Medical Specialty: Orthopedic
Sample Name: Condylectomy

TITLE OF OPERATION:,  Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA:  ,Monitored anesthesia care with 10 mL of 1:1 mixture of both 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  30 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED: , 3-0 Vicryl and 4-0 Vicryl.,INJECTABLES:,  Ancef 1 g IV 30 minutes preoperatively.,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 a normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe.  The incision was deepened through the 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 fifth left metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized.  The lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved.  The bony prominences were removed and passed off the operating table to be sent to pathology for identification.  The remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp.  The area was copiously flushed with saline.  Then, 3-0 Vicryl and 4-0 Vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively.  The incision was reinforced with Steri-Strips.  Range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited.  The patient's left ankle tourniquet at this time was deflated.  Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage and the patient's left foot was placed in a surgical shoe.  The patient was then transferred to the recovery 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 medications and instructions on how to control her postoperative course.  She was discharged from Hospital according to nursing protocol and was will follow up with Dr. X in one week's time for her first postoperative appointment.
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DESCRIPTION: Lateral and plantar condylectomy, fifth left metatarsal.

orthopedic, plantar condyle hypertrophy, condyle hypertrophy, subcutaneous tissues, ankle tourniquet, metatarsophalangeal joint, metatarsal head, plantar condylectomy, tourniquet, condylectomy, plantar, ankle, metatarsal,

The described procedure is a routine orthopedic surgery with detailed procedural steps and safety measures, such as controlled anesthesia, tourniquet use, and minimal estimated blood loss. While surgery inherently carries some level of risk, this procedure does not appear to involve life-threatening conditions or intricate surgical techniques. It is standard practice in orthopedic surgery, and the operation seems to have proceeded without complications. Thus, it is relatively low-stakes compared to more complex and high-risk surgeries.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Orthopedic
Sample Name: Closed Reduction Percutaneous Pinning

PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1.  Closed type-III supracondylar fracture, left distal humerus.,2.  Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , The entire operative procedure was done in the inpatient operating suite, room #2 at ABCD General Hospital.  A portion of the procedure was done in consult with Dr. X with separate dictation by him.,HISTORY AND GROSS FINDINGS:  ,This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing.  He apparently had not had previous problems with his left arm.  He was seen in the Emergency with a grossly deformed left elbow.  His parents' were both present preoperatively.  His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region.  Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible.  He did have a radial pulse palpable.,PROCEDURE: , After discussing the alternatives of the case as well as advantages and disadvantages, risks, complications, and expectations with the patient's parents including malunion, nonunion, gross deformity, growth arrest, infection, loss of elbow motions, stiffness, instability, need for surgery in the future, nerve problems, artery problems, and compartment syndrome, they elected to proceed.,The patient was laid supine upon operative table after receiving general anesthetic by Anesthesia Department.  Closed reduction was accomplished in a sequential manner.  Milking of the soft tissue envelope was carried out to try and reduce the shaft of the humerus back into its plane relative to the brachialis muscle and the neurovascular bundle anteriorly.  Then a slow longitudinal traction was carried out.  The elbow was hyperflexed.  Pressure placed upon the olecranon tip and two 0.045 K-wires placed first, one being on the lateral side and with this placement on the medial side of medial epicondyle with care taken to protect the ulnar nerve.  The close reduction was deemed to be acceptable once viewed on C-arm.,After this, pulse was attempted to be palpated distally.  Prior to the procedure, I talked to Dr. X of Vascular Surgery at ABCD Hospital.  He had scrubbed in to the case to follow up on the loss of the radial artery distally.  This was not present palpatory, but also by Doppler.  A weak ulnar artery pulse was present via Doppler.  Because of this, the severe displacement of the injury and the fact that the Doppler sound had an occlusion-type sound just above the fracture site or _______.  A long discussion was carried out with Dr. X and myself, and we decided to proceed with exploration of the brachial artery.  Prior to this, I went out to the waiting room to discuss with the patient's parents, the reasoning what we are going to do and the reasoning for this.  I then came back in and then we proceeded.  He was prepped and draped in the usual sterile manner.  Please see Dr. X's report for the discussion of the exploration and release of the brachial artery.  There was no indication that it was actually in the fracture site, the soft tissue had tethered in its right angle towards the fracture site, thus reducing its efficiency of providing blood distally.  Once it was released, both clinically on the table as well as by Doppler, the patient had bounding pulses.,We then proceeded to close utilizing a #4-0 Vicryl for subcutaneous fat closure and a running #5-0 Vicryl subcuticular stitch for skin closure.  Steri-Strips were placed.  The patient's arm was placed in just a slight degree of flexion with a neutral position.  He was splinted posteriorly.  Adaptic and fluffs have been placed around the patient's pin sites.  K-wires have been bent, cut, and pin caps placed.,Expected surgical prognosis on this patient is guarded for the obvious reasons noted above.  There is concern for growth plate disturbance.  He will be watched very closely for the potential development of re-perfusing compartment syndrome.,A full and complete neurologic exam will be impossible tonight, but will be carried on a sequential basis starting tomorrow morning.  There is always a potential for loss of elbow motion, overall cosmetic elbow alignment, and elbow function.
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DESCRIPTION: Closed reduction percutaneous pinning, left distal humerus.   Closed type-III supracondylar fracture, left distal humerus.  Tethered brachial artery, left elbow.

