in the vertebral body of C7. The holes were then drilled and after this self-tapping screws were placed into the vertebral body of C5, C6, and C7 across the plate to allow the plate to fit and stay flush with the vertebral body between C5, C6, and C7. With this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated. Hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down. A #10 round Jackson-Pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site. Then, the platysma was approximated using 2-0 Vicryl inverted interrupted stitches and the skin closed with 4-0 Vicryl running subcuticular stitch. Steri-Strips and sterile dressings were applied. The patient remained hemodynamically stable throughout the procedure. Throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling. In addition, intraoperative SSEP, EMG monitoring, and motor-evoked potentials remained stable throughout the procedure. The patient remained stable throughout the procedure.

orthopedic, cervical disk protrusions, cervical radiculopathy, cervical pain, cervical plate fixation, sofamor danek titanium window plate, anterior cervical discectomy, vertebral body, vertebral, disk, intraoperative, anterior, decompression, fluoroscopy, radiculopathy, discectomy, cervical,

Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.

Orthopedic

Anterior Cervical Discectomy - 2

ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:, This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs. She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted. Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery. She was interested in participating in the artificial disk replacement study and was entered into that study. She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007. She has done well postoperatively with a sensation of right arm pain and numbness in her fingers. She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well. She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment. She will contact our office prior to her appointment if she has problems. Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n. #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n. #60 with 1 refill.

orthopedic, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE

Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.

Orthopedic

Anterior Cervical Discectomy

PREOPERATIVE DIAGNOSES,1. Cervical spondylosis with myelopathy.,2. Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1. Cervical spondylosis with myelopathy.,2. Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1. Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2. Bilateral C6 nerve root decompression.,3. Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4. Bilateral C5 nerve root decompression.,5. Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6. Bilateral C4 nerve root decompression.,7. Harvesting of autologous bone from the vertebral bodies.,8. Grafting of allograft bone for creation of arthrodesis.,9. Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10. Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11. Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12. Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6. There was a herniated disk with cord compression and radiculopathy at C4-C5. C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels. Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives. He clearly understands and has no further questions and requests that I proceed.,PROCEDURE: ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease. Dissection was carried down through the platysma musculature and the anterior spine was exposed. The medial borders of the longus colli muscle were dissected free from their attachments to the spine. Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained. A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space. The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies. The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament. The ligament was incised and the underlying dura was exposed. I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen. There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact. However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right. The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5. I worked down through bony osteophytes and identified the posterior longitudinal ligament. The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces. The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen. The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it. Again the microscope was angled to the left side where similar decompression was achieved. Central decompression was achieved here where there was a moderate amount of spinal cord compression. This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space. Here there were large osteophytes projecting posteriorly against the cord. I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord. This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord. I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right. The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis. A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration. Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis. Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4. Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge. I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks. The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described. An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation. Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate. The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush. The holes were drilled and the screws were placed. Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6. All eight screws had good purchase. The locking screws were tightly applied. An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure. The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained. A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition. The sponge and needle counts were reported as correct. There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.

History and Physical for right ankle sprain

Orthopedic

Ankle Sprain - H&P

CHIEF COMPLAINT:, Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS:,Pulm: No cough, No wheezing, No shortness of breath,CV: No chest pain or palpitations,GI: No abdominal pain. No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE: No acute distress,VITAL SIGNS: Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK: Supple. No lymphadenopathy. No thyromegaly.,CHEST: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs.,ABDOMEN: Non-distended, nontender, normal active bowel sounds.,EXTREMITIES: No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL: The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending., ,IMPRESSION:, Right ankle sprain.,PLAN:,1. Motrin 800 mg t.i.d.,2. Tylenol 1 gm q.i.d. as needed.,3. Walking cast is prescribed.,4. I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.

Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.

Orthopedic

Achilles Tendon Repair

PREOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,POSTOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,PROCEDURE PERFORMED:, Primary repair left Achilles tendon.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME: ,40 minutes at 325 mmHg.,POSITION:, Prone.,HISTORY OF PRESENT ILLNESS: ,The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.,PROCEDURE:, After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained. The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff. While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient. The patient was then transferred to the operative table and placed in the prone position. All bony prominences were well padded at this time.,A nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time. Left lower extremity was sterilely prepped and draped in the usual sterile fashion. Once this was done, the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes. After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal. Careful dissection was then taken down to the level of the peritenon. Once this was reached, full thickness flaps were performed medially and laterally. Next, retractor was placed. All neurovascular structures were protected. A longitudinal incision was then made in the peritenon and opened up exposing the tendon. There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point. The plantar tendon was noted to be intact. The tendon was debrided at this time of hematoma as well as frayed tendon. Wound was copiously irrigated and dried. Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair. Next #0 PDS on a taper needle was selected and a Krackow stitch was then performed. Two sutures were then used and tied individually ________ from the tendon. The tendon came together very well and with a tight connection. Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon. The wound was once again copiously irrigated and dried. A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin. Steri-Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, Kerlix roll, sterile Kerlix and a short length fiberglass cast in a plantar position. At this time, the Department of anesthesia reversed the anesthetic. The patient was transferred back to hospital gurney to the Postanesthesia Care Unit. The patient tolerated the procedure well. There were no complications.

orthopedic, repair, achilles tendon rupture, longitudinal incision, tendon rupture, achilles tendon, tendon, achilles, rupture, extremity

Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.

