Medical Specialty: Pain Management
Sample Name: Acromioclavicular Joint Injection

ACROMIOCLAVICULAR JOINT INJECTION,PROCEDURE:,:  Informed consent was obtained from the patient.  All possible complications were mentioned including joint swelling, infection, and bruising.  The joint was prepared with Betadine and alcohol.  Then 1 mL of Depo-Medrol and 2 mL of 0.25% Marcaine were injected using the anterior approach.  This was injected easily using a 25 gauge needle with the patient sitting and the shoulder propped up on a pillow.  The joint was entered easily without any great difficulty.  Aspiration was performed prior to the injection to make sure there was no intravascular injection.  There were no complications and good relief of symptoms.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.
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DESCRIPTION: Acromioclavicular joint injection

Acromioclavicular joint injection

pain management, acromioclavicular joint injection, acromioclavicular, betadine, depo-medrol, alcohol, fevers, inflammation, intravascular injection, joint injection, redness, swelling, acromioclavicular joint, injection, jointNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The procedure described is a medical intervention involving an injection into the acromioclavicular joint for pain management. While the procedure itself is routine and typically low-risk when performed by a qualified practitioner, the stakes are moderately high due to potential complications such as infection or improper injection. These complications, while uncommon, can lead to more serious issues requiring medical attention. Additionally, an improper injection could result in inadequate pain relief. However, the procedure as described was completed without complications and provided symptom relief, suggesting it was executed well, mitigating the stakes.


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

Medical Specialty: Pain Management
Sample Name: Bilateral sacroiliac joint injections

BILATERAL SACROILIAC JOINT INJECTIONS,PROCEDURE:,:  Informed consent was obtained from the patient.  The patient was placed in the prone position.  After preparation and local anesthetic administration, and image intensifier control a 25 gauge spinal needle was directed into the inferior aspect of the sacroiliac joint using a posterior approach.  A small amount of contrast material was administered to outline the recesses of the joints.  Verification of the initial needle position with contrast administration, 1 mL of solution was administered at this site after aspiration, consisting of 0.5 mL of 0.25% Marcaine and 0.5 mL of Celestone.  Postprocedure, the needles were withdrawn and dressing was applied.  Postprocedure no complications were noted.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.
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DESCRIPTION: Bilateral sacroiliac joint injections

Bilateral sacroiliac joint injections

pain management, bilateral sacroiliac joint injections, 0.25% marcaine, celestone, postprocedure, fevers, image intensifier, inflammation, posterior approach, redness, sacroiliac joint, spinal needle, swelling, bilateral sacroiliac joint, sacroiliac joint injections, sacroiliac, injectionsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The procedure described, bilateral sacroiliac joint injections, involves injecting anesthetics and steroids into the joints to manage pain. Such procedures are common in pain management and, while they require precision and care, are not considered highly invasive or high-risk. Informed consent and post-procedure instructions are part of standard medical practice to ensure patient safety. The mention of monitoring for signs of complications like redness or swelling is routine precautionary advice. This context suggests that the situation, while requiring professional attention, isn't of a high-stakes nature within medical practice.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Youngswick Bunionectomy

PREOPERATIVE DIAGNOSES:,1.  Hallux rigidus, left foot.,2.  Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux rigidus, left foot.,2.  Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1.  Austin/Youngswick bunionectomy with Biopro implant.,2.  Screw fixation, left foot.,HISTORY: , This 51-year-old male presents to ABCD General Hospital with the above chief complaint.  The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time.  The patient desires surgical treatment.,PROCEDURE IN DETAIL: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 7 cc of 0.5% Marcaine plain was injected in a Mayo-type block.  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 then inflated to 250 mmHg.  The foot was lowered to the operating table, the stockinet was reflected, and the foot was cleansed with wet and dry sponge.,Attention was then directed to the left first metatarsophalangeal joint.  Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint, just medial to the extensor hallucis longus tendon.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was undermined medially, off of the joint capsule.  A dorsal linear capsular incision was then made.  Care was taken to identify and preserve the extensor hallucis longus tendon.  The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx.  There was noted to be a significant degenerative joint disease.  There was little to no remaining healthy articular cartilage left on the head of the first metatarsal.  There was significant osteophytic formation medially, dorsally, and laterally in the first metatarsal head as well as at the base of the proximal phalanx.  A sagittal saw was then used to resect the base of the proximal phalanx.  Care was taken to ensure that the resection was parallel to the nail.  After the bone was removed in toto, the area was inspected and the flexor tendon was noted to be intact.  The sagittal saw was then used to resect the osteophytic formation medially, dorsally, and laterally on the first metatarsal.  The first metatarsal was then re-modelled and smoothed in a more rounded position with a reciprocating rasp.  The sizers were then inserted for the Biopro implant.  A large was noted to be of the best size.  There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx.  Following inspection, the sagittal saw was used to clean both the medial and lateral sides of the base.  A small bar drill was then used to pre-drill for the Biopro sizer.  The bone was noted to be significantly hardened.  The sizer was placed and a large Biopro was deemed to be the correct size implant.  The sizer was removed and bar drill was then again used to ream the medullary canal.  The hand reamer with a Biopro set was then used to complete the process.  The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit.  There was noted to be distally increased range of motion after insertion of the implant.,Attention was then directed to the first metatarsal.  A long dorsal arm Austin osteotomy was then created.  A second osteotomy was then created just plantar and parallel to the first osteotomy site.  The wedge was then removed in toto.  The area was feathered to ensure high compression of the osteotomy site.  The head was noted to be in a more plantar flexed position.  The capital fragment was then temporarily fixated with two 0.45 K-wires.  A 2.7 x 16 mm screw was then inserted in the standard AO fashion.  A second more proximal 2.7 x 60 mm screw was also inserted in a standard AO fashion.  With both screws, there was noted to be tight compression at the osteotomy sites.,The K-wires were removed and the areas were then smoothed with reciprocating rash.  A screw driver was then used to check and ensure screw tightness.  The area was then flushed with copious amounts of sterile saline.  Subchondral drilling was performed with a 1.5 drill bit.  The area was then flushed with copious amounts of sterile saline.  Closure consisted of capsular closure with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl, followed by running subcuticular stitch of #5-0 Vicryl.  Dressings consisted of Steri-Strips, Owen silk, 4x4s, Kling, Kerlix, and Coban.  A total of 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected intraoperatively for further anesthesia.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well.  The patient was transported to PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q.  4-6h. p.o. p.r.n. pain.  The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema.  The patient is to follow up with Dr. X in his office as directed.
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DESCRIPTION: Austin & Youngswick bunionectomy with Biopro implant.  Screw fixation, left foot.