orthopedic, closed reduction, percutaneous pinning, distal humeru, supracondylar fracture, tethered brachial artery, artery, supracondylar, brachial, pinning, reduction, fracture, humerus, elbow,

The situation involves a surgical procedure on a young child with a complex and severe orthopedic injury. This includes a type-III supracondylar fracture and involvement of the brachial artery, which are critical due to the potential impact on blood flow and nerve function. The procedure requires careful handling to prevent complications such as nonunion, malunion, infection, growth disturbances, and permanent nerve damage. These factors make the situation high-stakes as the outcomes can significantly affect the child's future health and development, both physically and neurologically.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Closed ORIF - Ankle

PREOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA:  ,Spinal with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,TOTAL TOURNIQUET TIME:  ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed.  A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws.  There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed.  There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS:  ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall.  The patient noted while walking with a walker, apparently tripped and fell.  The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room.  At that time, a closed reduction was performed and she was placed in a Robert-Jones splint.  After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE:  ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained.  The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia.  The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position.  At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation.  All bony prominences were well padded at this time.  A nonsterile tourniquet was placed on the right upper thigh of the patient.  This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes.  Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle.  A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures.  Once the bone was reached, the fractured site was identified.  The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site.  The wound was copiously irrigated and dried.  Next, the fracture was then reduced in anatomic position.  There was noted to be quite a bit of comminution as well as soft overall status of the bone.  It was held in place with reduction forceps.  A six hole one-third tubular Synthes plate was then selected for instrumentation.  It was contoured using ________ and placed on the lateral aspect of the distal fibula.  Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each.  The most proximal was a 12 mm and the next two were 16 mm in length.  Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole.  The most distal with a 20 mm and two most proximal were 18 mm in length.  Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position.  There was no lateralization of the joints.  Attention was then directed towards the medial aspect of the ankle.  Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus.  Again, the dissection was carefully taken down the level of the fracture site.  The retractors were then placed to protect all neurovascular structures.  Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum.  The fracture site was then displaced and the ankle joint was visualized including the dome of the talus.  There appeared to be some minor degenerative changes of the talus, but no loose bodies.  Next, the wound was copiously irrigated and suctioned dry.  The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire.  Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length.  These appeared to hold the fracture site securely in an anatomic position.  Again, Xi-scan was brought in to confirm placement of the screws.  They were in good overall position and there was no lateralization of the joint.  At this time, each wound was copiously irrigated and suctioned dry.  The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin.  A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril.  A Robert-Jones style splint was then placed on the right lower extremity.  This was covered by a 4-inch Depuy dressing.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit.  The patient tolerated the procedure well.  There were no complications.
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DESCRIPTION: Trimalleolar ankle fracture and dislocation right ankle.  A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well.  Closed open reduction and internal fixation of right ankle.