Orthopedic

Anterior Cervical Discectomy - 1

PREOPERATIVE DIAGNOSIS: , Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression.,OPERATION PERFORMED,1. Anterior cervical discectomy of C3-C4.,2. Removal of herniated disc and osteophytes.,3. Bilateral C4 nerve root decompression.,4. Harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5. Grafting of fibular allograft bone for creation of arthrodesis.,6. Creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7. Placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has progressive and intractable right C4 radiculopathy with neck and shoulder pain. Conservative therapy has failed to improve the problem. Imaging studies showed severe spondylosis of C3-C4 with neuroforaminal narrowing and spinal cord compression.,A detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives. He clearly understood it and had no further questions and requested that I proceed.,PROCEDURE IN DETAIL: , The patient was placed on the operating room table and was intubated using a fiberoptic technique. The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses. The neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made on a skin crease on the left side of the neck. Dissection was carried down through the platysmal musculature and the anterior spine was exposed. The medial borders of the longus colli muscles were dissected free from their attachments to the spine. A needle was placed and it was believed to be at the C3-C4 interspace and an x-ray properly localized this space. Castoff self-retaining pins were placed into the body of the C3 and C4. Self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,The annulus was incised and a discectomy was performed. Quite a bit of overhanging osteophytes were identified and removed. As I worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,There was severe overgrowth of spondylitic spurs. A high-speed diamond bur was used to slowly drill these spurs away. I reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,Slowly and carefully I worked out towards the C3-C4 foramen. The dura was extremely thin and I could see through it in several areas. I removed the bony compression in the foramen and identified soft tissue and veins overlying the root. All of these were not stripped away for fear of tearing this very tissue-paper-thin dura. However, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen. An 8-mm of the root was exposed although I left the veins over the root intact.,The microscope was angled to the left side where a similar procedure was performed.,Once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration. Bone thus from the drilling was preserved for use for the arthrodesis.,Attention was turned to creation of the arthrodesis. As I had drilled quite a bit into the bodies, I selected a large 12-mm graft and distracted the space maximally. Under distraction the graft was placed and fit well. An x-ray showed good graft placement.,Attention was turned to spinal instrumentation. A Synthes Short Stature plate was used with four 3-mm screws. Holes were drilled with all four screws were placed with pretty good purchase. Next, the locking screws were then applied. An x-ray was obtained which showed good placement of graft, plate, and screws. The upper screws were near the upper endplate of C3. The C3 vertebral body that remained was narrow after drilling off the spurs. Rather than replace these screws and risk that the next holes would be too near the present holes I decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,Attention was turned to closure. A Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin. The wound was then carefully closed in layers. Sterile dressings were applied along with a rigid Philadelphia collar. The operation was then terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition. The sponge and needle counts were reported as correct and there were no intraoperative complications.,Specimens were sent to Pathology consisted of bone and soft tissue as well as C3-C4 disc material.

orthopedic, herniated, osteophytes, nerve root decompression, harvesting, autologous, vertebral, arthrodesis, anterior technique, anterior cervical discectomy, spinal cord compression, fibular allograft bone, creation of arthrodesis, cervical discectomy, spinal instrumentation, cord compression, vertebral body, vertebral bodies, spinal cord, bone, instrumentation, cervical, anterior, grafting, spinal, discectomy, allograft,

The patient was running and twisted her right ankle - right ankle sprain.

Orthopedic

Ankle Pain - Consult

IDENTIFICATION: , The patient is a 15-year-old female.,CHIEF COMPLAINT: , Right ankle pain.,HISTORY OF PRESENT ILLNESS:, The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician is Dr. Brown.,REVIEW OF SYSTEMS:, Otherwise negative except as stated above.,PAST MEDICAL HISTORY:, None.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:, None.,SOCIAL HISTORY: , Mother appears loving and caring. There is no evidence of abuse.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , General: The patient is alert and oriented x4 in mild distress without diaphoresis. She is nonlethargic and nontoxic. Vitals: Within normal limits. The right ankle shows no significant swelling. There is no ecchymosis. There is no significant tenderness to palpation. The ankle has good range of motion. The foot is nontender. Vascular: +2/2 dorsalis pedis pulse. All compartments are soft. Capillary refill less than 2 seconds.,DIAGNOSTIC TEST:, The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation.,MEDICAL DECISION MAKING: , Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home. She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain. She may need to see a specialist, but at this time this is a very mild ankle injury. There is no significant physical finding, and I foresee no complications. I will give her 1 week off of PE.,MORBIDITY/MORTALITY:, I expect no acute complications. A full medical screening exam was done and no emergency medical condition exists upon discharge.,COMPLEXITY:, Moderate. The differential includes fracture, contusion, abrasion, laceration, and sprain.,ASSESSMENT:, Right ankle sprain.,PLAN:, Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist. She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.

Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.

Orthopedic

Anterior Cervical Decompression

PREOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus, C5-C6.,2. Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus, C5-C6.,2. Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1. Anterior cervical decompression, C5-C6.,2. Anterior cervical decompression, C6-C7.,3. Anterior spine instrumentation.,4. Anterior cervical spine fusion, C5-C6.,5. Anterior cervical spine fusion, C6-C7.,6. Application of machined allograft at C5-C6.,7. Application of machined allograft at C6-C7.,8. Allograft, structural at C5-C6.,9. Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE: ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness. Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left. The patient has failed epidural steroid injections. Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position. After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion. A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body. It was taken down through the subcutaneous tissues exposing the platysmus muscle. The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine. An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level. Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed. The disk was very degenerated and brown in color. There was an acute disk herniation through posterior longitudinal ligament. The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed. Approximately, 5 mm of the nerve root on both the right and left side was visualized. A ball-ended probe could be passed up the foramen. Bleeding was controlled with bipolar electrocautery and Surgiflo. The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place. There was good bony apposition both proximally and distally. Next, attention was placed at the C6-C7 level. Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed. The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left. The posterior longitudinal ligament was removed. A bilateral foraminotomy was performed. Approximately, 5 mm of the C7 nerve root was visualized on both sides. A micro nerve hook was able to be passed up the foramen easily. Bleeding was controlled with bipolar electrocautery and Surgiflo. The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place. There was good bony apposition, both proximally and distally. Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws. Intraoperative x-ray confirmed appropriate positioning of the plate and the graft. The wound was then copiously irrigated with normal saline and bacitracin. There was no active bleeding upon closure of the wound. A small drain was placed deep. The platysmal muscle was closed with 3-0 Vicryl. The skin was closed with #4-0 Monocryl. Mastisol and Steri-Strips were applied. The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events. The patient was awoken and taken to the recovery room in satisfactory condition.

orthopedic, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,

Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.

Orthopedic

AC Separation Revision & Hardware Removal

PREOPERATIVE DIAGNOSIS:, Right AC separation.,POSTOPERATIVE DIAGNOSIS:, Right AC separation.,PROCEDURES:, Removal of the hardware and revision of right AC separation.,ANESTHESIA:, General.,BLOOD LOSS:, 100 cc.,COMPLICATIONS:, None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion. The incision was reopened and the hardware was removed without difficulty. The AC joint was inspected and reduced. An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle. And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability. This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy. The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied. He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct.

orthopedic, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware

Right Achilles tendon rupture.

