MUSCULOSKELETAL SYSTEM SAMPLE OP REPORTS

CASE 1

PREOPERATIVE DIAGNOSIS: Left hip degenerative joint disease.

POSTOPERATIVE DIAGNOSIS: Left hip degenerative joint disease.

PROCEDURE PERFORMED: Left hip intraarticular joint injection

with ultrasound.

SURGEON:

ANESTHESIA: MAC anesthesia with sedation was

provided, as the patient with chronic
pain and anxiety and required the
sedation, to lie still.

ANESTHESIOLOGIST:

INDICATIONS: Informed consent was obtained. We discussed the risks and benefits of the
procedure including pain, bleeding, infection, possible headache and possible nerve damage. The
patient is agreeable to proceed.

PROCEDURE IN DETAIL: The patient was brought back to the procedure room and
placed supine. Skin was prepped and draped in a sterile fashion. Skin was prepped and
draped in sterile fashion. The left head of the femur and neck of the femur was identified
using ultrasound and the skin was anesthetized with 1% lidocaine at the neck of the
femur and a #22-gauge, 3.5-inch spinal needle was then advanced to the neck of the
femur and junction of the head of the femur using ultrasound guidance. No heme was
aspirated. I then injected 5 cc mixture of 80 mg of Depo-Medrol and 4 cc of 0.5%
Marcaine into the left intraarticular hip joint. The needle was removed. Band-Aid was
applied. The patient tolerated the procedure well. No complications.

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 CASE 2

PROCEDURE PERFORMED: Bilateral diagnostic sacroiliac joint injections under

fluoroscopic guidance.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and
positioned prone on the x-ray table. His back was sterilely prepped and draped.
Fluoroscopic visualization was done. The patient had extensive retention of hardware,
including screws, bolts, and bridges. This covered the area from the top of L4 to the
bottom of S1. A copy was made of this for further reference. Above this fusion, there
seemed to be significant degeneration.

The right SI joint was first visualized. This was very sclerotic. A 22-gauge spinal needle
was used and the joint was entered after some difficulty. An arthrogram was done, but
this showed that the needle was not in far enough. There was some spill of dye inferior
to the joint. A second needle was used at a different angle, again, to get it intraarticularly
deep enough to get an arthrogram. The second needle was unsuccessful as well. Next, 2
mL of a standard joint solution were injected periarticularly.

Attention was then shifted to the left SI joint where there were the same findings. Two
attempts were made again. There was partial filling of the joint by the second needle, and
2 mL of the same joint solution were injected intraarticularly there. Coincidentally, the
hip joints which could be seen on the x-rays looked in normal condition for his age.

The patient was taken to the recovery room stable. He was awake. He became more
awake, and pre-discharge he had good pain relief. Because he has undergone this
procedure, I elected to give him an extra week’s supply of pain medication. The patient
was asked to take 24 hours of bedrest and to report any untoward events to my office
immediately. Otherwise, he will be followed up in routine fashion.

CPT CODES:

Medicare:

Non Medicare(Commercial payors):

 CASE 3

PREOPERATIVE DIAGNOSES: 1. Left ring trigger finger.

2. Left small trigger finger.

POSTOPERATIVE DIAGNOSES: 1. Left ring trigger finger.

2. Left small trigger finger.

PROCEDURES PERFORMED: 1. Left ring trigger finger release.

2. Left small trigger finger release.

ANESTHESIA: General.

ANESTHESIOLOGIST:

COMPLICATIONS: None.

OPERATIVE INDICATION: A 78-year-old female with a fracture of the fifth metacarpal,

which is not healing well, presents with severe triggering to the left small finger and moderate
triggering to the ring finger. In the office, she has rasped into the small finger and this gets stuck
consistent with the possible tendon tearing. Secondary to this, a plan for operative treatment was
made. She is also starting to have some numbness, but in the office this was not consistent
enough with carpal tunnel to proceed with testing or release. She understood that she may have
to have the nerve further evaluated.

PROCEDURE IN DETAIL: After informed consent was obtained, Ms. Cunningham was taken
to the operative suite. General anesthetic was administered. Sterile prep and drape was
performed to the left upper extremity. The arm was exsanguinated and the tourniquet was
inflated. Oblique incisions were made over the ring and small fingers. The ring was addressed
first. Subcutaneous dissection was blunt. The A1 pulley and all proximal tight tissue were
released. At this point, the small finger was addressed. Subcutaneous dissection was blunt.
There was approximately 10% fraying of the tendon present. This was trimmed proximal to the
A1 pulley. The A1 pulley was released. All proximal tight tissue was released. There had been
passive triggering to both fingers prior to release and now there is no passive triggering to the
small or ring fingers. At this point, the wounds were irrigated. The skin was closed using a
running nylon. A soft sterile dressing was applied after local anesthetic was infiltrated for postop
pain control.

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 CASE 4

PREOPERATIVE DIAGNOSIS: Left lateral hip lipoma.

POSTOPERATIVE DIAGNOSIS: Left lateral hip lipoma.
PROCEDURE PERFORMED: Excision of 10 cm left lateral hip
lipoma(soft tissue tumor).
ASSISTANT: None.
ANESTHESIA: General.
ANESTHESIOLOGIST:
INDICATIONS: Ms. Torres is a pleasant 50-year-old female with the above mentioned
diagnosis. I saw her in the office and we discussed options for excision under anesthesia. We
reviewed small risks of infection, bleeding, seroma and recurrence. All of her questions were
answered and consent was obtained for surgery.
DETAILS OF PROCEDURE: The patient was taken to the operating room and placed on table
in supine position. SCDs were placed on bilateral lower extremities and she underwent general
anesthesia. She was placed in the right lateral decubitus position with all of her extremities
carefully padded. She was marked in the preoperative area with an approximately 8 cm
transverse incision directly overlying the left greater trochanter region where there was a palpable
ballotable bulge. Ultrasound in the office had the findings consistent with lipoma. The area was
prepped and draped in a full sterile fashion and she received preoperative antibiotics. A
transverse incision approximately 8 to 10 cm was created directly over the center of the bulge
along the skin line. The subcutaneous tissue was divided and after going through approximately
1 to 1.5 cm of subcutaneous fat, there was a very well circumscribed lipomatous capsule and
using just finger blunt dissection, this was completely excised and sent off for final evaluation.
Longest measurement was approximately 10 cm. The cavity was seen to be hemostatic.
Additional local anesthesia was infused and the deep layer was closed with 3-0 Vicryl suture.
Skin was closed with 4-0 Monocryl suture. Steri-Strips and bandages were placed on top. This
was followed by an abdominal binder for compression to minimize risk of hematoma/seroma
formation.
The patient tolerated the procedure well. There were no complications. Estimated blood loss was
minimal. She was awoken from anesthesia and transferred to PACU in good condition.

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 CASE 5

PREOPERATIVE DIAGNOSES: 1. Right subtalar osteoarthritis.

2. Painful hardware, right ankle.

POSTOPERATIVE DIAGNOSES: 1. Right subtalar osteoarthritis.