orthopedic, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus,

This surgical procedure involves a closed open reduction and internal fixation (ORIF) of a trimalleolar fracture and dislocation in an elderly patient. Such procedures typically hold significant stakes due to the patient's age, complexity of the fracture, potential for complications, and impact on the patient's mobility and quality of life. However, in this particular situation, there were no recorded complications during the operation, blood loss was minimal, and the patient tolerated the procedure well, which might reduce the immediate reporting stakes slightly in this case. However, overall surgical interventions, particularly in elderly patients, generally carry high stakes due to potential risks involved and the need for successful outcomes to maintain patient autonomy and mobility.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - Endoscopic

PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.
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DESCRIPTION: Carpal tunnel syndrome.  Endoscopic carpal tunnel release.  After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.

orthopedic, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament

The procedure described is an endoscopic carpal tunnel release, which is a routine surgical treatment for carpal tunnel syndrome. It is a common and minimally invasive procedure with a high rate of success and low risk of complications when performed by a skilled professional. While any surgical procedure carries some inherent risks such as infection or nerve damage, these are well-managed in a controlled medical environment with proper preoperative and postoperative care. Thus, while it demands surgical expertise, it is not considered extremely high-stakes compared to more complex surgical interventions.


Medical Specialty: Orthopedic
Sample Name: Cartilage Loose Body Removal

PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:,  Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,ANESTHESIA: , General.,TOURNIQUET TIME:  ,Thirty-seven minutes.,MEDICATIONS: , The patient also received 30 mL of 0.5% Marcaine local anesthetic at the end of the case.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,INTRAOPERATIVE FINDINGS: , The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera.  This loose body was then subsequently removed.  It measured 24 x 14 mm.  This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle,HISTORY AND PHYSICAL: , The patient is 13-year-old male with persistent left knee pain.  He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee.  The patient presented here for a second opinion.  Surgery was recommended grossly due to the instability of the fragment.  Risks and benefits of surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis.  All questions were answered and parents agreed to the above plan.,DESCRIPTION OF PROCEDURE:  ,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.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The standard portals were marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  The portal incisions were then made by an #11 blade.  Camera was inserted into the lateral joint line.  There was a noted large cartilage loose body in the suprapatellar pouch.  This was subsequently removed with extension of the anterolateral portal.  Visualization of the rest of the knee revealed significant synovitis.  The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle.  The remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology.  ACL was also visualized to be intact in the intracondylar notch.,Attention was then turned back to the large defect.  The loose cartilage was debrided using a shaver.  Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances.  Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites.  All instruments were then removed.  The portals were closed using #4-0 Monocryl.  A total of 30 mL of 0.5% Marcaine was injected into the knee.  Wounds were then cleaned and dried, and dressed in Steri-Strips, Xeroform, 4 x 4s, and bias.  The patient was then placed in a knee immobilizer.  The patient tolerated the procedure well.  The tourniquet was released at 37 minutes.  He was taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The loose cartilage fragment was given to the family.  The intraoperative findings were relayed with intraoperative photos.  There was a large deficit in the weightbearing portion of medial femoral condyle.  His prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at Children's or possible cartilaginous transplant.  All questions were answered.  The patient will follow up in 10 days, may wet the wound in 5 days.
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DESCRIPTION: Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.

orthopedic, knee arthroscopy, chondroplasty, medial femoral condyle, cartilage loose body, loose cartilage, knee, arthroscopy, tourniquet, microfracture, femoral, cartilage,

The procedure described involves orthopedic surgery on a 13-year-old patient with osteochondritis dissecans in the left knee. While the surgery itself is significant and involves general anesthesia, it is a common orthopedic procedure with a straightforward plan and no intraoperative complications. The stakes involve the patient's long-term mobility and joint health, which are important but not immediately life-threatening. Since the patient is young and otherwise healthy, the risk is moderate. The situation might have long-term implications for the patient's knee health but is not an emergency or highly critical scenario.


Medical Specialty: Orthopedic
Sample Name: Cervical Spinal Stenosis

REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.
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DESCRIPTION: Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.