orthopedic, hallux rigidus, metatarsal, youngswick, bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, biopro implant, proximal phalanx, foot, austin, anesthesia, osteotomy, screw,

The detailed progress note describes a preplanned surgical procedure for a patient with specific foot diagnoses, conducted at an orthopedic specialty level. The stakes can be considered medium-high due to the nature of surgery, the patient's condition (hallux rigidus and elevated first metatarsal), and the use of implants, which carries inherent risks such as infection, improper healing, or complications with anesthesia. However, this is not an emergency procedure, and the direct life-threatening risk is limited, making this less than extremely high-stakes but certainly significant given the surgical intervention.


Medical Specialty: Orthopedic
Sample Name: Vertebroplasty

PREOPERATIVE DIAGNOSIS:,  T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:,  T11 compression fracture with intractable pain.,OPERATION PERFORMED:,  Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:,  Local with IV sedation.,COMPLICATIONS:,  None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Using AP and lateral fluoroscopic projections the T11 compression fracture was identified.  Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the T11 pedicle on the left.  The 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle.  At this point using AP and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times.  Once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body.  At this point polymethylmethacrylate was mixed for 60 seconds.  Once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body.  It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra.  A total 1.2 cc of cement was injected.  On lateral view, the cement crushed to the right side as well.  There was some dye infiltration into the disk space.  There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,At this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space.  Once the needle was withdrawn safely pressure was held over the site for three minutes.  There were no complications.  The patient was taken back to the recovery area in stable condition and kept flat for one hour.  Should be followed up the next morning.
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DESCRIPTION: Unilateral transpedicular T11 vertebroplasty.

orthopedic, transpedicular, vertebroplasty, fluoroscopic views, fluoroscopic images, epidural space, compression fracture, vertebral body, compression, pedicle, fluoroscopic, vertebral, needle

Vertebroplasty is a minimally invasive procedure used to relieve pain from vertebral compression fractures, which can be caused by osteoporosis or traumatic injury. While the procedure itself is generally considered safe, it involves injecting bone cement into a fractured vertebra, which carries some risks such as cement leakage, infection, or nerve damage. In this case, no complications arose during the procedure, and the patient was stable postoperatively. The stakes are moderate because although the procedure is routine, the potential risks can significantly impact the patient's health if complications occur.


Medical Specialty: Orthopedic
Sample Name: Ulnar Nerve Decompression

PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:,  The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel.  There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion.  A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg.  Perioperative antibiotics were infused.  Time-out procedure was called.  The medial epicondyle and the olecranon tip were well palpated.  The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally.  The ulnar nerve was identified proximally.  It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply.  The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches.  The ulnar nerve was well-isolated before it entered the cubital tunnel.  The arch of the FCU was well defined.  The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization.  Distally, the dissection was carried between the 2 heads of the FCU.  Decompression of the nerve was performed between the heads of the FCU.  The muscular branches were well protected.  Similarly, the cutaneous branches in the arm and forearm were well protected.  The venous plexus proximally and distally were well protected.  The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it.  Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected.  Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended.  There was no evidence of any subluxation.  Satisfactory decompression was performed.  Tourniquet was released.  Hemostasis was achieved.  Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples.  A well-padded dressing was applied.  The patient was then extubated and transferred to the recovery room in stable condition.  There were no intraoperative complications noted.  The patient tolerated the procedure very well.
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DESCRIPTION: Decompression of the ulnar nerve, left elbow.  Left cubital tunnel syndrome and ulnar nerve entrapment.

orthopedic, ulnar nerve entrapment, ulnar nerve, ulnar nerve decompression, cubital tunnel syndrome, ulnar, nerve, fascia, decompression, cubital, tunnel

The procedure described is a surgical operation for decompressing the ulnar nerve due to compression, which can lead to symptoms like pain or numbness. While ulnar nerve entrapment can be debilitating if untreated, this procedure is generally considered routine within orthopedic surgery. The operation was performed without complications under general anesthesia, and the patient was reported to be in stable condition post-surgery. Therefore, considering it is a well-established surgical procedure with a good outcome, the stakes are moderate but not extremely high.