Orthopedic

Achilles Ruptured Tendon

CHIEF COMPLAINT:, Achilles ruptured tendon.,HISTORY:, Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola. He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg. He was seen locally and diagnosed with an Achilles tendon rupture. He has been on crutches and has been nonweightbearing since that time. He had no pain prior to his injury. He has had some swelling that is mild. He has just been on aspirin a day due to his traveling time. Pain currently is minimal.,PAST MEDICAL HISTORY:, Denies diabetes, cardiovascular disease, or pulmonary disease.,CURRENT MEDICATIONS:, Malarone, which is an anti-malarial.,ALLERGIES:, NKDA,SOCIAL HISTORY:, He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco.,PHYSICAL EXAM:, Pleasant gentleman in no acute distress. He has some mild swelling on the right ankle and hindfoot. He has motion that is increased into dorsiflexion. He has good plantarflexion. Good subtalar, Chopart and forefoot motion. His motor function is intact although weak into plantarflexion. Sensation is intact. Pulses are strong. In the prone position, he has diminished tension on the affected side. There is some bruising around the posterior heel. He has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him. Squeezing the calf causes no plantarflexion of the foot.,RADIOGRAPHS:, Of his right ankle today show a preserved joint space. I don't see any evidence of fracture noted. Radiographs of the heel show no fracture noted with good alignment.,IMPRESSION:, Right Achilles tendon rupture.,PLAN:, I have gone over with Mr. XYZ the options available. We have discussed the risks, benefits and alternatives to operative versus nonoperative treatment. Based on his age and his activity level, I think his best option is for operative fixation. We went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery. We have discussed doing this as an outpatient procedure. He would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼" lift. He understands a 6-9 month return to sports overall. He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola. Today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1" lift also. He can weight bear until surgery and we will have it set up this week. His questions were all answered today.

orthopedic, achilles tendon rupture, alignment, crutches, joint space, nonweightbearing, plantarflexion, achilles ruptured tendon, achilles ruptured, ruptured tendon, achilles tendon, tendon rupture, achilles,

This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane. The patient is being brought in for YAG capsular discission.

Ophthalmology

YAG Laser Capsulotomy - 1

PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane. The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1% Mydriacyl, and Iopidine was instilled. The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied. A total of

ophthalmology, abraham capsulotomy, yag, yag laser capsulotomy, capsulotomy, laser, membrane, eye, capsular,

Bilateral open Achilles lengthening with placement of short leg walking cast.

Orthopedic

Achilles Lengthening

PREOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,POSTOPERATIVE DIAGNOSIS: , Idiopathic toe walker.,PROCEDURE: , Bilateral open Achilles lengthening with placement of short leg walking cast.,ANESTHESIA: , Surgery performed under general anesthesia. A total of 10 mL of 0.5% Marcaine local anesthetic was used.,COMPLICATIONS: ,No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,TOURNIQUET TIME: ,On the left side was 30 minutes, on the right was 21 minutes.,HISTORY AND PHYSICAL:, The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year. The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally. He does not walk with a crouched gait but does toe walk. Given his tightness, surgery versus observation was recommended to the family. Family however wanted to correct his toe walking. Surgery was then discussed. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems. All questions were answered and parents agreed to above surgical plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered. The patient received Ancef preoperatively. The patient was then subsequently placed prone with all bony prominences padded. Two bilateral nonsterile tourniquets were placed on each thigh. Both extremities were then prepped and draped in a standard surgical fashion. We turned our attention first towards the left side. A planned incision of 1 cm medial to the Achilles tendon was marked on the skin. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Incision was then made and carried down through subcutaneous fat down to the tendon sheath. Achilles tendon was identified and Z-lengthening was done with the medial distal half cut. Once Z-lengthening was completed proximally, the length of the Achilles tendon was then checked. This was trimmed to obtain an end-on-end repair with 0 Ethibond suture. This was also oversewn. Wound was then irrigated. Achilles tendon sheath was reapproximated using 2-0 Vicryl as well as the subcutaneous fat. The skin was closed using 4-0 Monocryl. Once the wound was cleaned and dried and dressed with Steri-Strips and Xeroform, the area was injected with 0.5% Marcaine. It was then dressed with 4 x 4 and Webril. Tourniquet was released at 30 minutes. The same procedure was repeated on the right side with tourniquet time of 21 minutes. While the patient was still prone, two short-leg walking casts were then placed. The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition.,POSTOPERATIVE PLAN: ,The patient will be discharged on the day of surgery. He may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks. He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs, which he will need up to 6 months. The patient may or may not need physical therapy while his Achilles lengthenings are healing. The patient is not to participate in any PE for at least 6 months. The patient is given Tylenol No. 3 for pain.

orthopedic, toe walker, achilles lengthening, idiopathic toe walker, short leg walking, subcutaneous fat, tendon sheath, leg walking, achilles tendon, toe, tourniquet, tendon, intraoperative,

Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.

Ophthalmology

Vitrectomy - 1

PREOPERATIVE DIAGNOSIS: , Vitreous hemorrhage and retinal detachment, right eye.,POSTOPERATIVE DIAGNOSIS:, Vitreous hemorrhage and retinal detachment, right eye.,NAME OF PROCEDURE: , Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.,ANESTHESIA: , Local with standby.,PROCEDURE: ,The patient was brought to the operating room, and an equal mixture of Marcaine 0.5% and lidocaine 2% was injected in a retrobulbar fashion. As soon as satisfactory anesthesia and akinesia had been achieved, the patient was prepped and draped in the usual manner for sterile ophthalmic surgery. A wire lid speculum was inserted. Three modified sclerotomies were selected at 9, 10, and 1 o'clock. At the 9 o'clock position, the Accurus infusion line was put in place and tied with a preplaced #7-0 Vicryl suture. The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position, and closed vitrectomy was begun. Initially formed core vitrectomy was performed and formed anterior vitreous was removed. After this was completed, attention was placed in the posterior segment. Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted. These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata. After all the vitreous had been removed and the membranes released, the retina was completely mobilized. Total fluid-air exchange was carried out with complete settling of the retina. Endolaser was applied around the margins of the retinal tears, and altogether several 100 applications were placed in the periphery. Good reaction was achieved. The eye was inspected with an indirect ophthalmoscope. The retina was noted to be completely attached. The instruments were removed from the eye. The sclerotomy sites were closed with #7-0 Vicryl suture. The infusion line was removed from the eye and tied with a #7-0 Vicryl suture. The conjunctivae and Tenon's were closed with #6-0 plain gut suture. A collagen shield soaked with Tobrex placed over the surface of the globe, and a pressure bandage was put in place. The patient left the operating room in a good condition.

ophthalmology, vitreous hemorrhage, retinal detachment, combined closed vitrectomy, vitrectomy, membrane peeling, fluid-air exchange, endolaser, vitrectomy with membrane peeling, membrane, peeling, hemorrhage, detachment, vicryl, eye, retinal,

Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.