The patient is experiencing worsening symptoms of cervical spinal stenosis, which include significant pain, weakness, and paresthesias in the upper extremities. These symptoms are affecting her daily activities and causing her distress. Despite undergoing nonoperative management, her condition continues to deteriorate. The situation requires a decision on whether to proceed with surgical intervention, which comes with various risks such as bleeding, infection, nerve damage, and more. The upcoming surgical procedure, anterior cervical decompression and fusion, is a significant intervention that intends to alleviate her symptoms and prevent further deterioration. The stakes are relatively high due to the potential impact of the condition on the patient's quality of life, the complexities of the surgery, and the associated risks.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 9

PREOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:,  Right carpal tunnel release.,ANESTHESIA:,  Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:,  We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable.  No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS:  ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position.  The patient underwent a Bier block by the Department of Anesthesia on the upper extremity.  The upper extremity was prepped and draped in usual sterile fashion and left free.  Attention was drawn then to the palm of the hand.  We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel.  Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves.  Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel.  We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament.  We found no evidence of tumor or space occupying lesion in the carpal tunnel.  We then irrigated copiously.  Tourniquet was taken down at that time and pressure was held.  There was no evidence of obvious bleeders.  We approximated the skin with nylon and placed a postoperative dressing with a volar splint.  The patient tolerated the procedure well.  She was placed back in the gurney and taken to PACU.
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DESCRIPTION: Right carpal tunnel release.  Right carpal tunnel syndrome.  This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.

orthopedic, carpal tunnel release, carpal tunnel syndrome, median nerve, bier block, carpal ligament, tunnel, carpal, transverse, median,

The procedure described is a routine carpal tunnel release surgery, which is a common and generally low-risk orthopedic procedure. It is performed to relieve pressure on the median nerve, typically resulting in a high success rate and minimal complications. The report indicates no complications, minimal blood loss, and the patient's stable condition post-operation. Although surgery inherently carries some risk, the stakes here are considered low given the nature of the procedure and the lack of complications.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 7

PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE:  ,The right upper extremity was prepped and draped in the usual fashion.  IV sedation was supplied by the anesthesiologist.  A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease.  It was carried sharply down to the transverse wrist crease.  The transverse carpal ligament was identified and released under direct vision.  Proximal to the transverse wrist crease it was released subcutaneously.  During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch.  The nerve appeared to be mildly constricted.  Closure was routine with running 5-0 nylon.  A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.
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DESCRIPTION: Right carpal tunnel syndrome.  Right carpal tunnel release.

orthopedic, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament,

The scenario describes a routine carpal tunnel release surgery, which is a common and relatively low-risk orthopedic procedure. The note outlines standard steps taken during the procedure, care to avoid nerve injury, and the use of local anesthesia with IV sedation. The terminology suggests that this is a regular surgical procedure with a pre-planned postoperative pathway. There are no unusual complications or high-risk factors mentioned. Considering that it is for carpal tunnel syndrome, which is a common and treatable condition, and that the patient is in good condition post-surgery, the stakes are not high.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 8

PREOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1.  Right carpal tunnel release.,2.  Right index and middle fingers release A1 pulley.,TOURNIQUET TIME:  ,70 minutes.,BLOOD LOSS: , Minimal.,GROSS INTRAOPERATIVE FINDINGS:,1.  A compressed median nerve at the carpal tunnel, which was flattened.,2.  A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers.  After the A1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,HISTORY:  ,This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking.  The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left.  He had positive EMG findings as well as clinical findings.  The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,All risks as well as complications were discussed with the patient and consent was obtained.,PROCEDURE:  ,The patient was wheeled back to the operating room #1 at ABCD General Hospital on 08/29/03.  He was placed supine on the operating room table.  Next, a non-sterile tourniquet was placed on the right forearm, but not inflated.  At this time, 8 cc of 0.25% Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia.  In addition, an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers.  At this time, the extremity was then prepped and draped in usual sterile fashion for this procedure.  First, we went for release of the carpal tunnel.  Approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region.  First, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to Ragnells retracting proximally and distally.  The palmaris brevis muscle was then identified and sharply transected.  At this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia.  Once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized.  The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly.  At this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel.  At this time, copious irrigation was used to irrigate the wound.  The wound was suctioned dry.  At this time, we proceeded to the release of the A1 pulleys.  Approximately, a 1.5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers.  First, we went for the index finger.  Once the skin incision was made, Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley.  A #15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally.  Once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity.  There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons.  Once a thorough release was performed, copious irrigation was used to irrigate that wound.  In the similar fashion, a 1.5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger.  A Littler scissor was used to bluntly dissect in the longitudinal fashion.  With the Ragnell retractors, we identified the A1 pulley of the right middle finger.,Using a #15 blade, the A1 pulley was scored with the #15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally.  We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity.  Again, there was evidence of some synovitis as well as fraying of both tendons.  The girth of both tendons and both wounds were within normal limits.  At this time, copious irrigation was used to irrigate the wound.  The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively.  In addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact.  At this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger.  The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery.  At this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll.  The patient was then carefully taken off of the operating room table to Recovery in stable condition.
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DESCRIPTION: Right carpal tunnel release and right index and middle fingers release A1 pulley.  Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.