Medical Specialty: Orthopedic
Sample Name: Total Knee Replacement - 1

PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, a tourniquet was placed on the upper thigh.  Sterile prepping and draping proceeded.  The tourniquet was inflated to 300 mmHg.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.  The lateral patellar retinacular ligaments were released and the patella was retracted laterally.  Proximal medial tibia was denuded, with mild release of medial soft tissues.  The ACL and PCL were released.  The medial and lateral menisci and suprapatellar fat pad were removed.  These releases allowed for anterior subluxation of tibia.  An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia.  Its alignment was checked with the rod and found to be adequate.  The tibia was then allowed to relocate under the femur.,An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques.  An anterior rough cut was made.  The distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed.  The distal cut was performed.,A spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment.  Femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made.  The notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made.  The trial femoral component was impacted onto the distal femur and found to have an excellent fit.  A trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes.  Appropriate rotation of the tibial component was identified and marked.  The trials were removed and the tibia was brought forward again.  The tibial plate size was checked and the plate was pinned to plateau.  A keel guide was placed and the keel was then made.  The femoral intramedullary hole was plugged with bone from the tibia.  The trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,The patella was held in a slightly everted position with knee in extension.  Patellar width was checked with calipers.  A free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers.  Sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy.  Any excess lateral patellar bone was recessed.  The trial patellar component was placed and found to have adequate tracking.  The trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried.  The cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted.  The excess cement was removed from the gutters and anterior and posterior parts of the knee.  The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened.  Once the cement had hardened, the tourniquet was deflated.  The knee was dislocated again, and any excess cement was removed with an osteotome.  Thorough irrigation and hemostasis were performed.  The real polyethylene component was placed and pinned.  Further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed.  The arthrotomy was closed using 0 Ethibond and Vicryl sutures.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was sealed with staples.  Xeroform and a sterile dressing were applied followed by a cold-pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.
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DESCRIPTION: Total knee replacement.  A midline incision was made, centered over the patella.  Dissection was sharply carried down through the subcutaneous tissues.  A median parapatellar arthrotomy was performed.

orthopedic, proximal medial tibia, total knee replacement, parapatellar arthrotomy, subcutaneous tissues, tibial plateau, incision, cutting, patella, femur, femoral, component, knee,

A total knee replacement is a major surgical procedure performed to relieve pain and restore function in a severely damaged knee. It involves removing damaged parts of the knee joint and replacing them with artificial components. This procedure requires a high level of skill and precision from the surgical team and carries significant risks, such as infection, blood clots, and complications related to anesthesia. Patients often undergo a lengthy rehabilitation process following surgery to regain full mobility. Due to these factors, the situation is high-stakes both in the surgical phase and in ensuring successful postoperative recovery.


Medical Specialty: Orthopedic
Sample Name: Total Knee Arthroplasty - Right

PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of Ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg.,A straight anterior incision was carried down through the skin and subcutaneous tissue. Unilateral flaps were developed and a median retinacular parapatellar incision was made. The extensor mechanism was partially divided and the patella was everted. Some of the femoral bone spurs were resected using an osteotome and a rongeur. Ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,At this point the ACL was resected. Some of the fat pad and synovium were resected, as well as both medial and lateral menisci. A posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. The intramedullary guide was used for cutting the tibia. It was set at 8 mm. An additional 2 mm was resected because of a moderate defect medially.,A trial reduction was done with a 71 tibial baseplate. This was pinned and drilled and then trial reduction done with a 10-mm insert.,This gave good stability and a full range of motion.,The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. A 34-mm component was drilled for.,A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. A packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. The tibia baseplate was secured and the patella was inserted, held with a clamp. The extraneous cement was removed. At this point the tibial baseplate was locked into place and the femoral component also seated solidly.,The knee was extended, held in this position for another 5-6 minutes until the cement was cured. Further extraneous cement was removed. The pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,Retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 Vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. A sterile, bulky compression dressing was placed. The patient was stable on operative release.
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DESCRIPTION: Right total knee arthroplasty - Osteoarthritis, right knee.

orthopedic, osteoarthritis, arthroplasty, knee, patella, retinacular parapatellar, total knee arthroplasty, total knee, knee arthroplasty, baseplate, femoral, tibia,

The situation involves a total knee arthroplasty, a common orthopedic surgery for osteoarthritis. This procedure carries inherent risks associated with surgery, like infection, blood clots, and complications from anesthesia, but it is generally considered routine for orthopedic surgeons. While successful knee arthroplasty can significantly improve quality of life, the stakes are not extremely high, such as those in life-threatening surgeries or emergency situations. Postoperative stability of the patient was confirmed, and the surgery went as planned, which also reduces the stakes.