Ophthalmology

YAG Laser Capsulotomy

PREOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES: ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye. The patient has had a mild decrease in visual acuity, which has been a gradual change. The posterior capsule opacity was felt to be related to the decline in vision. The risks, benefits, and alternatives (including observation) were discussed. I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. Pupil was dilated per protocol. Patient was positioned at the YAG laser. Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis. A total of ** shots were used. Total energy was **. The patient tolerated the procedure well and there were no complications. The lens remained well centered and stable. Postoperative instructions were provided. Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg. Postoperative instructions were provided and the patient had no further questions.

ophthalmology, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia

Vitrectomy under local anesthesia.

Ophthalmology

Vitrectomy - Local Anesthesia

DESCRIPTION OF PROCEDURE:, After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture.

ophthalmology, lid speculum, conjunctival, peritomy, vitrectomy, operating, superonasally, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.

Ophthalmology

Vitrectomy

PREOPERATIVE DIAGNOSIS:, Vitreous hemorrhage, right eye.,POSTOPERATIVE DIAGNOSIS: , Vitreous hemorrhage, right eye.,PROCEDURE: ,Vitrectomy, right eye.,PROCEDURE IN DETAIL: ,The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia. Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus. MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture. Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed. All strands of significance were removed. Tractional detachment foci were apparent posteriorly along the temporal arcades. Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control. Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control. The intraocular pressure was within the normal range. The globe was irrigated with a topical antibiotic. The MVR incisions were closed with 7-0 Vicryl. No further manipulations were necessary. The conjunctiva was closed with 6-0 plain catgut. An eye patch was applied and the patient was sent to the recovery area in good condition.

ophthalmology, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva

Vitrectomy under general anesthesia

Ophthalmology

Vitrectomy - General Anesthesia

DESCRIPTION OF PROCEDURE: , After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture.

ophthalmology, ophthalmic fashion, vitrectomy, operating, superonasally, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.

Ophthalmology

Vitrectomy - 3

DESCRIPTION OF OPERATION:, The patient was brought to the operating room and appropriately identified. Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants. Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. The MVR blade was used to make a sclerotomy between the pre-placed sutures. An 8-0 nylon suture was then pre-placed for later sclerotomy closure. The infusion cannula was inspected and found to be in good working order. The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures. The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants. The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed. There was moderately severe vitreous hemorrhage, which was removed. Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades. These were dissected with curved scissors and judicious use of the vitrectomy cutter. There was some bleeding from the inferotemporal frond. This was managed by raising the intraocular pressure and using intraocular cautery. The surgical view became cloudy and the corneal epithelium was removed with a beaver blade. This improved the view. There is an area suspicious for retinal break near where the severe traction was inferotemporally. The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment. The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen. There was some residual hemorrhagic vitreous skirt seen. The soft-tip cannula was then used to perform an air-fluid exchange. Additional laser was placed around the suspicious area inferotemporally. The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut. A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye. The lid speculum was removed. Maxitrol ointment was instilled over the eye and the eye was patched. The patient was brought to the recovery room in stable condition.

ophthalmology, conjunctival peritomy, westcott scissors, lid speculum, inferotemporal quadrants, inferotemporal, conjunctival, scissors, supranasal, supratemporal, sclerotomy, eye, vitreous, vitrectomy, infusion, cannulaNOTE

The patient with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.

Ophthalmology

Uveitis

PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:, Positive for only for left knee arthritis. She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers. She has no skin rashes. She has no connective tissue disorders.,PAST OCULAR HISTORY: , Significant for cataract and glaucoma surgery of the right eye.,PHYSICAL EXAMINATION: , On examination, visual acuity measures hand motions on the right and 20/25 in the left. There is an afferent pupillary defect on the right. On examination, there is a right hypertropia. There is dense anterior chamber inflammation on the right eye with a stagnant aqueous. There is either neovascularization on the iris or reactive iris vessels, it is difficult to discern. This seems to be complete iris synechia to the anterior lens capsule. There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface. The anterior chamber appears narrow. On the left, there is also dense inflammation at 4+ cell. There is 1+ nuclear sclerosis. Dilated fundus examination cannot be performed on the right secondary to intense inflammation. On the left, there is no evidence of active posterior uveitis. There is some inferior vitreous debris.,ASSESSMENT/PLAN:, Chronic bilateral recurrent nongranulomatous diffuse uveitis. Currently, there is very severe right eye inflammation and severe left eye. I discussed at length with the patient that this will likely take an oral steroid to quite her down. Since she has only one seeing eye, I am anxious to obtain a decreased inflammation as soon as possible. She has been on oral steroids in the past. We also discussed, considering the aggressive recurrent nature of this process, it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left. I anticipate we will likely start methotrexate in the near future. In this acute phase, I have recommended oral steroids at a dose of 60 mg a day, hourly topical Pred Forte as well as atropine sulfate. We will watch her closely in clinic. I am sending a copy of this dictation to her primary care doctor, she said she has had a negative HLA-B27, rheumatoid factor, and ANA in the past. At this stage, to be thorough I would ask Dr. X to assist us in repeating her chest x-ray, PPD if not current, and an RPR. Additionally, in anticipation of need for methotrexate, it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C.

ophthalmology, iritis, nongranulomatous, uveitis, eye inflammation, photophobia, recurrent nongranulomatous anterior iritis, headache and photophobia, anterior chamber, anterior, chamber, inflammation,

Pars plana vitrectomy, membrane peel, 23-gauge, right eye.

Ophthalmology

Vitrectomy - 2

PREOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye. CME, right eye.,POSTOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye. CME, right eye.,PROCEDURES: , Pars plana vitrectomy, membrane peel, 23-gauge, right eye.,PREOPERATIVE FINDINGS:, The patient had epiretinal membrane causing cystoid macular edema. Options were discussed with the patient stressing that the visual outcome was guarded. Especially since this membrane was of chronic duration there is no guarantee of visual outcome.,DESCRIPTION OF PROCEDURE: , The patient was wheeled to the OR table. Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified. Preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified. The fluid was run. Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock. Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ILM forceps, the membrane was peeled off in its entirety. There were no complications. DVT precautions were in place. I, as attending, was present in the entire case.

ophthalmology, epiretinal membrane, pars plana vitrectomy, membrane peel, macular edema, cystoid, eye, retrobulbar, epiretinal, vitrectomy, membrane,

Vitrectomy opening. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.

Ophthalmology

Vitrectomy Opening

VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified. General anesthesia was induced by the anesthesiologist. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants. Hemostasis was maintained with wet-field cautery. Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant. A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. The MVR blade was used to make a sclerotomy between the preplaced sutures. An 8-0 nylon suture was then preplaced for a later sclerotomy closure. The infusion cannula was inspected and found to be in good working order. The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture. The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on. Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants.

ophthalmology, westcott scissors, inferotemporal quadrants, conjunctival, peritomy, sclerotomy, vitrectomy, supranasal, supratemporal, cannula, inferotemporalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Scleral buckle opening under local anesthesia.