orthopedic, compressed median nerve, stenosing tenosynovitis, carpal tunnel release, carpal tunnel syndrome, middle fingers, carpal tunnel, littler scissors, median nerve, copious irrigation, volar aspect, tunnel, pulley, carpal, fingers, index, tourniquet, ligament, tenosynovitis, superficialis, tendons,

The provided case details a routine orthopedic surgical procedure, specifically a carpal tunnel release and an A1 pulley release on a 78-year-old male patient with diagnoses of carpal tunnel syndrome and tenosynovitis. The procedure and the patient's condition, while requiring surgical intervention, are fairly common and not typically life-threatening. The risks associated with such surgeries are standard and manageable. The situation does not involve critical or life-saving surgery but rather aims to improve the patient's quality of life by alleviating symptoms like pain and numbness. Therefore, this scenario does not represent a high-stakes medical situation.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 4

PREOPERATIVE DIAGNOSIS:  ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1.  Right open carpal tunnel release.,2.  Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,INDICATIONS:,  This patient is a 50-year-old male with bilateral carpal tunnel syndrome, which is measured out as severe.  He is scheduled for the above-mentioned procedures.  The planned procedures were discussed with the patient including the associated risks.  The risks included but are not limited to bleeding, infection, nerve damage, failure to heal, possible need for reoperation, possible recurrence, or any associated risk of the anesthesia.  He voiced understanding and agreed to proceed as planned.,DESCRIPTION OF PROCEDURE: , The patient was identified in the holding area and correct operative site was identified by the surgeon's mark.  Informed consent was obtained.  The patient was then brought to the operating room and transferred to the operating table in supine position.  Time-out was then performed at which point the surgeon, nursing staff, and anesthesia staff all confirmed the correct identification.,After adequate general LMA anesthesia was obtained, a well-padded tourniquet was placed on the patient's right upper arm.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Planned skin incision was marked along the base of the patient's right palm.  Right upper extremity was then exsanguinated using Esmarch.  The tourniquet was then inflated to 250 mmHg.  Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision.  Bleeding points were identified with electrocautery using bipolar electrocautery.  Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament, and this was then divided longitudinally under direct vision.  Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band.  Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed.  This was confirmed by visually and palpably.  Next, baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia, and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision.  Carpal canal was then inspected.  The median nerve was flattened and injected.  No other abnormalities were noted.  Wounds were then irrigated with normal saline and antibiotic additive.  Decadron 4 mg was then placed adjacent to the median nerve.  Skin incision was then closed with interrupted 5-0 nylon suture.  The wound was then dressed with Adaptic, 4 x 4s, Kling, and Coban.  The tourniquet was then deflated.  Attention was then directed to the left side.  Using sterile technique, the left carpal canal was injected with a mixture of 40 mg of Depo-Medrol, 1 cc of 1% lidocaine, and 1 cc of 0.25% Marcaine.  Band-Aid was then placed over the injection site.  The patient was then awakened, extubated, and transferred over to his hospital bed.  He was transported to recovery room in stable condition.  There were no intraoperative or immediate postoperative complications.  All counts were reported as correct.
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DESCRIPTION: Right open carpal tunnel release and cortisone injection, left carpal tunnel.