2. Painful hardware, right ankle.

PROCEDURES PERFORMED: 1. Right subtalar fusion.

2. Right iliac crest bone graft
harvest.
3. Short-leg splint application.

DESCRIPTION OF PROCEDURE: The patient was identified in the preoperative

holding area. The appropriate extremity was marked. Informed consent was obtained.
She was taken back to the operating room and placed supine on the operating room table.
A non-sterile tourniquet was placed on the right thigh and the right lower extremity was
prepped and draped in the usual sterile fashion. Prior to beginning, a time-out was taken
to ensure antibiotic delivery, proper operative site, and equipment in the room. Once this
was done, an Esmarch tourniquet was used to exsanguinate the limb and the tourniquet
was elevated. Next, attention was turned to the right iliac crest. A small incision was
made. It was taken down through the skin and subcutaneous tissue. The pelvic brim was
identified. Trephine reamer was used to breach out the cortex and core small cancellous
bone was taken between the inner and outer table. The wound was irrigated and closed in
sequential fashion. Attention was then turned to the right ankle. The retained screw in
the ankle was cannulated. A small incision was made and we were able to get down to
the screw, but the screw had tripped and we were unable to remove the screw and
because of this, this attempt was aborted. Attention was then turned to the subtalar
fusion. A small incision was made at the sinus tarsi. This was taken down through the
skin and subcutaneous tissue. Sinus tarsi was opened and the capsule of the subtalar joint
was opened. Laminar spreader was placed and the subtalar joint was placed on stretch.
There was almost no cartilage remaining in the joint. A combination of curette and bur
were used to remove any remaining fibrous tissue as well as any remaining cartilage.
The subchondral bone was exposed and this was taken out down to healthy bleeding
cancellous bone. This was then fish-scaled with a small osteotome and drilled with a 1.5
mm drill bit. After this was done, the iliac crest was placed at the fusion site. Two 6.7
mm screws were placed across the fusion site, getting good bite with good compression
across the fusion site. Good alignment was confirmed with fluoroscopic imaging. The
wounds were irrigated and closed in sequential fashion. Sterile dressings were placed. A
posterior sugar-tong splint was applied and the patient was awakened without
complication and taken to Postanesthesia Care Unit for further recovery.
CPT CODES:

CASE 6

PREOPERATIVE DIAGNOSIS: Right hallux valgus deformity.

POSTOPERATIVE DIAGNOSIS: Right hallux valgus deformity.

OPERATIONS PERFORMED: Austin bunionectomy, right foot.

PROCEDURE: The patient was identified, brought to the operating room, and placed
on the operating table in supine position. Time-out was held to identifying the patient
and procedure against the medical record, and consent obtained within the chart after
being deemed correct. Anesthesia was administered from general with laryngeal mask
airway and popliteal block right lower extremity. A well-padded pneumatic ankle
tourniquet was applied to the right foot and right foot was scrubbed, prepped, and draped
in usual aseptic manner and surgical procedure ensued. An Esmarch bandage was
utilized to exsanguinate the right lower extremity and tourniquet was inflated to 250
mmHg, would be utilized less than 50 minutes for the entirety of the case. The attention
was directed to the dorsal aspect of the right first metatarsophalangeal joint where
curvilinear longitudinal incision was made of the first metatarsophalangeal joint and
incision deepened through the subcutaneous tissue with care being taken to retract all
vital and neurovascular structures. All bleeders were ligated and cauterized as necessary.
Dissection was carried down through periosteal and capsule exposing the metatarsal in
the operative field. Metatarsal head showed clear smooth hyaline cartilage and large
medial eminence noted. Sagittal saw was resecting a large medial eminence at this time.
The joint was inspected and noted to have firm adductory pull therefore point dissection
was carried down into the first interspace to perform a lateral release for successfully
done fraying the conjoint adductor tendon from the fibular sesamoid and with the aid of
lateral capsulotomy. At this point, through-and-through Chevron-shaped osteotomy was
performed of the metatarsal head from medial and lateral. Capital fragment being
translocated laterally. With the metatarsal head and new corrective position was assessed
and noted to be good orientation and good joint motion. At this point, 0.62 K-wire was
utilized to pilot the hole in preparation for 2.7 mm screw, which was to be inserted
according in a standard AO technique. At this point, with the capital fragment secured
and stabilized the redundant medial eminence was resected with saw at this time, passing
from the operating field. Surgical site was irrigated copiously and closure ensued with
Vicryl subcutaneously in layered fashion with nylon to re-approximate the skin.
Dressing with Adaptic 4x4s, Kling, and Ace wrap was applied to the right foot. This
completed the surgical procedure at this time. Tourniquet was released. Prompt
hyperemic response noted all digits of the right foot. The patient was transferred to the
recovery room with vital signs stable and vascular status intact. The patient will be
discharged to home following clearance by Anesthesia and follow up in the office within
one week’s time.
CPT CODES:

CASE 7

PREOPERATIVE DIAGNOSES: 1. Hallux valgus, right foot.

2. Hammertoe, second and third digits.

POSTOPERATIVE DIAGNOSES: 1. Hallux valgus, right foot.

2. Hammertoe, second and third digits.

PROCEDURES PERFORMED: 1. Lapidus bunionectomy, right foot.

2. Weil osteotomy, right second metatarsal.
3. Hammertoe repair, second and third digits,
right foot.

DESCRIPTION OF PROCEDURE: The patient was brought into the operating room
and placed on the operating table in the supine position. She had been given a popliteal
block preoperatively. Time-out protocol was followed, confirming the correct site of
surgery and patient. The foot was then prepped and draped in the usual sterile manner.
She did not yet have the block set up and it was decided to convert to a general.

An incision was made medially over the first metatarsocuneiform joint approximately 6
cm in length. This incision was deepened via sharp and blunt dissection, taking care to
retract vital structures and maintaining hemostasis as necessary. Dissection was carried
down to the level of the joint where capsulotomy was performed. The capsular structures
were freed off of the base of the first metatarsal, mobilizing the bone. A laminar spreader
was then used and then a power saw was used to resect the cartilage on both sides. Next,
osteotome and mallet were used to fenestrate the bones and this was done after irrigating
the wound. The toe was placed in corrected position. The first MP joint was still
prominent with a bunion medially. The incision was made dorsally over the first
metatarsal head, roughly 5 cm in length. The incision was deepened by sharp and blunt
dissection, taking care to retract the vital structures and maintaining hemostasis as
necessary.

Dissection was carried down to the level of the capsule. An inverted L-capsulotomy was
performed at the medial first metatarsal head. The capsular structures were freed off the
medial eminence which was then resected. Through the same incision. dissection was
carried down in the first interspace where a complete lateral release was performed. This
allowed for a full reduction of the deformity. The arthrodesis site at the
metatarsocuneiform joint was temporarily fixated with K-wires and the Lapidus plantar
plate was then placed and fixated with a typical AO technique. Excellent stability was
noted. It should be noted that some bone graft from the medial eminence was placed at
the more medial aspect of the fusion site prior to fixation. The tourniquet was then
deflated.
Attention was directed to the medial wound which was then closed. The tourniquet was
then inflated and incision was made over the second metatarsal extending onto the toe
with an ellipse over the PIP joint. Incision was deepened via sharp and blunt dissection
taking care to retract the vital structures and maintain hemostasis as necessary. The
extensor tendon was freed of the expansion and the retracted laterally. Transverse
capsulotomy was performed and the head of the metatarsal was freed via sharp
dissection.