Medical Specialty: Orthopedic
Sample Name: Total Knee Replacement

PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03.  The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X.,TOURNIQUET TIME: , 76 minutes.,BLOOD LOSS: , 150 cc.,ANESTHESIA:  ,General.,IMPLANT USED FOR PROCEDURE:,  NexGen size F femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component.  The patella on the left was not resurfaced.,GROSS INTRAOPERATIVE FINDINGS: , Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.  The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,HISTORY:  ,This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living.  He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc.  This has only provided him with temporary relief.  It is for that reason, he is elected to undergo the above-named procedure.,All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain.  He has agreed to undergo this procedure and a consent was obtained preoperatively.,PROCEDURE: , The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table.  At this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated.  An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure.  The tourniquet was then inflated to 325 mmHg.  At this time, a standard midline incision was made towards the total knee.  We did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus.  We did start off with a small midline skin incision in case we were going to do a unicompartmental.  Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement.  It is for this reason that we extended the incision and underwent with the total knee replacement.  Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella.  Once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide.  A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee.  At this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur.  At this time, the intramedullary guide was then inserted and placed in three degrees of external rotation.  Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues.  Next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus.  This was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed.  At this time, the intramedullary guide was removed and a final cutting block was placed.  This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking.  At this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues.  An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut.  Peg holes were then drilled.,The block was then removed and an osteotome was then used to remove all the bony cut pieces.  At this time with a better exposure of the proximal tibia, we placed external tibial guide.  This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia.  At this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy.  Prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection.  At this time, a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments.  Once this was removed, we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface.  The knee was taken through range of motion and revealed excellent femorotibial articulation.  The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release.  Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis.  At this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut.  At this time, the prosthesis was removed.  A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia.  Once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components.  At this time, polymethyl methacrylate cement was then mixed.  The cement was placed on the tibial surface as well as the underneath surface of the component.  The component was then placed and impacted with excess cement removed.  In a similar fashion, the femoral component was also placed.  A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content.  Once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone.  Once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry.  The knee was again taken through range of motion with a 12 mm plastic as well as #14.  The #14 appeared to be a bit too tight especially in extremes of flexion.  We decided to go with a #12 mm polyethylene tray.  At this time, this was placed to the tibial articulation and then left in place.  This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia.  The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact.  A drain was placed and cut to length.,At this time, the knee was irrigated and copiously suction dried.  #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion.  A tight capsular closure was performed.  This was reinforced with a #1-0 running Vicryl suture.  At this time, the knee was again taken through range of motion to assure tight capsular closure.  At this time, copious irrigation was used to irrigate the superficial wound.  #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture.  The skin was then approximated with staples.  The leg was then cleansed.  Sterile dressing consisting of Adaptic, 4x4, ABDs, and Kerlix roll were then applied.  At this time, the patient was extubated and transferred to recovery in stable condition.  Prognosis is good for this patient.
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DESCRIPTION: Total left knee replacement.  Degenerative arthritis of the left knee.  Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.

orthopedic, degenerative arthritis, nexgen, polyethylene, cruciate, total knee replacement, proximal tibia, knee replacement, femoral, cutting, tibial, knee, arthritis, femur, cementation,

Total knee replacement surgery is generally a critical procedure given the patient's condition with degenerative arthritis, and there are inherent risks as discussed in the document such as infection, deep vein thrombosis, and pulmonary embolism. These surgeries are significant due to potential complications, effects on quality of life, and the need for a successful outcome to relieve symptoms and improve functionality. The situation would be considered high-stakes because surgery outcomes directly affect the patient's quality of life and continuing management of their condition.


Medical Specialty: Orthopedic
Sample Name: Trigger Thumb Release

PROCEDURE:  ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx.  Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Trigger thumb release.  A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.

orthopedic, neurovascular, a1 pulley, trigger thumb release, mpj crease, trigger thumb, flexor sheath, triggering, sheath, proximal, incision

Trigger thumb release is a common orthopedic procedure used to relieve the locking or triggering of a thumb, which is generally not life-threatening. The procedure involves minor surgery to release the A1 pulley and is typically successful with minor risks of complications if performed correctly. While surgery always carries some risk, this procedure is considered routine and not inherently high-stakes. The description indicates that the patient tolerated the procedure well and that standard precautions, such as the use of sterile techniques and hemostasis, were carefully followed.


Medical Specialty: Orthopedic
Sample Name: Total Hip Arthroplasty - Revision

PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:,  Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1.  Removal of antibiotic spacer.,2.  Revision total hip arthroplasty.,IMPLANTS,1.  Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2.  Zimmer femoral component, 13.5 x 220 mm with a size AA femoral body.,3.  A 32-mm femoral head with a +0 neck length.,ANESTHESIA:  ,Regional.,ESTIMATED BLOOD LOSS: , 500 cc.,COMPLICATIONS:,  None.,DRAINS: , Hemovac times one and incisional VAC times one.,INDICATIONS:,  The patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma.  This subsequently became infected.  She has undergone removal of this prosthesis and placement of antibiotic spacer.  She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room by anesthesia personnel.  She was placed supine on the operating table.  A Foley catheter was inserted.  A formal time out was obtained in identifying the correct patient, operative site.  Preoperative antibiotics were held for intraoperative cultures.  The patient was placed into the lateral decubitus position with the right side up.  The previous surgical incision was identified.  The right lower extremity was prepped and draped in standard fashion.  The old surgical incision was reopened along its proximal extent.  Immediately encountered was a large amount of fibrous scar tissue.  Dissection was carried sharply down through this scar tissue.  Soft tissue plains were extremely difficult to visualize due to all the scarring.  There was no native tissue to orient oneself with.  We carried our dissection down through the scar tissue to what seemed to be a fascial layer.  We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter.  Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed.  This was used as a landmark to orient remainder of the dissection.  The antibiotic spacer was exposed and followed distally to expose the proximal femur.  Dissection was continued posteriorly and proximally to expose the acetabulum.  A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure.  Once improved visualization was obtained, the antibiotic spacer was removed from the femur.  This allowed further improved visualization of the acetabulum.  The acetabulum was filled with soft tissue debris and scar tissue.  This was removed with sharp excision with a knife as well as with a rongeur and a Bovie.  Once soft tissue was removed, the acetabulum was reamed.  Reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell.  The 50 mm shell was trialed and had good stability and fit.  Attention was then turned to continue preparation of the femur.  The canal was then debrided with femoral canal curettes.  Some fibrous tissue was removed from the canal.  The length of the femoral stem was then checked with this canal curette in place.  Following x-rays, we prepared to begin reaming the femur.  This femur was reamed over a guide rod using flexible reaming rods.  The canal was reamed up to 13.5 mm distally in preparation for 14 mm stem.  The stem was selected and initially size A body was placed in trial.  The body was too tight proximally to fit.  The proximal canal was then reamed for a size AA body.  A longer stem with an anterior bow was selected and a size AA trial was assembled.  This fit nicely in the canal and had good fit and fill.  Intraoperative radiographs were obtained to determine component position.  Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur.  The remainder of the trial was then assembled and the hip was relocated and trialed.  Initially, it was found to be unstable posteriorly.  We changed from a 10 degree lip liner to 20 degree lip liner.  Again, the hip was trialed and found to be unstable posteriorly.  This was due to reversion of the femoral component.  As we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion.  The stem was extracted and retrialed.  Improved stability was obtained and we decided to proceed with the real components.  A 20 degree liner was inserted into the acetabular shell.  The real femoral components were assembled and inserted into the femoral canal.  Again, the hip was trialed.  The components were found to be in relative retroversion.  The real components were then backed down and the neck was placed in the more anteversion and reinserted.  Again, the stem attempted to follow in the relative retroversion.  Along with this time, however, it was improved from previous attempts.  The femoral head trial was placed back on the components and the hip relocated.  It was taken to a range of motion and found to have improved stability compared to previous trialing.  Decision was made to accept the component position.  The real femoral head was selected and implanted.  The hip was then taken again to a range of motion.  It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation.  The patient reached full extension and had no instability anteriorly.,The wound was then irrigated again with pulsatile lavage.  Six liters of pulsatile lavage was used during the procedure.,The wound was then closed in a layered fashion.  A Hemovac drain was placed deep to the fascial layer.  The subcutaneous tissues were closed with #1 PDS, 2-0 PDS, and staples in the skin.  An incisional VAC was then placed over the wound as well.  Sponge and needle counts were correct at the close of the case.,DISPOSITION:,  The patient will be weightbearing as tolerated with posterior hip precautions.
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DESCRIPTION: Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.  Removal of antibiotic spacer and revision total hip arthroplasty.