orthopedic, carpal tunnel syndrome, 4 x 4s, adaptic, carpal canal, coban, cortisone injection, esmarch, kling, metzenbaum, carpal tunnel release, electrocautery, fibrous band, palmar fascia, tourniquet, transverse carpal ligament, bilateral carpal tunnel, baby metzenbaum scissors, carpal ligament, bilateral carpal, metzenbaum scissors, carpal tunnel, carpal, tunnel,

The procedure involves a right open carpal tunnel release and a cortisone injection on the left hand, which are fairly routine and well-practiced procedures in orthopedics. The patient's condition, bilateral carpal tunnel syndrome, while severe, is not life-threatening, and the risk of serious complications is generally low. The report notes that the patient was stable post-surgery, with no complications. The described stakes are related to potential surgical risks and the patient's understanding of these risks, which is typical for surgical procedures. While there is always some inherent risk in surgical interventions, this particular situation does not carry a high level of stakes compared to more critical or complex medical scenarios.


Medical Specialty: Orthopedic
Sample Name: Carpal Ligament Release - 2

PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1.  Endoscopic release of left transverse carpal ligament.,2.  Steroid injection, stenosing tenosynovitis of right middle finger.,ANESTHESIA:  ,Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME: , Left upper extremity was 15 minutes.,OPERATIVE PROCEDURE IN DETAIL:,  With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One mL of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.,Attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 mL of 1% plain Xylocaine and 0.5 mL of Depo-Medrol 40 mg/mL.  A Band-Aid dressing was then applied.,The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Endoscopic release of left transverse carpal ligament.  Steroid injection, stenosing tenosynovitis of right middle finger.

orthopedic, carpal tunnel syndrome, agee inside job, steroid injection, antebrachial fascia, forearm, ring ray, synovial elevator, tenosynovitis, tourniquet, transverse incision, trigger finger, tenosynovitis of right middle, transverse carpal ligament, transverse carpal, carpal ligament, steri strips, stenosing tenosynovitis, middle finger, ligament, carpal, endoscopic, finger

The procedure described is a surgical intervention for carpal tunnel syndrome and a steroid injection for trigger finger. These conditions can cause significant discomfort and impede daily activities, but they are routine procedures with low risk under standard medical practices. The outcome depends on factors like healing time and patient recovery, but life-threatening complications are rare. Therefore, while important for the patient's quality of life, the stakes are not extremely high.