Next, a Weil osteotomy was made through the metatarsal head parallel to the ground.
This was then translated proximally several millimeters and confirmed on x-ray and then
fixated with 2 Arthrex headless compression screws.

Attention was then directed back to the second toe at the PIP joint. The transverse
tenotomy/capsulotomy was performed. The head of the proximal phalanx was then freed
of soft tissue attachments. This was resected using a bone saw just proximal to the
cartilage. The medial, plantar and lateral aspects were then resected, leaving the dorsal
and central portion of the phalanx as a peg. A power bur was then used to make a
corresponding hole in the base of the intermediate phalanx. The wound was irrigated and
then fixated with a 0.062 K-wire. This was driven through the intermediate phalanx and
out the end of the toe and then driven into the proximal phalanx and into the second MP
joint with the toe in corrected position. This was confirmed with fluoroscopy.

Attention was then directed to the third toe. Incision was made extending the MP joint
onto the toe. The incision was deepened to the MP joint level where the extensor tendon
was transected as was the capsule which allowed for good reduction of the deformity at
the MP joint. The same procedure at the PIP joint was performed, fashioning a new peg
and hole and then fixated with a 0.062 K-wire.

The wounds were then irrigated and tourniquet was deflated. The first MP joint capsule
was closed using 2-0 Monocryl with a medial capsulorrhaphy performed. The MP joints
were then closed using 4-0 Monocryl at the first, second and third MP joints closing
subcutaneous tissues. Skin closure was the achieved using 4-0 nylon. The K-wires were
cut and capped. A sterile compression dressing was applied along with a posterior splint.
The patient tolerated the procedure and anesthesia well and left the OR for recovery with
vital signs stable and vascular status intact to all digits. She will be discharged home
nonweightbearing using crutches or a knee scooter. She has an appointment for her first
followup visit, her postop instructions and postop pain medication.

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 CASE 8

PREOPERATIVE DIAGNOSIS: Osteomyelitis of the right third toe.

POSTOPERATIVE DIAGNOSIS: Osteomyelitis of the right third toe.

OPERATION PERFORMED: Amputation of the right third toe.

DESCRIPTION OF THE PROCEDURE: The patient was brought to the operating

room and placed in a supine position. A time-out was called to identify the correct
patient, procedure and surgical site. After anesthesia services provided general sedation,
a local nerve conduction block was performed to the patient’s right third toe utilizing 9 cc
of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain. A pneumatic ankle
tourniquet was applied, but not inflated. The right lower extremity was then prepped
draped in usual sterile manner. Attention was directed to the patient’s right second toe.
The procedure was started. After exsanguination, the pneumatic ankle tourniquet was
inflated to 250 mmHg and the skin marker was used to demarcate the intended incision
overlying the metatarsophalangeal joint. A fresh #15-blade was then used to make a full-
thickness incision encompassing the entire third toe. The toe was then disarticulated at
the metatarsophalangeal joint and cultured for anaerobic and aerobic acid fast, and fungal
analysis and was sent to pathology. The incision site was then copiously irrigated with
normal saline solution. The deep tissues were re-approximated with 3-0 Vicryl and final
skin closure was made with 4-0 Prolene. This was followed by Xeroform, 4 x 4s, Kling
and Coban applied to the patient’s right foot. The patient tolerated the anesthesia and
procedure well. The patient was then transported from the OR to the PACU with
neurovascular status intact to the right foot.

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 CASE 9

PREOPERATIVE DIAGNOSES:
1. Right knee anterior cruciate ligament tear.
2. Medial meniscus tear.

POSTOPERATIVE DIAGNOSES:
1. Right knee anterior cruciate ligament tear.
2. Medial meniscus tear.
3. Lateral meniscus tear.

PROCEDURE:
1. Right knee arthroscopy with anterior cruciate ligament reconstruction using a bone-patellar-
tendon bone
allograft.
2. Partial medial and lateral meniscectomy.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed in a
supine
position, and underwent general endotracheal anesthesia. Prior to his arrival, the appropriate dose
of IV
antibiotics was administered. Next, his right lower extremity was placed in an arthroscopic leg
holder and
his left lower extremity was placed in a well-leg holder and his right lower extremity was prepped
and draped
in the usual sterile fashion. To begin with, standard anteromedial and inferolateral arthroscopic
portals were
placed and his knee was systematically examined. To begin with, the suprapatellar pouch was
identified
and there were found to be no abnormalities. Next, the patellofemoral joint was identified and
there was
found to be no abnormalities. Next, the medial and lateral gutters were identified and there were
found to be
no abnormalities. Next, the femoral notch was identified and there was found under the complete
rupture of
his anterior cruciate ligament. The posterior cruciate ligament was probed and felt to be stable.
Next, the
medial compartment was identified and there was found to be areas of grade I and II
chondromalacia of the
medial femoral condyle. In addition, there is tearing of the posterior horn of the medial meniscus.
This was
in a red-white zone. A partial meniscectomy was performed with baskets and smoothed with a
shaver.
Next, the lateral compartment was identified and there was found to be no significant
chondromalacia.
There was a tear of the posterior horn of the lateral meniscus in the red-white zone and partial
meniscectomy was performed with baskets and smoothed with a shaver. Next, a notchplasty was
performed first removing the stump of the ACL with the shaver and then performed a notchplasty
with
curved gouges and a bur. Next, the Arthrex posterior cruciate ligament referencing guide was
placed into
the knee and a guidepin was placed up the tibia into the knee. This was overdrilled with a 10.5
mm drill bit.
Next, the over-the-top guide was placed and a Beath needle was placed through the tibial and
drilled up the
femur. The femoral side was overdrilled with a 10.5 mm drill bit. Next, a previously prepared
bone-tendon-bone allograft was placed through the tibia went into the femur. The femoral side
was held in
place with a bioabsorbable Arthrex screw. The knee was taken through range of motion and there
was felt
to be excellent isometry and there was no graft impingement on the roof. Next, knee was placed
in
approximately 30 degrees of flexion with a slight posterior drawer and a bioabsorbable Arthrex
screw was
placed in the tibial tunnel securing this into place. Upon completion, there was an excellent
endpoint with
Lachman. The knee joint was then copiously irrigated. Deep tissue was closed with 2-0 Vicryl
and the skin
was closed with 3-0 Vicryl. Steri-Strips were then applied. The patient tolerated the procedure
well. There
were no complications to the procedure. Estimated blood loss was minimal. Sponge and needle
counts
were correct x2 and the patient was taken to recovery room in stable condition.

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 CASE 10

PREOPERATIVE DIAGNOSIS: Right hip labral tear.