orthopedic, infected, bipolar arthroplasty, antibiotic spacer, revision, placement of antibiotic spacer, total hip arthroplasty, scar tissue, soft tissue, antibiotic, spacer, femoral, hip, arthroplasty, total, acetabulum, femur,

The situation involves a surgical procedure for a revision total hip arthroplasty due to an infection. Surgical procedures, especially revisions after complications like an infection, are inherently high-stakes due to the risks involved, such as infection recurrence, blood loss, and the technical challenges of the procedure caused by scarring. The success of the surgery directly impacts the patient's mobility and quality of life. Additionally, the report indicates significant blood loss (500 cc) and challenges faced during the procedure, which add to the stakes.


Medical Specialty: Orthopedic
Sample Name: Tarsectomy

PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient 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 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.
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DESCRIPTION: Painful enlarged navicula, right foot.  Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.

orthopedic, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone

This scenario involves a surgical procedure to address painful bone growths in the foot: a partial tarsectomy and metatarsectomy. While surgeries can carry inherent risks, this particular procedure seems to be a routine orthopedic intervention for managing osteochondromas. The patient is stable, the surgery went as planned without complications, and postoperative instructions are standard. The stakes are moderate because it involves surgery with potential impacts on mobility and quality of life if issues arise, but it's not immediately life-threatening or highly complex from what is described.


Medical Specialty: Orthopedic
Sample Name: Tailor Bunionectomy with Screw Fixation

PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.
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DESCRIPTION: Tailor bunionectomy, right foot, Weil-type with screw fixation.  Hallux abductovalgus deformity and tailor bunion deformity, right foot.

orthopedic, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis,

The situation presented involves a surgical procedure, specifically a tailor bunionectomy with screw fixation. While surgery itself involves some risk, this particular procedure is described in detail as having minimal complications, with minimal blood loss, no specimens taken, and no complications noted during the surgery. The patient tolerated the surgery well and was discharged the same day with stable vital signs and intact neurovascular status. Considering these factors, this situation does not involve life-threatening stakes or high-risk factors typical of more serious surgeries or medical situations. Thus, it is of moderate stakes typical of routine orthopedic surgeries with planned recovery.


Medical Specialty: Orthopedic
Sample Name: Rotator Cuff Repair

PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1.  Sixty-percent rotator cuff tear, joint side.,2.  Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1.  Arthroscopic subacromial decompression.,2.  Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff.  The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon.  This was confirmed later when the bursal side was opened up.  Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion.  He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:,  He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope.  With the scope in the posterior portal, the above findings were noted, and an anterior portal was established.  A curved shaver was placed for debridement of the tear.  I established this was about a 60-70% tear with a probable complete area of tear which was very small.  There were no problems at the biceps or the rest of the joint.  The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur.  I did not debride the acromioclavicular joint.  The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid.  The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed.  The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur.  Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair.  The shoulder was carried through a range of motion.  I could see no evidence of impingement.  Copious irrigation was carried out.  The deltoid deep fascia was anatomically closed, as was the superficial fascia.  The subcutaneous tissue and skin were closed in layers.  A sterile dressing was applied.  The patient appeared to tolerate the procedure well.
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DESCRIPTION: Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy.

orthopedic, rotator cuff tear, mini-arthrotomy, repair of rotator cuff, arthroscopic subacromial decompression, arthroscopic subacromial, cuff tear, subacromial space, subacromial decompression, mini arthrotomy, acromioclavicular joint, rotator cuff, arthroscopic, decompression, acromioclavicular, impingement, rotator, cuff,

The procedure described involves arthroscopic subacromial decompression and rotator cuff repair, which are surgeries performed to address a rotator cuff tear and impingement syndrome. This is a common orthopedic surgery, and while it is not without risks, it is generally considered routine with low-to-moderate stakes, assuming the patient is in good health and there are no complications during surgery. The stakes would be higher if there were other major risks involved, like severe patient comorbidities or potential for significant postoperative complications, but none are indicated in this scenario.