Ophthalmology

Scleral Buckle Opening - Local Anesthesia

PROCEDURE IN DETAIL:, After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. The 4 rectus muscles were looped and isolated using 2-0 silk suture. The retinal periphery was then inspected via indirect ophthalmoscopy.,

ophthalmology, retinal periphery, ophthalmoscopy, scleral, buckle, operating, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye. Uncontrolled open angle glaucoma and conjunctival scarring, left eye.

Ophthalmology

Trabeculectomy & Tenonectomy

PREOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Negligible.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines. In the preoperative area, the patient received pilocarpine drops. The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain. Approximately 3 mL were given. The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye. During the draping process, care was taken to isolate the lashes. A screw type speculum was inserted to maintain patency of lids. A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva. A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea. All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis. A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade. This was approximately one-half scleral depth in thickness. A crescent blade was then used to dissect forward the clear cornea. Hemostasis was again achieved with wet-field cautery. A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes. The site was then profusely irrigated with balanced salt solution. A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed. A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed. Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps. The iris was then repositioned into the eye and the anterior chamber was inflated with BSS. The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried. The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle. BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage. Antibiotic and steroid drops were placed in the eye as was homatropine 5%. The antibiotic consisted of Vigamox and the steroid was Econopred Plus. A patch and shield were placed over the eye after the drape was removed. The patient was taken to the recovery room in good condition. She will be seen in followup in the office tomorrow.

ophthalmology, uncontrolled open angle glaucoma, open angle, conjunctival, scarring, trabeculectomy, tenonectomy, iridectomy, paracentesis, watertight conjunctival closure, conjunctival scarring, eye, glaucoma, cornea, scleral,

Tube Shunt - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template.

Ophthalmology

Tube Shunt - Ahmed Valve Implant

PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.

ophthalmology, tube shunt, ahmed valve, healon, maxitrol ointment, ocuflox, open angle, anterior chamber, bleeding, conjunctival peritomy, cornea, corneal edema, corneal hemorrhage, diplopia, elevated pressure, glaucoma, hypotony, infection, loss of the eye, loss of vision, ophthalmic fashion, ptosis, reoperation, retinal detachment, sclera, superotemporal, worsening of glaucoma, ahmed valve model, superotemporal limbus, eye, ahmed, implant, bss, valve, limbus,

Scleral buckle opening. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.

Ophthalmology

Scleral Buckle Opening

SCLERAL BUCKLE OPENING,The patient was brought to the operating room and appropriately identified. General anesthesia was induced by the anesthesiologist. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye. A 360-degree limbal conjunctival peritomy was created with Westcott scissors. Curved tenotomy scissors were used to enter each of the intermuscular quadrants. The inferior rectus muscle was isolated with a muscle hook, freed of its Tenon's attachment and tied with a 2-0 silk suture. The 3 other rectus muscles were isolated in a similar fashion. The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.

ophthalmology, tenotomy, scleral quadrants, scleral thinning, scleral buckle, staphylomaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Trabeculectomy with mitomycin C - Sample/Template.

Ophthalmology

Trabeculectomy

PREOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Trabeculectomy with mitomycin C, XXX eye 0.3 c per mg times three minutes.,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox, Ocular, and pilocarpine. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position. A Lieberman lid speculum was used to provide exposure. Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly. This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap. Residual episcleral vessels were cauterized with Eraser-tip cautery. Sponges soaked in mitomycin C 0.3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock. Sponges were removed and area was copiously irrigated with balanced salt solution. A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap. This was dissected anteriorly with a crescent blade to clear cornea. A temporal paracentesis was then made. Scleral flap was lifted and a Super blade was used to enter the anterior chamber. A Kelly-Descemet punch was used to remove a block of limbal tissue. DeWecker scissors were used to perform a surgical iridectomy. The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea. A scleral flap was then re- approximated back on the bed. One end of the scleral flap was closed with a #10-0 nylon suture in interrupted fashion and the knot was buried. The other end of the scleral flap was closed with #10-0 nylon suture in interrupted fashion and the knot was buried. The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber. Therefore it was felt that another #10-0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed. The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber. Conjunctiva was then re-approximated to the limbus and closed with #9-0 Vicryl suture on a TG needle at each of the peritomy ends. Then a horizontal mattress style #9-0 Vicryl suture was placed at the center of the conjunctival peritomy. The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck- cel sponge. The anterior chamber was inflated and there was noted that the superior bleb was well formed. At the end of the case, the pupil was round, the chamber was formed and the pressure was felt to be adequate. Speculum and drapes were carefully removed. Ocuflox and Maxitrol ointment were placed over the eye. Atropine was also placed over the eye. Then an eye patch and eye shield were placed over the eye. The patient was taken to the recovery room in good condition. There were no complications.

ophthalmology, trabeculectomy, kelly-descemet punch, maxitrol ointment, open angle glaucoma, tg needle, bleeding, corneal edema, corneal hemorrhage hypotony, diplopia, elevated pressure, glaucoma, infection, iridectomy, loss of the eye, loss of vision, mitomycin c, ptosis, reoperation, retinal detachment, temporal paracentesis, worsening of glaucoma, balanced salt solution, anterior chamber, scleral flap, eye, angle, mitomycin, conjunctival, chamber, flap,

Scleral Buckle opening under general anesthesia.

Ophthalmology

Scleral Buckle Opening - General Anesthesia

PROCEDURE IN DETAIL:, After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty. The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. The 4 rectus muscles were looped and isolated using 2-0 silk suture. The retinal periphery was then inspected via indirect ophthalmoscopy.

ophthalmology, retinal periphery, conjunctival peritomy, ophthalmoscopy, scleral, buckle, operating, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Repair of ruptured globe involving posterior sclera - Sample/Template.

Ophthalmology

Ruptured Globe Repair - Posterior Sclera

PREOPERATIVE DIAGNOSIS: , Ruptured globe OX.,POSTOPERATIVE DIAGNOSIS:, Ruptured globe OX.,PROCEDURE: , Repair of ruptured globe OX.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS: ,None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.,Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.,At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried. ,Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.

ophthalmology, ruptured globe, ancef, bss, maxitrol ointment, ocuflox, anterior chamber, bleeding, conjunctiva, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, scleral rupture, wire lid speculum, repair of ruptured globe, ruptured, anterior, chamber, globe

Ruptured globe with full-thickness corneal laceration repair - Sample/Template.