POSTOPERATIVE DIAGNOSES: 1. Right hip labral tear.

2. Right hip fibrous Cam
impingement.

PROCEDURES PERFORMED: 1. Right hip arthroscopy with

anterior two-anchor acetabular
labral repair.
2. Right hip arthroscopy with
femoral neck fibrous osteoplasty.

DESCRIPTION OF PROCEDURE: The patient was properly identified, brought to

the operating room, laid supine on the operating room table. After the anesthesiologist
applied appropriate anesthetic, 1 g of Ancef, she was positioned on hip arthroscopy table
with well-padded perineal posts and boots. The right hip was then prepped and draped in
the usual sterile fashion. Traction was applied. We had excellent distraction. Standard
anterolateral portal was then established followed by a mid anterior portal under direct
visualization. Diagnostic arthroscopy was performed and the above findings were noted.
Upon entering the joint, it was already noted that there could be seen tearing at the
chondral labral junction approximately at 1 o’clock area. There was some irritation at the
iliopsoas sulcus at the 1 to 2 o’clock area with extensive sublabral sulcus and instability
in this area. The tear then came out towards the 1 o’clock area towards the 2 o’clock area
at the chondral labral junction. At this point, we elected to proceed with a repair. There
was some synovitis and synovectomy was performed in this area. Small capsulotomies
were performed. We then brought in a meniscal rasp and the articular side of the
iliopsoas sulcus was rasped and debrided with a shaver to get good bleeding tissue. I
then placed a distal anterolateral portal. I placed one suture anchor on the iliopsoas
sulcus and one at approximately 1 o’clock area. These were pierced through the labrum
utilizing suture piercing device. These were then looped around the labrum and secured
nicely back down to the anatomic position, showing no separation of the chondral labral
junction. The rest of the femoral head cartilage was in excellent condition. There was a
little instability of the cotyloid fossa and this was debrided. Traction was then released
and the peripheral compartment was inspected. The seal nicely had been restored by
repair. Even at neutral, we were able to see some extra synovial fold tissue at the
head/neck junction. When coming up towards flexion, there was a significant
impingement of fibrous tissue that was bunching up in this area. A shaver was brought in
and extensive debridement, osteoplasty was performed at the fibrous area. Final pictures
were then taken. The area was evacuated of fluid. The portals were closed with nylon
and dressed with Xeroform gauze. The drapes were removed. The patient was awakened
and brought to the recovery room in stable condition. She tolerated the procedure well
without apparent complication.

CPT CODES:
CASE 11

PREOPERATIVE DIAGNOSES:
Left carpal tunnel syndrome.

POSTOPERATIVE DIAGNOSES:
Left carpal tunnel syndrome.

PROCEDURES PERFORMED:
Left endoscopic carpal tunnel release.

DESCRIPTION OF PROCEDURE: The patient was correctly identified in the

holding area, taken back to the operating room, and placed in the supine position.
General anesthesia was induced. A non-sterile tourniquet was applied to her left upper
arm and hand was prepped and draped in the usual sterile fashion. After confirming the
correct operative site, the arm was exsanguinated and the tourniquet was inflated to 250
mmHg.

A transverse incision was made in the volar wrist 1 cm proximal to the distal wrist crease,
just ulnar to the palmaris longus tendon going sharply through skin. The subcutaneous
tissue was dissected using tenotomy scissors down to the distal antebrachial fascia. This
was split transversely and the distal edge was picked up. The synovium was elevated off
of the underside of the distal edge using tenotomy scissors. Then, a synovial elevator
was used to sound the carpal tunnel, feeling the hook of the hamate down the ulnar side,
sweeping from proximal to distal and ulnar to radial, elevating the synovium off the
undersurface of the transverse carpal ligament, feeling the washboard texture of the
transverse carpal ligament. Next, the carpal tunnel was dilated using two sequential
dilators and a camera was inserted. The transverse carpal ligament was clearly visualized
with no subluxation of the nerve and no overlying synovium. The distal edge was
identified and the blade was deployed at this level. The scope was withdrawn to the
midportion of the transverse carpal ligament. The blade was then retracted and the scope
was reinserted. There were a few remaining fibers distally which were released by
redeploying the blade. Release was then continued from this midportion proximally by
redeploying the blade at the previous release level and withdrawing the scope out of the
wound, releasing the transverse carpal ligament under direct visualization. The camera
was then reinserted and inspection of the release was performed. There was adequate
release with no remaining fibers, and the nerve was also visualized and was in continuity
along its entire length. The camera was then withdrawn. The wound was irrigated with
normal saline irrigation. The skin was closed using a 5-0 nylon sutures.

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 CASE 12

PREOPERATIVE DIAGNOSIS:
Left ankle instability.

POSTOPERATIVE DIAGNOSIS:
Left ankle lateral instability.

PROCEDURES PERFORMED:
Left ankle open modified Brostrom repair of the lateral ligament of left ankle.

DESCRIPTION OF PROCEDURE:
The patient was properly identified and consent was obtained. The patient was taken to
the operating suite, placed supine on the operating table. 3 g of Ancef was given
preoperatively. The left lower extremity was exsanguinated. A lateral utility incision
was made along the peroneal tendons and distally curved anteriorly between the talus and
the distal fibula. Dissection was carried down carefully through the skin and
subcutaneous tissue. Hemostasis was maintained with electrocautery.
The deep fascia was cut in line with the incision. The retinaculum was identified and
cleaned freely. I then found the soft spot between the lateral talus and the distal fibula. I
made an incision in the retinaculum and capsule and anterior talofibular ligament leaving
a tag on both sides. Following this, I did a pants-over-vest technique of repair using #2-
FiberWire with locking figure-of-eight with the foot held in a dorsiflexed everted
position. I had an excellent repair using this technique. I also had opened a portion of
the peroneal retinaculum and had viewed the peroneal tendon. I did not appreciate any
significant tearing of the peroneal tendon. Following this, the wound was copiously
irrigated with sterile saline. I then closed all of the retinaculum and soft tissue. I then
copiously irrigated the wound. Subcutaneous was closed with 2-0 Vicryl, the skin with
Monocryl, and also supplemented with some nylon. Dressed with bacitracin, Xeroform,
4x4s, Kerlix, and a posterior splint in a slightly dorsiflexed everted position. The patient
was taken to Recovery in stable condition.

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CASE 13

PREOPERATIVE DIAGNOSIS: Left shoulder adhesive capsulitis.

POSTOPERATIVE DIAGNOSIS: Left shoulder adhesive capsulitis.

PROCEDURES PERFORMED: 1. Left shoulder manipulation under

anesthesia.
4. Left shoulder arthroscopy with
capsular releases and
debridement.

FIRST ASSISTANT: Katie Beckham, PA.

ANESTHESIA: General plus interscalene block.

ESTIMATED BLOOD LOSS: Minimal.

DRAINS: None.

SPECIMENS: None.