Medical Specialty: Orthopedic
Sample Name: Right Shoulder Hemiarthroplasty

PREOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,POSTOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,PROCEDURE PERFORMED: ,Right shoulder hemiarthroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Approximately 125 cc.,COMPLICATIONS:,  None.,COMPONENTS: , A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used.,BRIEF HISTORY:  ,The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.,PROCEDURE: , The patient was taken to the operative suite, placed on the operative field.  Department of Anesthesia administered general anesthetic.  Once adequately sedated, the patient was placed in the beach chair position.  Care was ensured that she was well positioned, adequately secured and padded.  At this point, the right upper extremity was then prepped and draped in the usual sterile fashion.  A deltopectoral approach was used and taken down to the skin with a #15 blade scalpel.,At this point, blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue.  Any perforating bleeders were cauterized with Bovie to obtain hemostasis.  Once the bursa was seen, it was removed with a Rongeur and subscapular tendon could be easily visualized.  At this point, the rotator cuff in the subacromial region was evaluated.  There was noted to be a large rotator cuff, which was irreparable.  There was eburnated bone on the greater tuberosity noted.  The articular surface could be visualized.  The biceps tendon was intact.  There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface.  The under surface of the acromion, it was felt there was mild ware on this as well.  At this point, the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture.  It was separated from the capsule to have a two layered repair at closure.  The capsule was also reflected posterior.  At this point, the glenoid surface could be easily visualized.  It was evaluated and had good cartilage contact and appeared to be intact.  The humeral head was evaluated.  There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head.  At this point, decision was made to proceed with the arthroplasty, since the rotator cuff tear was irreparable and there was significant ware of the humoral head.  The arm was adequately positioned.  An oscillating saw was used to make the head articular cut.  This was done at the margin of the articular surface with the anatomic neck.  This was taken down to appropriate level until this articular surface was adequately removed.  At this point, the intramedullary canal and cancellous bone could be easily visualized.  The opening hand reamers were then used and this was advanced to a size #10.  Under direct visualization, this was performed easily.  At this point, the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins.  This was then removed.  A trial component was then impacted into place, which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured.  It did not appear overstuffed with evidence of excellent range of motion and no impingement.  At this point, the trial component was removed.  Wound was copiously irrigated and suctioned dry.  Cement was then placed with a cement gun into the canal and taken up to the level of the cut.  The prosthesis was then inserted into place and held under direct visualization.  All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself.  This _______ cement was adequately hard at this point.  The final component of the head was impacted into place, secured on the Morris taper and checked, and this was reduced.,The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position.  The wound was again copiously irrigated and suctioned dry.  At this point, the capsule was then reattached to its insertion site in the anterior portion.  Once adequately sutured with #1-Vicryl, attention was directed to the subscapular.  The subscapular was advanced superiorly and anchored not only to the biceps tendon region, but also to the top anterior portion of the greater tuberosity.  This was opened to allow some type of coverage points of the massive rotator cuff tear.  This was secured to the tissue and interosseous sutures with size #2 fiber wire.  After this was adequately secured, the wound was again copiously irrigated and suctioned dry.  The deltoid fascial split was then repaired using interrupted #2-0 Vicryl, subcutaneous tissue was then approximated using interrupted #24-0 Vicryl, skin was approximated using a running #4-0 Vicryl.  Steri-Strips and Adaptic, 4 x 4s, and ABDs were then applied.  The patient was then placed in a sling and transferred back to the gurney, reversed by Department of Anesthesia.,DISPOSITION: , The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition.
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DESCRIPTION: Right shoulder hemiarthroplasty.   Right shoulder rotator cuff tear.  Glenohumeral rotator cuff arthroscopy.  Degenerative joint disease.

orthopedic, glenohumeral rotator cuff, arthroscopy, degenerative joint disease, shoulder hemiarthroplasty, rotator, cuff, subscapular, shoulder,

The situation involves a surgical procedure called right shoulder hemiarthroplasty, which is an orthopedic surgery for a patient with a significant shoulder rotator cuff tear and degenerative joint disease. While the surgery itself is serious and requires considerable skill and care, it is a routine elective surgery in the orthopedic field and is commonly performed on patients with similar conditions. The fact that there were no complications and the procedure was completed successfully suggests the stakes are not extremely high, but given the patient's age and the complexity of the surgery, it still involves moderate stakes.


Medical Specialty: Orthopedic
Sample Name: Release of A1 Pulley - 1

PREOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,POSTOPERATIVE DIAGNOSIS: , Stenosing tendinosis, right thumb (trigger finger).,PROCEDURE PERFORMED:,  Release of A1 pulley, right thumb.,ANESTHESIA:,  IV regional with sedation.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , Approximately 20 minutes at 250 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be thickening of the A1 pulley.  There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,HISTORY:  ,This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb.  She was actually able to spontaneously trigger the thumb.  She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley.  All risks and benefits of the surgery was discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE:  ,On 08/21/03, she was taken to operating room at ABCD General Hospital and placed supine on the operating table.  A regional anesthetic was applied by the Anesthesia Department.  Tourniquet was placed on her proximal arm.  The upper extremity was sterilely prepped and draped in the usual fashion.,An incision was made over the proximal crease of the thumb.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The nerves were identified and retracted throughout the entire procedure.  The fibers of the A1 pulley were identified.  They were sharply dissected to release the tendon.  The tendon was then pulled up into the wound and inspected.  There was no evidence of gross tear noted.  Fibrous nodule was noted within the tendon itself.  There was no evidence of continuous locking.  Once release of the pulley had been performed, the wound was copiously irrigated.  It was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures.  Sterile dressing was applied to the upper extremity.  Tourniquet was deflated.  It was noted that the thumb was warm and pink with good capillary refill.  The patient was transferred to Recovery in apparent stable and satisfactory condition.  Prognosis is fair.
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DESCRIPTION: Release of A1 pulley, right thumb.   Stenosing tendinosis, right thumb (trigger finger).  There was noted to be thickening of the A1 pulley.  There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.