Ophthalmology

Ruptured Globe Repair - Cornea

PREOPERATIVE DIAGNOSIS:, Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE: ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.

ophthalmology, ruptured globe, alphagan, bss, ocuflox, pred forte, superblade, timolol, viscoat cannula, anterior chamber, astigmatism, bleeding, cataract, corneal laceration, full-thickness corneal laceration, infection, laceration repair, loss of the eye, loss of vision, paracentesis, re-operation, wire lid speculum, viscoat, corneal, laceration,

Repair of ruptured globe with repositing of uveal tissue - Sample/Template.

Ophthalmology

Ruptured Globe Repair - Sclera and Limbus

PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:, Ruptured globe with uveal prolapse OX.,PROCEDURE: ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: , The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.

ophthalmology, ruptured globe, bss, subconjunctival, bleeding, conjunctiva, eye patch, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, supranasal quadrant, uveal prolapse, wire lid speculum, iris tissue, anterior chamber, laceration, iris, chamber, ruptured, globe, eye,

Small office note on premature retina and vitreous.

Ophthalmology

Premature retina and vitreous

OCULAR FINDINGS: , Anterior chamber space: Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole. No dilated blood vessels seen in each eye.,Periphery: The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION: ,Premature retina and vitreous, each eye.,PLAN: ,Recheck in two weeks.,

ophthalmology, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye,

Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.

Ophthalmology

Repair of Canthal & Lid Defect

PREOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,POSTOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,PROCEDURES:,1. Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2. Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,ASSISTANT: , None.,ANESTHESIA: , Attended local by Strickland and Associates.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position. Dressing was removed from the left eye, which revealed the defect as noted above. After systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid. The patient was prepped and draped in the usual ophthalmic fashion. Protective scleral shell was placed in the left eye. A 4-0 silk traction sutures placed through the upper eyelid margin. The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound. The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid. Relaxing incisions were made both medially and laterally and Mueller's muscle was subsequently dissected free from the superior tarsal border. The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 Vicryl sutures and one 4-0 Vicryl suture. The protective scleral shell was removed from the eye. The medial aspect of the eyelid was advanced temporally. The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 Vicryl sutures. The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 Vicryl suture. The upper eyelid wound was present. It was advanced to the advanced tarsoconjunctival pedicle temporally. The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 Vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 Vicryl sutures. Skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 Vicryl sutures. Burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 Vicryl suture. Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 Vicryl suture to the periosteum overlying the lateral orbital rim. The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 Vicryl followed by wound closure temporally with interrupted 7-0 Vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure. Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure. The patient tolerated the procedure well and left the operating room in excellent condition. There were no apparent complications.

ophthalmology, mohs resection epithelial skin, lid left lateral canthus, lateral canthal defect, tarsoconjunctival pedicle flap, lateral canthal tendon, skin muscle flap, interrupted vicryl sutures, canthal defect, mohs resection, lid defect, pedicle flap, canthal tendon, lateral canthus, upper eyelid, lateral orbital, eyelid, vicryl, sutures, repair, eye, canthal, defect, tarsoconjunctival, pedicle

Macular edema, right eye. Insertion of radioactive plaque, right eye with lateral canthotomy. The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron. The placement was confirmed with indirect ophthalmoscopy.

Ophthalmology

Radioactive Plaque - Insertion

PREOPERATIVE DIAGNOSIS:, Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS: ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: ,The patient was prepped and draped in the usual manner for a local eye procedure. Initially, a 5 cc retrobulbar injection of 2% Xylocaine was done. Then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus. A 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed. The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron. The placement was confirmed with indirect ophthalmoscopy. Next, the eye was irrigated with Neosporin and the conjunctiva was closed with 6-0 plain catgut. The intraocular pressure was found to be within normal limits. An eye patch was applied and the patient was sent to the Recovery Room in good condition. A lateral canthotomy had been done.

ophthalmology, canthotomy, ophthalmoscopy, radioactive plaque, scleral surface, macular edema, lateral canthotomy, macular

Bilateral rectus recession with the microscopic control, 8 mm, both eyes.

Ophthalmology

Rectus Recession

PREOPERATIVE DIAGNOSIS:, Congenital bilateral esotropia, 42 prism diopters.,PROCEDURE:, Bilateral rectus recession with the microscopic control, 8 mm, both eyes.,POSTOPERATIVE DIAGNOSIS: , Congenital bilateral esotropia, 42 prism diopters.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , The patient was taken to the Surgery Room and placed in the supine position. The general anesthesia was achieved with intubation with no problems. Both eyes were prepped and draped in usual manner. The attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape. The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem. The eyeball rotated medially and upwards by holding the limbus at 7 o'clock position. Inferior fornix conjunctival incision was made and Tenons capsule buttonholed. The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook. The Tenons capsule was buttonholed. The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle. __________ extension of the muscle was excised. The 7-0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders. The muscle was disinserted from original insertion. The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion. The suture was pulled, tied, and cut. The muscle was in good position. The conjunctiva was closed with 7-0 Vicryl suture in running fashion. The suture was pulled, tied, and cut. The eye speculum was taken out.,Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion. The suture was pulled, tied and cut. The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut. TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition. To be seen in the office in 1 week.

ophthalmology, congenital bilateral esotropia, esotropia, tenons capsule, rectus muscle, bilateral rectus recession, rectus recession, eye speculum, muscle hook, eyes, muscle, rectus,

Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.

Ophthalmology

Rhytidectomy & Blepharoplasty

PREOPERATIVE DIAGNOSIS:, Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1. Cervical facial rhytidectomy.,2. Quadrilateral blepharoplasty.,3. Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION: ,This is a 62-year-old female for the above-planned procedure. She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied. Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table. Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen. This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized. Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty. Markers were applied to both upper lids in symmetrical fashion. The skin was excised from the right upper lid first followed by appropriate muscle resection. Minimal fat removed from the medial upper portion of the eyelid. Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture. Attention was then turned to the lower lid. A classic skin muscle flap was created accordingly. Fat was resected from the middle, medial, and lateral quadrant. The fat was allowed to open drain the arcus marginalis for appropriate contour. Hemostasis was controlled with the pinpoint cautery accordingly. Skin was redraped with a conservative amount resected. Running closure with 7-0 nylon was accomplished without difficulty. The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes. Eye mass was likewise clamped. Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure. The right face was first operated. It was injected with a 0.25% Marcaine 1:200,000 adrenaline. A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula. She had minimal subcutaneous extra fat as noted. Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline. The flap was elevated without difficulty with various facelift scissors. Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision. Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery. The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication. The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene. The skin was draped appropriately and appropriate tissue was resected. A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface. Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon. The hairline temporal incision was closed with running 5-0 nylon. The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described. Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly. Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly. Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure. The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure. She will be discharged in the morning.,Estimated blood loss was less than 75 cc. No complications noted, and the patient tolerated the procedure well.

ophthalmology, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,

Radioactive plaque macular edema. Removal of radioactive plaque, right eye with lateral canthotomy. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.