INDICATIONS FOR OPERATION: A 37-year-old female with significant past

medical history of kidney failure and transplant who has bilateral shoulder adhesive
capsulitis. She failed conservative measures, admitted now for manipulation under
anesthesia and diagnostic arthroscopy with releases. She expressed understanding of the
risks associated with the surgery including no guarantee of outcomes and agrees to
proceed.

DESCRIPTION OF PROCEDURE: After adequate general anesthesia was obtained,

an interscalene block had been placed in the left shoulder. The patient was placed in
right lateral decubitus position and held in position with a beanbag. Bony prominences
were well padded and axillary roll placed. We confirmed the left shoulder was the
operative site during time-out. Ancef was given preoperatively. We were unable to
elevate the arm to less than 90 degrees of abduction, manipulated to get to 170 to 180
degrees of elevation. Manipulation was real audible and palpable lysis of adhesions. We
were then able to fully internally and externally rotate the arm. The left upper extremity
was then prepped and draped in normal sterile fashion. I used a Spider device for lateral
traction. We did not put much pressure on the AV fistula in the left upper extremity.
Bony landmarks were noted on the skin with a skin marker. The needle was placed in the
glenohumeral joint and injected with normal saline. The scope was placed in the
shoulder. The articular surfaces were normal. The labrum was normal. The patient had
a capsular rent from the manipulation. Some tight capsule scarring anteriorly. Done with
debridement then we used the Arthrex wand and did releases of the anterior capsule and
removed all of the soft tissue in the rotator interval. Biceps was normal in appearance.
The undersurface of the cuff was normal in appearance. We removed the instruments.
Portals were closed with subcuticular 4-0 Monocryl. The wounds were dressed with
Mastisol, Steri-Strips, plain gauze, ABD pad, and tape. The patient tolerated the
procedure well and was stable en route to Recovery. She was placed into a sling. All
counts were correct. Katie Beckham was present throughout the case and provided
necessary assistance in preparing the patient, closing the wound at the end of the case.

CASE 14

PREOPERATIVE DIAGNOSES: 1. Left full-thickness rotator cuff

tear.
3. Left shoulder impingement.
4. Left AC arthrosis.

POSTOPERATIVE DIAGNOSES: 1. Left high-grade partial-thickness

bursal-sided rotator cuff tear.
2. Left shoulder impingement.
3. Left AC arthrosis.
4. Left superior labral tear from
anterior to posterior.

PROCEDURES PERFORMED: 1. Left shoulder arthroscopy with

arthroscopic rotator cuff repair.
5. Arthroscopic subacromial
decompression.
6. Arthroscopic distal clavicle
resection.
7. Arthroscopic debridement of
labrum.
8. Open biceps tenodesis.

ASSISTANT:

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Less than 100 cc.

COMPLICATIONS: None immediate.

SPECIMENS: None.

DRAINS: None.

OPERATIVE INDICATIONS: Lawrence Hatem is a 49-year-old gentleman who I

have been following for pain in the left shoulder as well as a known history of a right
rotator cuff repair several years ago. He is injured at work and a workup, which included
an MRI, showed a high-grade partial-thickness bursal-sided tear probably small full-
thickness component. After failing conservative options, given the presence of possible
full-thickness tear in the young patient, I recommended to proceed with the operative
repair. Preoperatively, the risks and benefits of the surgery including bleeding, infection,
vascular or neurologic injury, blood clots, heart attack, stroke, and death were all
discussed. The patient understood these risks and wished to proceed.

DESCRIPTION OF PROCEDURE: Mr. Hatem was correctly identified in the

preoperative holding area and informed consent was reviewed. He was transferred to the
operating theater by Anesthetic Service and placed supine on the operating table.
General anesthesia was administered by endotracheal tube. An interscalene block was
placed preoperatively. The left shoulder was examined under anesthesia. He had
forward elevation of 180 degrees, abduction 180 degrees, internal rotation 35 degrees,
abduction with external rotation was 90 degrees, and abduction with internal rotation was
90 degrees. There was no instability anteriorly or posteriorly. The patient was then
placed in the right lateral decubitus position. All bony prominences were padded. The
left shoulder and upper extremity were prepped and draped in surgical sterile fashion. A
time-out was performed by entire surgical team and the left shoulder was the operative
shoulder. A standard portal was created. Trocar was introduced into the joint. Routine
diagnostic scope was then performed. Examination of the humeral head and glenoid
showed essentially normal. There were no chondral lesions. The labrum was frayed
anteriorly and then superiorly it did peel off consistent with a superior labral tear from
anterior to posterior. An anterior portal was then created using outside-in technique. I
probed the labrum and I felt that it did not need a repair, but just debridement and then a
biceps tenodesis. There was also a partial-thickness cuff tear from the articular side,
which was debrided and again in that we could see that from the articular side, the cuff
appeared to be intact. We tied the biceps with #0 PDS using a spinal needle, kept the
biceps tendon insertion of the labrum and retained it for later tenodesis. After final
debridement, we removed the trocar from the joint and placed in the subacromial space.
Then, a lateral portal was then created using a combination of ArthroCare wand and an
oscillating shaver and did a subacromial decompression. We released the CA ligament,
identified the anterior and lateral aspects of the acromion. A large bone spur anteriorly
and there was very little space in the subacromial space and also the cuff itself was
impinging medially. So, there was significant amount of bursal tissue. There was no
obvious significant full-thickness tear, so we debrided all the bursa and released the CA
ligament with significant acromioplasty with a 5.5 mm bur used to bur down the anterior
acromion plus the posterior spine of scapula. That significantly opened up the space, to
allow more space for the cuff as well as more working room. Distal clavicle at this point
was then visualized and was found to be arthritic as expected by some preoperative
imaging. So, we put the cannulas in place, we started to débride and we could see that
there was a high-grade bursal-sided rotator cuff tear with exposure of the footprint, but it
was not complete. There were still some fibers most medially and that was still intact,
which corresponded to the articular sided examination of arthroscopy. So, we prepped
the tuberosity, put a single 4.5 mm BioComposite anchor and passed the sutures through
the cuff and then pulled over with two horizontal mattress stitches in the anterior limb
and posterior limb and pulled them down. We tied them down and then pulled over and
put a PushLock for modified SutureBridge configuration. Cuff was found to be down
without any evidence of a dog ear. We then turned our attention to the distal clavicle.
We then released inferior AC ligaments with ArthroCare wand and then burred down end
of the collar bone with a 5.5 mm bur. We removed about 10 mm of distal clavicle. They
both adequately decompressed and we removed all instrumentation from the subacromial
space. At this point, we then turned our attention to the biceps. The arm was brought out
of balanced traction and externally rotated, made about a 3 to 4 cm incision on the
anterior aspect of the shoulder. The incision was carried down through skin and
subcutaneous tissue. Flaps were elevated medially and laterally. We identified the
cephalic vein and mobilized it laterally with the deltoid. We opened up the deltopectoral
interval and released the CA ligament, incised the biceps tendon sheath, pulled the biceps
tendon out, prepared the groove and placed a single G4 anchor in the groove and passed
sutures through using a combination of locking sliding knot in a horizontal mattress
followed by tension on the biceps. We tied it down, cut the excess biceps tendon,
irrigated thoroughly, and closed the wound in layers with 2-0 Vicryl and then 3-0 nylon.
The portals were closed with 3-0 nylon. We placed sterile dressing, Adaptic, 4x4s,
ABDs, foam tape and a sling with adduction pillow. The patient was awakened and
transferred to the PACU in stable condition with no immediate complications. I
performed the entire procedure. Melissa Rogers assisted me. No residents were
available.