Medical Specialty: Orthopedic
Sample Name: Bunionectomy & Akin Osteotomy

PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2.  Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had worsening bunion deformity for as long as she could not remember.  She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a 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 were injected in a Mayo block type fashion surrounding the lower left first metatarsal.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating field.  The stockinette was reflected, the foot was cleansed with a wet and dry sponge.  Approximately 5 cm incision was made dorsomedially over the first metatarsal.,The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  Care was taken to preserve the extensor digitorum longus tendon.  The capsule over the first metatarsal phalangeal then was identified where a dorsal capsular incision was then created down to the level of bone.  Capsule and periosteum was reflected off the first metatarsal head.  At this time, the cartilage was inspected and noted to be white, shiny, and healthy cartilage.  There was noted to be a prominent medial eminence.  Attention was then directed to first interspace where a combination of blunt and sharp dissection was done to perform a standard lateral release.  The abductor tendon attachments were identified and transected.  The lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Attention was then directed to the prominent medial eminence, which was resected with a sagittal saw.  Intraoperative assessment of pes was performed and pes was noted to be normal.,At this time, a regional incision was carried more approximately about 1.5 cm.  The capsular incision was then extended and the proximal capsule and periosteum were reflected off the first metatarsal.  The first metatarsal cuneiform joint was identified.  A 0.45 K-wire was then inserted into the base of the first metatarsal approximately 1 cm from the first cuneiform joint perpendicular to the weightbearing surface.  This K-wire was used as an access guide for a Juvaro type oblique base wedge osteotomy.  The sagittal saw was then used to creat a closing base wedge osteotomy with the apex being proximal medial.  The osteotomy site was then feathered and tilted with tight estimation of the bony edges.  The cortical hinge was maintained.  A 0.27 x 24 mm screw was then inserted in a standard AO fashion.  At this time, there was noted to be tight compression of the osteotomy site.  A second 2.7 x 16 mm screw was then inserted more distally in the standard AO fashion with compression noted.  The ________ angle was noted to be significantly released.  Reciprocating rasp was then used to smoothen any remaining sharp edges.  The 0.45 k-wire was removed.  The foot was loaded and was noted to fill the remaining abduction of the hallux.  At this time, it was incised to perform an Akin osteotomy.,Original incision was then extended distally approximately 1 cm.  The incision was then deepened down to the level of capsule over the base of the proximal phalanx.  Again care was taken to preserve the extensor digitorum longus tendon.  The capsule was reflected off of the base of the proximal phalanx.  An Akin osteotomy was performed with the apex being lateral and the base being medial.  After where the bone was resected, it was feathered until tight compression was noted without tension at the osteotomy site.  Care was taken to preserve the lateral hinge.  At 1.5 wire passed and a drill was then used to create drill hole proximal and distally to the osteotomy site in order for passage of 28 gauge monofilament wire.  The #28 gauge monofilament wire was passed through the drill hole and tightened down until compression and tight ________ osteotomy site was noted.  The remaining edge of the wire was then buried in the medial most distal drill hole.  The area was then inspected and the foot was noted with significant reduction of the bunion deformity.  The area was then flushed with copious amounts of sterile saline.  Capsule was closed with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl in order to decrease tension of the incision site.  A running #5-0 subcuticular stitch was then performed.  Steri-Strips were applied.  Total of 1 cc dexamethasone phosphate was then injected into the surgical site.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  Posterior splint was then placed on the patient in the operating room.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred back to the PACU with vital signs stable and vascular status intact to the left foot.  The patient was given postoperative instructions to be strictly nonweightbearing on the left foot.  The patient was given postop pain prescriptions for Vicodin and instructed to take one q.4-6h. p.r.n. for pain as well as Naprosyn 500 mg p.o. q. b.i.d.  The patient is to follow-up with Dr. X in his office in four to five days as directed.
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DESCRIPTION: Bunion, left foot.  Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot.

orthopedic, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot

The situation describes a medical surgical procedure for correcting a bunion in a patient with Charcot-Marie-Tooth disease. Although the procedure is routine for orthopedic surgeons, the context is medical and surgical, which generally implies higher stakes due to the inherent risks associated with surgery, anesthesia, and postoperative care. However, this procedure is not life-threatening and is typically performed to alleviate pain and deformity. Given the specifics of the case, it holds moderate importance due to the patient's condition and the need for precision in surgical execution.