orthopedic, release of a1 pulley, tendinosis, thumb, flexor tendon, trigger finger, fibrous nodule, stenosing tendinosis, tourniquet, stenosing, tendon, release, pulley

The situation involves an orthopedic procedure specifically aimed at addressing trigger finger in a patient. The procedure is standard and common for this condition, involving the release of the A1 pulley in the thumb. There are no complications during the surgery, and the estimated blood loss is minimal. The patient is stable post-procedure with a prognosis considered fair. While surgery always carries some risk, this particular procedure is routine and low risk in a controlled medical environment.


Medical Specialty: Orthopedic
Sample Name: Release of A1 Pulley

PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:,  General LMA.,TOURNIQUET TIME:  ,9 minutes at 200 torr.,FINDINGS:,  The patient was found to have limitations to extension at the IP joint to the right thumb.  He was found to have full extension after release of A1 pulley.,INDICATIONS:,  The patient is 2-1/2-year-old.  He has a history of a trigger thumb.  This was evaluated in the office.  He was indicated for release of A1 pulley to allow for full excursion.  Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family.  They wanted to proceed.,PROCEDURE:,  The patient was brought into the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  The right upper extremity was then prepped and draped in a standard fashion.  Limb was exsanguinated with an Esmarch bandage.  Tourniquet was raised to 200 torr.  Transverse incision was then made at the base of thumb.  The underlying soft tissues were carefully spread in line longitudinally.  The underlying tendon was then identified.  The accompanied A1 pulley was also identified.  This was incised longitudinally using #11 blade.  Inspection of the entire tendon then demonstrated good motion both in flexion and extension.  The leaflets of the pulley were easily identified.,The wound was then irrigated and closed.  The skin was closed using interrupted #4-0 Monocryl simple sutures.  The area was injected with 5 mL of 0.25% Marcaine.  The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban.  The patient was awakened from anesthesia and taken to the recovery room in good condition.  There were no complications.  All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home.  He will return in 1-1/2 weeks for wound inspection.
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DESCRIPTION: The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.

orthopedic, a1 pulley, release of a1 pulley, trigger thumb, limitations to extension, ip joint

The described surgical procedure, a Release of A1 Pulley for a 2.5-year-old patient with a trigger thumb, appears to be relatively routine and low-risk in the field of orthopedic surgery. While general anesthesia and surgical intervention always carry some inherent risks, the preoperative and postoperative diagnoses are the same, indicating a straightforward case without complications. The short tourniquet time, successful identification and treatment of the issue, absence of complications, and the plan for routine postoperative follow-up further suggest this is a low-stakes situation in the context of surgical procedures.


Medical Specialty: Orthopedic
Sample Name: RICE Therapy

RICE, stands for the most important elements of treatment for many injuries---rest, ice, compression, and elevation.,REST:,Stop using the injured part as soon as you realize that an injury has taken place. Use crutches to avoid bearing weight on injuries of the foot, ankle, knee, or leg. Use splints for injuries of the hand, wrist, elbow, or arm. Continued exercise or activity could cause further injury, increased pain, or a delay in healing.,ICE:,Ice helps stop bleeding from injured blood vessels and capillaries. Sudden cold causes the small blood vessels to contract. This contraction decreases the amount of blood that can collect around the wound. The more blood that collects, the longer the healing time. Ice can be safely applied in many ways:,*  For injuries to small areas, such as a finger, toe, foot, or wrist, immerse the injured area for 15 to 35 minutes in a bucket of ice water. Use ice cubes to keep the water cold, adding more as the ice cubes dissolve.,*  For injuries to larger areas, use ice packs. Avoid placing the ice directly on the skin. Before applying the ice, place a towel, cloth, or one or two layers of an elasticized compression bandage on the skin to be iced. To make the ice pack, put ice chips or ice cubes in a plastic bag or wrap them in a thin towel. Place the ice pack over the cloth. The pack may sit directly on the injured part, or it may be wrapped in place.,*  Ice the injured area for about 30 minutes.,*  Remove the ice to allow the skin to warm for 15 minutes.,*  Reapply the ice.,*  Repeat the icing and warming cycles for 3 hours. Follow the instructions below for compression and elevation. If pain and swelling persist after 3 hours call our office. You may need to change the icing schedule after the first 3 hours. Regular ice treatment is often discontinued after 24 to 48 hours. At that point, heat is sometimes more comfortable.,COMPRESSION:,Compression decreases swelling by slowing bleeding and limiting the accumulation of blood and plasma near the injured site. Without compression, fluid from adjacent normal tissue seeps into the injured area. To apply compression safely to an injury:,*  Use an elasticized bandage (Ace bandage) for compression, if possible. If you do not have one available, any kind of cloth will suffice for a short time.,*  Wrap the injured part firmly, wrapping over the ice. Begin wrapping below the injury site and extend above the injury site.,*  Be careful not to compress the area so tightly that the blood supply is impaired. Signs of deprivation of the blood supply include pain, numbness, cramping, and blue or dusky nails. Remove the compression bandage immediately if any of theses symptoms appears. Leave the bandage off until all signs of impaired circulation disappear. Then rewrap the area--less tightly this time.,ELEVATION:,Elevating the injured part above the level of the heart is another way to decrease swelling and pain at the injury site. Elevate the iced, compressed area in whatever way is most convenient. Prop an injured leg on a solid object or pillows. Elevate an injured arm by lying down and placing pillows under the arm or on the chest with the arm folded across.
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DESCRIPTION: A sample note on RICE Therapy