CPT CODES:

CASE 15

PREOPERATIVE DIAGNOSES: 1. Right anterior cruciate ligament

tear.
2. Possible lateral meniscal tear.

POSTOPERATIVE DIAGNOSES: 1. Right knee anterior cruciate

ligament tear.
2. Right knee radial tear of the root of
the posterior horn of the lateral
meniscus.

PROCEDURES PERFORMED: 1. Right knee arthroscopy with anterior

cruciate ligament reconstruction
using autologous quadriceps tendon
graft.
2. Right knee arthroscopy with lateral
meniscal repair.

ASSISTANT: Craig Callovini.

SURGEON:
ANESTHESIA: General with regional nerve block.

ANESTHESIOLOGIST:

ESTIMATED BLOOD LOSS: Less than 25 cc.

FLUIDS: 1300 cc of lactated Ringer's.

TOURNIQUET TIME: 130 minutes at 300 mmHg.

COMPLICATIONS: None.

DISPOSITION: To PACU in stable condition.

IMPLANTS: DePuy Mitek Truespan anchors x2 for

lateral meniscal repair and Arthrex ACL
TightRope for both femoral and tibial
fixation of ACL graft.

INDICATION FOR PROCEDURE: This 14-year-old young lady who presents with right knee
instability. MRI scan revealed complete anterior cruciate ligament tear with possible posterior
horn lateral meniscal tear as well. The risks, benefits, and alternatives were discussed with the
patient and her mother. Informed consent was obtained. She did test positive for 5/5 Beighton
signs of ligamentous hyperlaxity, therefore recommend autologous quadriceps tendon graft.
Informed consent was obtained.

PROCEDURE IN DETAIL: After verification and marking of the correct surgical site and
administration of regional anesthesia in the holding area, the patient was taken to the operating
room #1. After induction of general anesthesia, the patient was placed in the supine position. All
bony prominences were padded. The right knee was examined under anesthesia. She did have
significant hypermobility with approximately 15 degrees of knee hyperextension, symmetric with
the contralateral side. Lachman’s was 3+. Pivot shift was positive. Varus and valgus stress
testing was symmetric with the contralateral side. The right lower extremity was prepped and
draped in sterile fashion. A surgical time-out was performed. The right lower extremity was then
exsanguinated with an Esmarch bandage and a pneumatic tourniquet was inflated to 300 mmHg.
A small incision was made on the anterior aspect of the distal quadriceps tendon near its insertion
on the patella. Sharp dissection was carried out through the skin and subcutaneous tissue. The
fascia was identified. We then placed an elevator to sweep the fascia from the quadriceps tendon.
We used the arthroscope to direct this to the central portion of the tendon proximally and marked
this on the surface of the skin. We then used our 10 mm graft harvesting knife to harvest an
approximately 70 mm x 10 mm strip of quadriceps tendon. This was then passed off to the
technician on the back table who prepared the graft by incorporating the TightRope devices
utilizing FiberTape suture. We incorporated the TightRope devices. The graft was measured. It
measured 10 mm in diameter in its smallest portion at the midpoint, however, it was 11 mm at the
end. We then selected 11 mm for our tunnel diameter. While this was being prepared, diagnostic
arthroscopy was performed after closure of the harvest site. The harvest site was closed with #0
Vicryl followed by 3-0 nylon for the skin. We then placed the arthroscope through an
inferolateral portal. Tour of the knee revealed the following findings. The suprapatellar pouch
was free of loose bodies. The articular cartilage on the patella and trochlea were both pristine.
The medial compartment revealed pristine articular cartilage on the medial femoral condyle and
medial tibial plateau. Medial meniscus was intact and later found to be stable to probing. The
intercondylar notch was stenotic. The PCL was intact. The ACL was completely torn. The
stump was noted on the tibial side. The lateral compartment revealed pristine articular cartilage
on lateral femoral condyle and lateral tibial plateau. The lateral meniscus had a radial tear near
the insertion of the root. Remainder of the meniscus was intact. An inferomedial portal was
created. A partial synovectomy was performed. We then repaired the meniscus with two
Truespan anchors in mattress fashion, which essentially gave us a side-to-side closure of this
radial tear. This was probed and found to be stable. We then performed a notchplasty to
accommodate our 11 mm graft. Once satisfied with this, we then placed the femoral aiming
device through the inferolateral portal and brought our FlipCutter in and placed the FlipCutter at
the insertion site of the ACL and the femur. We then reamed 11 mm socket by approximately 20
to 25 mm deep. We then removed excess bone. We passed the shuttling suture. We then placed
the arthroscope back in the inferolateral portal and through the inferomedial portal placed our
tibial aiming device. We brought this FlipCutter into the remnant of the ACL stump on the tibial
side. This was a good landmark for referencing. We brought this right up in the center. We then
reamed an 11 x 30 mm deep socket. We then removed excess soft tissue from around the tunnel.
We then shuttled the femoral end of the graft with the femoral TightRope device. Once the
button was deployed on the lateral femoral cortex, we used the TightRope to cinch the graft into
the femoral socket. We then shuttled the tibial end of the graft into the socket and cycled the
knee through a range of motion 20 times. We placed the knee in full extension with the slight
posterior drawer in the tibia and then deployed our tibial button on the tibial cortex and cinched
the tibial TightRope. Lachman’s was eliminated as was pivot shift. She still had quite a bit of
hyperextension. We then irrigated the joint. We confirmed that we were not impinging in
flexion or extension. We then closed the arthroscopy portals and small incisions with 3-0 nylon
for the skin. Sterile dressings were applied followed by hinged knee brace. The patient tolerated
the procedure well and was taken to the Postanesthesia Care Unit in stable condition.

CPT CODES:

CASE 16

PREOPERATIVE DIAGNOSIS: Left knee medial meniscus tear.

POSTOPERATIVE DIAGNOSES: 1. Left knee medial meniscus tear.

2. Lateral femoral condyle,
chondromalacia of grade III and
IV.

PROCEDURES PERFORMED: 1. Left knee arthroscopy with

partial medial meniscectomy.
2. Abrasion arthroplasty and
chondroplasty of lateral femoral
condyle.

ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.

DRAINS: None.

SPECIMENS: None.

TOURNIQUET TIME: Approximately 26 minutes at 300

mmHg.

INDICATIONS FOR OPERATION: A 52-year-old male with ongoing knee pain

following on-job incident. He had failed conservative measures. MRI suggested medial
meniscus tear. Because of his ongoing pain despite appropriate conservative care, the
patient is admitted now for diagnostic arthroscopy and treatment pathology was
identified. He expressed understanding of the risks, especially with the surgery including
no guarantee of outcomes and agrees to proceed.

