EXAMPLE
Barry Tuch, M.D.
OPERATIVE REPORT
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ANESTHESIOLOGIST: Mark Ahn, M.D.
ANESTHESIA: General.
PREOPERATIVE DIAGNOSES: Peritrochanteric subtrochanteric
fracture, left hip.
POSTOPERATIVE DIAGNOSES: Peritrochanteric subtrochanteric
fracture, left hip.
PLANNED PROCEDURE: Open reduction internal fixation of left hip,
pertrochanteric subtrochanteric hip fracture with Synthes 12 hole
135 degree angled hip compression screw side plate.
HISTORY OF PRESENT ILLNESS: Patient is an 89-year-old female who
missed a step last night and fell on to her left side and
sustained the fracture noted above.
OPERATIVE PROCEDURE: The patient was placed supine on the
fracture table. The left hip and thigh were prepped sterilely and
draped off in the usual sterile manner after longitudinal
traction was first applied to the left leg. The C-arm was used to
confirm that the fracture was well reduced in the AP plane but
because of the severe comminution of the fracture, the proximal
fragment was displaced anterior compared to the posterior
fragment. A crutch was placed under the thigh after being covered
with a sterile cover to help reduce the fracture and this helped
somewhat to correct the anterior displacement of the proximal
fragment.
It was elected to attempt to fix the fracture with a gamma nail.
Accordingly, a longitudinal skin incision was made over the
trochanter proximally. This was deepened by sharp and blunt
dissection and bleeders were coagulated with Bovie encounter.
Patient had an extensive amount of adipose tissue and the greater
trochanter was deep within the wound. It was however visualized
and a starting awl was inserted over the tip of the trochanter.
The position was confirmed with the C-arm. The awl was introduced
and then a long ball-tipped guidewire was inserted into the
proximal fragment. Using the C-arm and various attempts at closed
reduction, the ball-tipped guidewire was introduced a cross the
fracture and into the distal fragment. This was verified in the
AP and lateral planes.
The proximal fragment was then reamed with a 17.5 reamer and then
a 180 mm gamma nail was passed over the guidewire ,under C-arm
control. It hung up on the lateral cortex of the distal fragment.
Reaming was done with flexible reamers into the distal fragment
up to 14 mm for an 11 mm nail, but despite this, the nail
continued to hang up on the lateral cortex and could not be
passed distally. I did not want to force it, for fear that I
would further comminute the fracture that was already comminuted
to begin with and it would have made it much worse.
Therefore, I elected to open the incision at the fracture site,
so the incision was extended down to the level of the fracture
and under direct vision the fracture was reduced and held with
bone clamps. Despite this, the nail still would not pass into the
distal fragment. Multiple attempts were made, but again I did not
want to further comminute the bone. Also, because of the length
of time already spent at this point of the procedure, the patient
was losing a fair amount of blood and was hypovolemic.
Consequently, it was elected to abandon the attempts to place an
intramedullary nail and instead proceed with a long side plate
Synthes hip compression screw.
A guidewire was drilled through the lateral femoral cortex,
opposite the lesser trochanter into the center of the head and
neck of the femur. This was verified in both planes with the Carm and the guide pin was placed into the subchondral bone. A
cannulated reamer was used to ream a distance of 80 mm over the
guidewire and then a 70 mm Synthes lag screw was inserted after
first tapping with a tap. The screw was inserted into the
subchondral region of the femoral head and had excellent
purchase. Its position was verified to be down the center of the
head and neck in both the AP and lateral planes.
It was elected to use a 12-hole, 135 degree angled slide plate as
this allowed the distal screws to be well below the level of the
fracture. The fracture was reduced and held in place with the
plate in place as well with Lowman bone clamps. The position of
the plate, as well as the fracture was verified to be
satisfactory in both the AP and lateral planes. 8 of the 12 screw
holes were utilized with 4.5 mm cortical screws gaining excellent
purchase in both cortices. The most proximal screw hole was
utilized and the screw was angled superiorly and medially gaining
excellent purchase. The next 4 screw holes could not be utilized
because the medial cortex was completely gone and there was no
medial cortex to engage with the screws. On the other hand, the
distal 8 remaining screw holes were filled with 4.5 mm screws,
all gaining excellent purchase in both cortices.
It was elected therefore to use 3 Zimmer 1.25 mm cerelage cables
around the portion of the plate and bone where there was medial
bone missing. This enabled excellent stabilization of the plate
against the femur. A compression screw was inserted and left in
place. The C-arm was used to take permanent pictures of the hip
and femur, the entire length of the plate in both the AP and
lateral planes and all the way into the hip joint as well. This
was used for documentation purposes and the films confirmed that
the implants and fractures were in excellent position and
basically were anatomic.
The wound was irrigated copiously with Bacitracin antibiotic
solution. Also, about 3 to 4 hours into the procedure, a gram of
Ancef was given intravenously. In addition, 1 gram was given
intravenously just prior to onset of surgery. After thorough
irrigation of the wound, the wound was closed in layers. The
vastus lateralis was closed with a running #1 Vicryl. The deep
fascia was closed with running #1 Vicryl. The subcutaneous fatty
tissues were closed with interrupted 2 Vicryl. The skin was
closed with staples. A 1/8 inch Hemovac drain was left within the
depths of the wound and brought out through a stab incision
distally. A sterile bulky compressive dressing was applied. The
patient was awake and then taken to the ICU for recovery in
satisfactory condition.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 2 liters and the patient received 4 units
of packed cells during the procedure. The extensive blood loss
was a combination of the large size of the wound that was
necessary, as well as the length of the operative procedure.