A sample note on RICE Therapy

orthopedic, rest, ice, compression, and elevation, foot, ankle, knee, leg, splints, hand, wrist, elbow, arm, ace bandage, compression and elevation, rice therapy, compression bandage, ice packs, rice, elevation, swelling, bandage, therapy

The RICE (Rest, Ice, Compression, Elevation) therapy is a common protocol used in managing minor orthopedic injuries. This treatment is aimed at reducing pain, swelling, and promoting healing in injuries such as sprains and strains. The situation describes a process of self-care and management for injuries which generally do not involve life-threatening conditions or require immediate advanced medical intervention. While important for proper injury management, the stakes are not particularly high for most cases where RICE is applicable, as they are usually for injuries that will resolve with conservative treatment. However, it is important to follow the instructions carefully to avoid potential complications, such as impaired circulation if compression is applied improperly.


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

Medical Specialty: Orthopedic
Sample Name: Radiofrequency Ablation

PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3.  Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement.  Motor stimulation was applied at 2 Hz with 1 millisecond duration.  No extremity movement was noted at less than 2 volts.  Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue.  After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS:  ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.
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DESCRIPTION: Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

orthopedic, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,

The procedure described is a medical intervention for managing sacroiliac joint pain through radiofrequency ablation. Such a procedure involves risks commonly associated with invasive medical interventions such as infection, bleeding, and potential nerve damage, albeit these are relatively uncommon. However, this type of procedure is performed regularly and has well-established protocols and safety measures, which were clearly followed in this case, as indicated by the comprehensive informed consent and monitoring during the procedure. The absence of complications also suggests it was conducted without immediate high-risk issues. While this is a significant medical procedure for the patient, it doesn't involve life-threatening stakes typical of surgeries involving vital organs. Therefore, it is a moderate level stake situation within the context of routine medical interventions.


Medical Specialty: Orthopedic
Sample Name: Pilon Fracture External Fixation

PREOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1.  External fixation of left pilon fracture.,2.  Closed reduction of left great toe, T1 fracture.,ANESTHESIA:  ,General.,BLOOD LOSS:  ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:,  None.,INDICATION FOR OPERATION:  ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009.  The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time.  The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness.  She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome.  Risks and benefits of procedure were discussed in detail with the patient and her husband.  All questions were answered, and consent was obtained.  The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1.  There was a comminuted distal tibia fracture with a fibular shaft fracture.  Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2.  The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement.  As the reduction was stable with buddy taping, no pinning was performed.,3.  Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL:  ,The patient was identified in the preoperative holding area.  The left leg was identified and marked at the surgical site of the patient.  She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team.  She received Ancef for antibiotic prophylaxis.  A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics.  When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion.  At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site.  A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able.  When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture.  Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive.  X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture.  At this point, the pins were cut short and capped to protect the sharp ends.  The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition.  Please note there was no break in sterile technique throughout the case.,PLAN:  ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication.  She will maintain her buddy taping in regards to her great toe fracture.
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DESCRIPTION: External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.

orthopedic, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation,

The situation involves a medical procedure for treating a patient who suffered significant injuries in an auto accident, including a comminuted distal tibia fracture and a great toe fracture. While the primary procedure described is an external fixation of the pilon fracture, it is part of a staged surgery plan that includes potential complications and risks, such as infection, nerve damage, and possible need for further surgery. The patient's overall health and recovery may be affected by these factors, and the situation requires careful medical planning and intervention. However, immediate life-threatening issues have been stabilized, and the operation appears to be part of a carefully planned surgical protocol.


Medical Specialty: Orthopedic
Sample Name: Phalanx Amputation

PREOPERATIVE DIAGNOSIS:,  Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:,  Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity.  The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed.  The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis.  The patient desires to attempt a surgical correction.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X.  The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist.  Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block.  The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm.  There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally.  The toe was 2.5 times to the normal size.  There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected.  The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively.  X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx.  A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx.  The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact.  Next, the distal phalanx was disarticulated at the interphalangeal joint and removed.  The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology.  Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected.  Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx.  This bone was also sent off for culture and was labeled proximal margin.  Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected.  The flexor tendon distally was gray discolored and was not viable.  A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally.  None was found.  No purulent drainage or abscess was found.  The proximal margin of the surgical site tissue was viable and healthy.  There was no malodor.  Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology.  Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension.  The plantar flap was viable and was debulked with Metzenbaum scissors.  The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures.  Iris scissors were used to modify and remodel the plantar flap.  An excellent cosmetic result was achieved.  No tourniquet was used in this case.  The patient tolerated the above anesthesia and surgery without apparent complications.  A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban.  The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot.  He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications.  Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches.  He will elevate his right foot and rest the foot, keep it clean and dry.  He is to follow up with Dr. X on Monday or Tuesday of next week.
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DESCRIPTION: Amputation distal phalanx and partial proximal phalanx, right hallux.   Osteomyelitis, right hallux.

orthopedic, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal

The situation describes a surgical procedure for amputation of the distal and partial proximal phalanx of the right hallux due to osteomyelitis. The stakes are primarily medical and pertain to the management and treatment of a chronic infection that has resisted conservative treatments in a diabetic patient. There are surgical risks involved, and the procedure is necessary to manage the infection and prevent further complications. However, as it is a localized procedure and the condition is not immediately life-threatening, it does not reach the highest levels of stakes, such as those involving life-threatening conditions or critical organ failure.