DESCRIPTION OF PROCEDURE: After adequate general anesthesia was obtained,

the patient was placed supine on the table. The tourniquet was placed on the left upper
thigh. The left lower extremity was exsanguinated and tourniquet inflated to 300 mmHg.
The left thigh was then placed in leg holder and the end of the bed flexed down and was
allowed the leg to dangle free. The left lower extremity was then prepped and draped in
normal sterile fashion. Ancef was given prior to tourniquet inflation. We identified the
left knee as the operative site during time-out. The anterolateral portal was established
for inflow. We passed the arthroscope. An anteromedial portal was established under
direct vision. Attention was turned medially. The patient had mild amount of
chondromalacia grade II on the medial femoral condyle. We did a chondroplasty using a
shaver with that. Posteriorly, he had a flap tear of posterior horn of the medial meniscus.
Using the biter and shaver, we removed the meniscal tear, resecting about 40% and
removed the meniscus. The ACL was intact to visualization and probing. The lateral
compartment and meniscus was intact. On the anterior aspect of lateral femoral condyle,
there was area of grade III and even grade IV chondromalacia. Patellofemoral joint itself
was normal in appearance. We laterally debrided the edges using a shaver. We did
abrasion arthroplasty in the central portion of the lesion till bleeding bone. The lesion
measured well over centimeter in size. We then irrigated the knee thoroughly.
Instruments were removed. The portals were closed with subcuticular 4-0 Monocryl.
The knee was injected pre and postoperatively with Marcaine and morphine mixture.
The wound was dressed with Mastisol, Steri-Strips, plain gauze, cast padding, and Ace
wrap. The patient tolerated the procedure well and was stable en route to Recovery.

CPT CODES:

CASE 17
PREOPERATIVE DIAGNOSIS: Left medial femoral condyle
osteochondral lesion.
POSTOPERATIVE DIAGNOSIS: Left medial femoral condyle
osteochondral lesion.
PROCEDURES PERFORMED: 1. Left knee arthroscopically-
assisted fixation of medial
femoral condyle OCD lesion.
2. Retrograde drilling of left knee
OCD lesion (arthroscopic).
ASSISTANT: None.
ANESTHESIA: General.
SPECIMENS: None.
DRAINS: None.
DRESSING: Soft sterile with hinged knee brace
locked in extension.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CONDITION: The patient leaving the operating
room stable.
FINDINGS:
1. On preoperative examination under anesthesia, the patient had no gross deformity
about the left knee. She had a small effusion. Knee range of motion was 0 to 140
degrees. The knee was stable to varus and valgus stress as well as Lachman and
posterior drawer.
2. Left knee medial femoral condyle OCD lesion adjacent to intercondylar notch. The
lesion measured approximately 1 cm x 1 cm. There was a bulging of the articular
cartilage at the side of the lesion consistent with instability, but there was no fracture
line extending through the articular cartilage.
3. Patellofemoral compartment and lateral compartment articular cartilage intact.
4. Cruciate ligaments intact.
5. Medial and lateral menisci intact.
6. One Acutrak screw in good position postoperatively (please see intraoperative
fluoroscopy).
OPERATIVE INDICATIONS: The patient is a 10-year-old female who has been
followed in the Wake Orthopedics’ office for worsening left medial knee pain and
mechanical symptoms. Her initial exam was concerning for a meniscal tear. MRI
demonstrated a medial femoral condyle OCD lesion with undermining of the
osteochondral fragments consistent with developing instability. Given the unstable
appearing OCD lesion and worsening mechanical symptoms, I recommended
arthroscopic evaluation and arthroscopic versus open fixation of the osteochondral lesion.
I also recommended possible retrograde drilling depending on intraoperative findings.
Surgical risks including pain, bleeding, infection, stiffness, nonunion of the osteochondral
fragment, reaction to anesthesia, progressive knee DJD and need for further surgery
including a possible cartilage restoration procedure were discussed. Consent was signed
and witnessed prior to the procedure.
DESCRIPTION OF PROCEDURE: The patient was identified preoperatively and all
questions were answered. The operative site was marked. She was taken to the operating
room and general anesthesia was induced. After time-out, confirming the operative site
and administration of IV antibiotics within one hour of incision time, the left lower
extremity was examined under anesthesia and then prepped and draped in the usual
sterile fashion over a tourniquet. The tourniquet was elevated at 250 mmHg. A
#11-blade scalpel was used to make routine anterolateral and anteromedial arthroscopy
portals. The arthroscope was introduced. The knee was insufflated. Diagnostic
arthroscopy of the knee including the suprapatellar pouch, patellofemoral articulation,
medial and lateral gutters and compartments, and intercondylar notch was performed with
the above findings. The patient was noted to have a 1 cm x 1 cm bulging of the articular
cartilage of the medial femoral condyle adjacent to the intercondylar notch consistent
with her OCD lesion. There was no obvious fracture penetrating the articular cartilage.
The lesion was ballotable consistent with instability. The remainder of the articular
cartilage, cruciate ligaments and menisci were intact. The spinal needle was used to
localize placement of a transpatellar tendon portal that was made using a #11-blade
scalpel. The guidewire for an Acutrak 2.7 mm screw was then placed through the
transpatellar tendon portal at the center of the OCD lesion and advanced using
fluoroscopy to the level of physis. Position was confirmed on AP and lateral fluoroscopy
views. The guidewire was overdrilled and a 22 mm x 2.7 mm Acutrak screw was
advanced over the guidewire. Fluoroscopy demonstrated that the screw was in good
position and remained distal to the femoral physis. The screw was advanced
approximately 4 mm beneath the articular cartilage. The guidewire was removed. An
ACL guide was then used to guide placement of a 2 mm drill bit that was placed through
a 1 cm medial stab incision and used to perform a retrograde drilling of the OCD lesion.
Final fluoroscopic and arthroscopic images were obtained. The wounds were then re-
approximated with 3-0 nylon suture. The tourniquet was let down. Soft sterile dressings
were applied. Drapes were removed. Anesthesia was reversed. The patient was taken to
the Postoperative Recovery in stable condition.

CPT CODES:

CASE 18
PREOPERATIVE DIAGNOSIS: Left wrist pain.

POSTOPERATIVE DIAGNOSIS: Left wrist pain.

PROCEDURES PERFORMED: Left wrist arthroscopy with joint and

TFCC debridement.

COUNTS: Correct.

CONDITION: Stable.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Minimal.