Ophthalmology

Radioactive Plaque - Removal

PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:, Radioactive plaque macular edema.,TITLE OF OPERATION:, Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure. Then a retrobulbar injection of 2% Xylocaine was performed. A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus. A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed. Next, the plaque was identified and the two scleral sutures were removed. The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture. The fundus was inspected with direct ophthalmoscopy. An eye patch was applied following Neosporin solution irrigation. The patient was sent to the recovery room in good condition. A lateral canthotomy had been done.

ophthalmology, conjunctiva, eye patch, ophthalmoscopy, radioactive plaque, traction, suture, eye, radioactive, plaque

Phacoemulsification of cataract, extraocular lens implant in left eye.

Ophthalmology

Phacoemulsification of Cataract - 1

PREOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:, Alcon, model SN60WF, power of 22.5 diopters., ,PHACOEMULSIFICATION TIME:, 1 minute 41 seconds at 44.4% power., ,INDICATIONS FOR PROCEDURE: , This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40. The patient complains of difficulties with glare in performing activities of daily living.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery. All questions from the patient were answered after the surgical procedure was explained in detail. The risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc. Alternative of the procedure is to do nothing or seek a second opinion. Informed consent for this procedure was obtained from the patient.,OPERATIVE TECHNIQUE: , The patient was brought to the holding area. Previously, an intravenous infusion was begun at a keep vein open rate. After adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye. A total of 10 mL mixture with a 70/30 mixture of 2% Xylocaine without epinephrine and 0.75% bupivacaine without epinephrine. An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area. Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted. Vital sign monitors were detached from the patient. The patient was moved to the operative suite and the same monitors were reattached. The periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery. The speculum was set into place and the operative microscope was brought over the eye. The eye was examined. Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea. Then a pocket incision was created without entering the anterior chamber of the eye. Two peripheral paracentesis ports were created on each side of the initial incision site. Viscoelastic was used to deepen the anterior chamber of the eye. A 2.65 mm keratome was then used to complete the corneal valve incision. A cystitome was bent and created using a tuberculin syringe needle. It was placed in the anterior chamber of the eye. A continuous curvilinear capsulorrhexis was begun. It was completed using O'Gawa Utrata forceps. A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus. The lens nucleus was noted to be freely mobile in the bag.,The phacoemulsification tip was placed into the anterior chamber of the eye. The lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique. All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports. The posterior capsule remained intact throughout the entire procedure. Provisc was used to deepen the anterior chamber of the eye. A crescent blade was used to expand the internal aspect of the wound. The lens was taken from its container and inspected. No defects were found. The lens power selected was compared with the surgery worksheet from Dr. X's office. The lens was placed in an inserter under Provisc. It was placed through the wound, into the capsular bag and extruded gently from the inserter. It was noted to be adequately centered in the capsular bag using a Sinskey hook. The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique. The eye was noted to be inflated without overinflation. The wounds were tested for leaks, none were found. Five drops dilute Betadine solution was placed over the eye. The eye was irrigated. The speculum was removed. The drapes were removed. The periocular area was cleaned and dried. Maxitrol ophthalmic ointment was placed into the interpalpebral space. A semi-pressure patch and shield was placed over the eye. The patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with Dr. X tomorrow morning in the office.

ophthalmology, senile nuclear cataract, senile, phacoemulsification, phacoemulsification of cataract, lens implant, lens nucleus, anterior chamber, lens, alcon, eye, cataract,

Sample post dilation patient instructions.

Ophthalmology

Post Dilation Instructions

The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.

ophthalmology, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Phacoemulsification with posterior chamber intraocular lens insertion.

Ophthalmology

Phacoemulsification & Lens Implantation - 6

PROCEDURE: , Phacoemulsification with posterior chamber intraocular lens insertion.,INTRAOCULAR LENS: , Allergan Medical Optics model S140MB XXX diopter chamber lens.,PHACO TIME:, Not known.,ANESTHESIA: , Retrobulbar block with local minimal anesthesia care.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS:, None.,DESCRIPTION OF PROCEDURE: , While the patient was in the holding area, the operative eye was dilated with four sets of drops. The drops consisted of Cyclogyl 1%, Acular, and Neo-Synephrine 2.5 %. Additionally, a peripheral IV was established by the anesthesia team. Once the eye was dilated, the patient was wheeled to the operating suite.,Inside the operating suite, central monitoring lines were established. Through the peripheral IV, the patient received intravenous sedation consisting of Propofol and once somnolent from this, retrobulbar block was administered consisting of 2 cc's of 2% Xylocaine plain with 150 units of Wydase. The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained. Digital pressure was applied for approximately five minutes.,The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery. A Betadine prep was carried out of the face, lids, and eye. During the draping process, care was taken to isolate the lashes. A wire lid speculum was inserted to maintain patency of the lids. With benefit of the operating microscope, a diamond blade was used to place a groove temporally. A paracentesis wound was also placed temporally using the same blade. Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2.8 mm. diamond keratome was used to enter the anterior chamber through the previously placed groove. The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty. The capsular remnant was withdrawn from the eye using long angled McPherson forceps. Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed. The lens was noted to rotate freely within the capsular bag. The phaco instrument was then inserted into the eye using the Kelman tip. The lens nucleus was grooved and broken into two halves. One of the halves was in turn broken into quarters. Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification. Attention was then turned toward the remaining half of the nucleus and this, in turn, was removed as well, with the splitting maneuver. Once the nucleus had been removed from the eye, the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections. Once the cortical material had been completely removed, a diamond dusted cannula was inserted into the eye and the posterior capsule was polished. Viscoelastic was again instilled into the capsular bag as well as the anterior chamber. The wound was enlarged slightly using the diamond keratome. The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps. Once inside the eye, the lens was unfolded into the capsular bag in a single maneuver. It was noted to be centered nicely. The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine.,Next, Miostat was instilled into the operative eye and the wound was checked for water tightness. It was found to be such. After removing the drapes and speculum, TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye.,The patient tolerated the procedure extremely well and was taken to the recovery area in good condition. The patient is scheduled to be seen in follow-up in the office tomorrow, but should any complications arise this evening, the patient is to contact me immediately.

ophthalmology, diopter, intraocular lens insertio, phacoemulsification, posterior chamber, diamond keratome, anterior chamber, capsular bag, intraocular lens, intraocular, allergan, eye, capsular, chamber, lens,

Phacoemulsification of cataract and posterior chamber lens implant, right eye.