Medical Specialty: Orthopedic
Sample Name: Bunionectomy & Arthrodesis

PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1.  Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2.  Arthrodesis, right second, third, and fourth toes with external rod fixation.,3.  Hammertoe repair, right fifth toe.,4.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5.  Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion.  The patient has a long history of crippling severe rheumatoid arthritis.  She has pain with shoe gear and pain with every step.  She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief.  At this time, she desires attempted surgical reconstruction/correction.  The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection.  Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril.  Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmHg.  The foot was lowered in the operative field.  The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint.  The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe.  In addition, the range of motion was less than 5 degrees of the first ray.  There was medial pinch callus and callus on the plantar right second metatarsal.  Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length.  Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery.  Next, the medial and lateral wound margins were undermined with sharp dissection.  The joint capsule was then visualized.  Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule.  A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade.  The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal  phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint.  In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal.  Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head.  A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare.  Next, the bone was passed out as specimen.  The head of the metatarsal had evidence of erosion and eburnation.  The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue.  This was hindering the range of motion of the joint and was removed.  The fibular sesamoid was in the interspace.  A lateral release was performed in addition.  Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed.  The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure.  Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint.  A small drill hole was made in the central aspect at the base of the proximal phalanx.  The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline.  A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position.  It had an excellent fit and the range of motion again was markedly increased from the preoperative level.  Next, the wound was again flushed with copious amounts of saline.  The flexor tendon was inspected and was found to be intact plantarly.  A #3-0 Vicryl was used to close the capsule in a running fashion.  A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature.  There was a clavus in the dorsal aspect of the head of the proximal phalanx noted.  A linear incision was made over the proximal phalanx approximately 2 cm in length.  The incision was deepened with #15 blade down to the subcutaneous tissue.  Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint.  The tendon was peeled off sharply, proximally, and distally.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded.  The base of the middle phalanx, however, had a normal-appearing cartilage.  A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare.  Next, the base of the middle phalanx was also resected.  A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft.  The toe assumed a straight and markedly increased straight position.  An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique.  The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated.  The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated.  The same suture material was used.  However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight.  Next, attention was directed to the fifth digit, which was found to be contracted as well.  A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length.  A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected.  The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound.  A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare.  The toe assumed to more rectus position.  The reciprocating rasp was used to smooth the all bony surfaces.  The joint was again flushed with saline.  Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique.  The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin.  A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head.  The incision was deepened with a #15 blade to the subcutaneous tissue.  Any small vein traversing subcutaneous layer were ligated with electrocautery.  Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively.  Next, the dorsal linear capsular incision was made down to the bone with a #15 blade.  The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly.  A sagittal saw was used to resect all hypertrophic bone.  A reciprocating rasp was used to smooth all bony surfaces.  Next, the wound was flushed with copious amounts of saline.  The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures.  The skin was closed with #5-0 Monocryl in a running subcuticular fashion.  The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl.  Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated.  Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon.  The tendon was transected.  Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed.  Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position.  One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds.  Betadine-soaked Owen silk was applied to all wounds.  Betadine-soaked 4 x 4 splints were applied to all toes.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  All the wires have previously been bent and cut and all were capped.  A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c.  She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office.  She was given emergency contact numbers and standard postoperative instructions.  She was given Darco OrthoWedge shoe and a pair of crutches.  She was discharged in stable condition.
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DESCRIPTION: Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.  Arthrodesis, right second, third, and fourth toes with external rod fixation.  Hammertoe repair, right fifth toe.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.  Modified Tailor's bunionectomy, right fifth metatarsal.

The situation described involves a complex surgical procedure addressing multiple orthopedic issues in the patient's foot, such as bunions, hammer toes, and degenerative joint disease. While these conditions have significant impacts on the patient's quality of life and require surgical intervention, they are not life-threatening or high-emergency situations. The stakes involve potential surgical risks, recovery, and mobility outcomes, which are important but not critical in a life-or-death sense. Therefore, the stakes are moderate rather than extremely high.


Medical Specialty: Orthopedic
Sample Name: 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.,
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DESCRIPTION: Back injury with RLE radicular symptoms.  The patient is a 52-year-old male who is here for independent medical evaluation.

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

The situation involves a patient with ongoing and unresolved back pain and radicular symptoms, which impact his quality of life and ability to work. The independent medical evaluation is important for determining the extent of impairment and appropriate treatment or restrictions. However, it does not pose an immediate threat to life or necessitate urgent medical intervention. The case has significance due to potential long-term disability, impacts on work capability, and the need for pain management, but it's considered manageable in a healthcare setting.


Medical Specialty: Orthopedic
Sample Name: 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.
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DESCRIPTION: 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, femoral head, femoral, hip, hemiarthroplasty, ethibond, acetabulum,

This situation involves an orthopedic surgical procedure for a displaced subcapital fracture of the hip, requiring detailed preoperative and postoperative care management. The stakes are fairly high, as surgical interventions, particularly hip surgeries, involve significant risks such as infection, blood loss, and potential complications affecting mobility and recovery. While not life-threatening if managed properly, the procedure does have a substantial impact on the patient's health and quality of life, and requires precise execution and postoperative care to ensure successful healing and function restoration.


Medical Specialty: Orthopedic
Sample Name: 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.
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DESCRIPTION: 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, 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,

The situation involves a detailed description of an orthopedic surgical procedure, specifically for treating chronic instability of the shoulder. Such surgeries carry inherent risks, including infection, nerve or artery damage, and potential complications related to anesthesia. Given that the surgery involves multiple intricate procedures like arthroscopy, debridement, repairs, and capsular shift, it requires precision and carries moderate to significant risks for the patient. While not among the most life-threatening surgeries, the potential for serious complications and the impact on the patient's quality of life makes it relatively high-stakes.