INDICATIONS FOR PROCEDURE: Brianna is a 16-year-old female with a

longstanding history of pain along the ulnar aspect of her left wrist. Conservative
treatment options including corticosteroid injections given her temporary relief only.
Risks and benefits of proceeding with a wrist arthroscopy with joint debridement were
discussed and she elected to proceed at this time.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room,

supine on a stretcher. All bony prominences were carefully padded. Sedation was
induced by the Anesthesia Team. A regional block had been performed preoperatively
by the Anesthesia Team as well. Antibiotics were given. A tourniquet was placed on the
left upper arm. The arm was prepped and draped in the usual sterile fashion. A time-out
was performed. The arm was placed into a wrist traction tower with 12 pounds of
pressure applied through fingertraps. The arm was exsanguinated with an Esmarch
bandage and the tourniquet was inflated. A 3-4 portal was localized using a #18-gauge
needle. The joint was insufflated with 3 cc of normal saline. A portal was then made
using a #15-blade through the skin and a blunt hemostat through the joint capsule. A
trocar was placed through this portal. The camera was placed through the trocar. The 4-
5 portal was made using a similar needle localization technique. A diagnostic wrist
arthroscopy was performed. All of the cartilage surfaces appeared normal. The SL
ligament appeared normal. The volar wrist ligaments appeared normal. There was some
synovitis along the dorsal and ulnar aspect of the wrist joint. There was also a central
TFCC tear. The TFCC tear was debrided back to a stable rim using a shaver and
radiofrequency ablator. The ulnar synovitis was also debrided using a shaver and
radiofrequency ablator. At the conclusion of these debridements, final pictures were
taken. The instruments were removed from the radiocarpal joint. A radial midcarpal
portal was made using a similar needle localization technique. A diagnostic midcarpal
arthroscopy was performed. All the cartilage surfaces appeared intact. The SL and LT
intervals were well reduced with no step-offs or gaps. The instruments were removed.
The portals were closed using 4-0 nylon. A volar cockup splint was placed. The
tourniquet was deflated and the patient was taken to the PACU in stable condition.
CPT CODES:

CASE 19

PREOPERATIVE DIAGNOSES: 1. Right tibiotalar arthritis.

2. Right ankle loose body.
3. Right talus osteochondral defect.
4. Right lateral ankle instability.

POSTOPERATIVE DIAGNOSES: 1. Right tibiotalar arthritis.

2. Right ankle loose body.
3. Right talus osteochondral defect.
4. Right lateral ankle instability.

PROCEDURES PERFORMED: 1. Right ankle arthroscopy with

extensive debridement and
anterior cheilectomy.
2. Right ankle loose body, 15 mm x
15 mm x 8 mm excision.
3. Right lateral talar dome
osteochondral defect
microfracture.
4. Right lateral ankle ligament
Brostrom-Gould reconstruction.

ANESTHESIA: General with popliteal nerve block.

TOURNIQUET TIME: 96 minutes at 250 mmHg and then

let down for 20 minutes and then
inflated back up for a 45 additional
minutes.

INDICATIONS FOR PROCEDURE: Rolando is a 46-year-old male, who initially

injured his right ankle while he was on tour for military duty in August of 2004. He
neglected his ankle at that time, however, he has had considerable worsening symptoms
in his ankle including sensations of instability and his ankle giving way as well as
popping and catching in the ankle. He was found radiographically and on MRI to have a
large osteochondral loose body in the anterior joint as well as evidence of arthritic
changes throughout the joint with medial and lateral osteochondral lesions. Additionally,
on examination, he demonstrated a significant laxity of the lateral ankle ligament.
Therefore, he was deemed an operative candidate for the above procedure. The risks and
benefits were explained including, but not limited to pain, bleeding, infection, damage to
neurovascular structures including arteries, nerves and veins, failure of treatment and
need for additional surgery in the future as well as risks of general anesthesia including
heart attack, stroke and/or death and risks in the perioperative period including blood
clots and/or pulmonary embolism. The patient demonstrated clear understanding and
agreed to proceed.

PROCEDURE IN DETAIL: The patient was brought to the operating suite. The
anesthesiologist was placed a popliteal nerve block under ultrasound guidance. The
patient was then transitioned supine on the operating room table and placed under
anesthesia. All bony prominences were well padded. The right lower extremity was then
sterilely prepped and draped in the usual fashion. A time-out was performed to identify
appropriate person, limb and procedure with all parties in agreement. The patient
received 2 g of IV Ancef for perioperative infection prophylaxis. An Esmarch was used
for exsanguination followed by inflation of a well-padded thigh tourniquet to 250 mmHg.
The foot was then placed in the foot holder and the ankle joint was distracted. The ankle
was insufflated with sterile saline. Standard anteromedial portal was then made. The
arthroscopic camera was advanced within the joint. Under direct visualization,
anterolateral portal was made with care to avoid the palpable superficial peroneal nerve.
A diagnostic arthroscopy was then performed. There was extensive fibrosis and synovitis
at the anterior ankle joint line. This was debrided with an arthroscopic shaver. There
was significant debris within the medial and lateral gutters as well, which was cleaned up.
The medial gutter demonstrated full-thickness cartilage loss at the medial aspect of the
talus with a loose cartilage flap displaced posteriorly. This was debrided with the
arthroscopic shaver. There was no discrete osteochondral lesion identified medially.
There was however an osteochondral defect noted laterally, which measured
approximately 10 mm x 5 mm. This was debrided to stable rim of cartilage with a
curette. Microfracture was then performed with a microfracture pick. There were bone
marrow elements emanating from beneath the subchondral surface. Remainder of the
joint demonstrated significant arthritic changes with grade II-III cartilage wear. Attention
was then directed to the anterior joint line. Significant spurring at the distal tibia was
taken down with combination of the arthroscopic shaver and arthroscopic bur. Adequate
cheilectomy was demonstrated on fluoroscopy as compared to prior images. Lastly, the
large osteochondral loose body was identified within the anterior portion of the joint.
The anteromedial portal was extended to accommodate excision of the large loose body.
The loose body was retrieved and excised. It measured approximately 15 mm x 15 mm x
8 mm. The joint was then evacuated of the arthroscopic fluid. At this point, the
tourniquet was let down. The portals were closed with 2-0 Monocryl for the deeper layer
and 3-0 nylon for the skin. Attention was then directed to the lateral ankle with a direct
incision made over the distal fibula. Approach identified the inferior extensor
retinaculum, which was preserved for the planned Gould reconstruction. The ATFL and
CFL ligaments were released from the tip of distal fibula and elevated from the bony
surface. The tip of the distal fibula was decorticated with a rongeur to provide a healthy
bleeding surface for the repair site. With the ankle then placed in maximal eversion, the
ATFL and CFL ligaments were then repaired with imbrication in pants-over-vest fashion
using 2-0 Ethibond. A second layer to the repair using 2-0 Ethibond was then performed,
lastly again with the hindfoot in maximal eversion. The inferior extensor retinaculum
was advanced superiorly onto the distal fibula for the Gould modification. This was
repaired with 2-0 chromic suture following the Brostrom-Gould reconstruction. There
was significant restoration of stability to inversion talar tilt and anterior drawer. The
wound was then irrigated with sterile saline and closed with 2-0 Monocryl for the dermal
layer and 3-0 nylon for the skin. A sterile dressing with Xeroform, 4x4, Sof-Rol and a
well-padded bulky splint was provided. The patient was then awoken, extubated and
exited the operating suite. No complications were encountered.

CPT CODES:

_________________________________THE END_____________________________