Ophthalmology

Phacoemulsification & Lens Implantation - 4

OPERATION PERFORMED:, Phacoemulsification of cataract and posterior chamber lens implant, right eye., ,ANESTHESIA:, Retrobulbar nerve block, right eye, ,DESCRIPTION OF OPERATION: ,The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine and a Honan balloon. Once anesthesia was achieved, the right eye was prepped with Betadine, rinsed with saline, and draped in a sterile fashion. A lid speculum was placed and 4-0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe. A fornix-based conjunctival flap was prepared superiorly from 10 to 12 o'clock and episcleral vessels were cauterized using a wet-field. A surgical groove was applied with a 69 Beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o'clock position. A lamellar dissection was carried anteriorly to clear cornea using a crescent knife. A stab incision was applied with a Superblade at the 2 o'clock position at the limbus. The chamber was also entered through the lamellar groove using a 3-mm keratome in a beveled fashion. Viscoat was injected into the chamber and an anterior capsulorrhexis performed. Hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber. A deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side-port incision. A second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants. Each quadrant was emulsified under burst power within the capsular bag. The epinuclear bowl was manipulated with vacuum, flipped into the iris plane, and emulsified under pulse power. I&A was used to aspirate cortex from the capsular bag. A scratcher was used to polish the capsule, and Viscoat was injected inflating the capsular bag and chamber. The wound was enlarged with a shortcut blade to 5.5 mm. The intraocular lens was examined, found to be adequate, irrigated with balanced salt, and inserted into the capsular bag. The lens centralized nicely and Viscoat was removed using the I&A. Balanced salt was injected through the side-port incision. The wound was tested, found to be secure, and a single 10-0 nylon suture was applied to the wound with the knot buried within the sclera. The conjunctiva was pulled over the suture, and Ancef 50 mg and Decadron 4 mg were injected sub-Tenon in the inferonasal and inferotemporal quadrants. Maxitrol ointment was applied topically followed by an eye pad and shield. The patient tolerated the procedure and was taken from the operating room in good condition.

ophthalmology, retrobulbar nerve block, posterior chamber lens implant, phacoemulsification of cataract, lens implantation, capsular bag, cataract, phacoemulsification, nucleus, capsular, lens, eye

Phacoemulsification with posterior chamber intraocular lens implant in the right eye.

Ophthalmology

Phacoemulsification & Lens Implantation - 7

TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child. He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract. He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,PREOP DIAGNOSIS:,1. History of open globe to the right eye.,2. History of retinal detachment status post repair in the right eye.,3. Silicone oil in anterior chamber.,4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,POSTOP DIAGNOSIS:,1. History of open globe to the right eye.,2. History of retinal detachment status post repair in the right eye.,3. Silicone oil in anterior chamber.,4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,ANESTHESIA: , General.,PROS DEV IMPLANT: , ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,NARRATIVE: , Informed consent was obtained. All questions were answered. The patient was brought to preoperative holding area where the operative right eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced by the anesthesia service. A time-out was called to confirm the procedure and operative eye. The right operative eye was disinfected and draped in a standard fashion for eye surgery. A lid speculum was placed. The vitreoretinal team placed the infusion cannula after performing a peritomy. At this point in the case, the patient was turned over to the cornea service with Mrs. Jun. A paracentesis was made at the approximately 3 o'clock position. Healon was placed into the anterior chamber. The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis. This incision was then shelved anteriorly and used to enter the anterior chamber. The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome. Hydrodissection was performed. The lens nucleus was removed using phacoemulsification and irrigation and aspiration. Lens cortex also was removed using irrigation and aspiration. Viscoelastic was placed to inflate the capsular remnant. The diamond knife was used to enlarge the phaco incision. Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty. The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed. The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber. This was done without difficulty. The anterior chamber was secured and watertight at the end of the procedure. Intraocular pressure was satisfactory. The patient tolerated the procedure well and then was turned over to the retina service in good condition. They will dictate a separate note.

ophthalmology, phacoemulsification, intraocular lens implant, posterior chamber, chamber, eye, intraocular, lens,

Cataract, right eye. Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.

Ophthalmology

Phacoemulsification Of Cataract - 2

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE: ,Phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,ANESTHESIA: ,Topical.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,The patient was identified. The operative eye was treated with tetracaine 1% topically in the preoperative holding area. The patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,Attention was turned to the left/right eye. The lashes were tapped using Steri-Strips to prevent blinking. A lid speculum was placed to prevent lid closure. Anesthesia was verified. Then, a 3.5-mm groove was created with a diamond blade temporarily. This was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane. A 1% nonpreserved lidocaine was injected intracamerally and followed with Viscoat. A paracentesis was made. A round capsulorrhexis was performed. The anterior capsular flap was removed. Hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique. The irrigating-aspirating machine was used to clear residual cortex. The Provisc was instilled. An SN60WS diopter intraocular lens was inserted into the capsular bag, and the position was verified. The viscoelastic was removed. Intraocular lens remained well centered. The incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal. The anterior chamber remained deep, and there was no wound leak. The patient tolerated the procedure well. The eye was dressed with Maxitrol ointment. A tight patch and Fox shield were placed. The patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.

ophthalmology, cataract, posterior chamber, intraocular lens, hydrodelineation, phacoemulsification of cataract, phacoemulsification, lens, anterior, chamber, eye, intraocular

Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.

Ophthalmology

Phacoemulsification of Cataract

PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.

ophthalmology, cataract, implantation, intraocular, intraocular lens, lens implantation, phacoemulsification, capsular bag, capsule, intraocular lens implantation, cornea tunnel wound, phacoemulsification of cataract, cornea tunnel, anterior chamber, anesthesia, cornea, lens, chamber,

Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.

Ophthalmology

Phacoemulsification & Lens Implantation - 5

PREOPERATIVE DIAGNOSIS:, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,OPERATION PERFORMED: , Phacoemulsification with IOL, right eye.,ANESTHESIA:, Topical with MAC.,COMPLICATIONS,: None.,ESTIMATED BLOOD LOSS: , None.,PROCEDURE IN DETAIL: After appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat. A 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata. BSS on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I&A. Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I&A, which then removed all remaining cortex as well as viscoelastic material. BSS on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed. Under microscope, the anterior chamber being soft and well formed. Pred Forte, Vigamox, and Iopidine were placed in the eye. A shield was placed over the eye. The patient was followed to recovery where he was noted to be in good condition.

ophthalmology, lid speculum, lens, iol, viscoat, posterior, capsule, cataract, speculum, incision, phacoemulsification