Operative Note Report Sample:

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OPERATIVE NOTE

DATE OF OPERATION:  09/05/12
PREOPERATIVE DIAGNOSIS:
Right hallux limitus, right foot. 
Superior DJD with osteophytic changes, right first MPJ   
POSTOPERATIVE DIAGNOSIS:

Right hallux limitus, right foot. 
Superior DJD with osteophytic changes, right first MPJ 
OPERATIVE PROCEDURE:
Exostectomy of right first MPJ.
Subchondral drilling of damaged articular surface, first MPJ right foot.
SURGEON: Harry Richard, M.D.
ASSISTANT: Pamela Walker, D.P.M 
ANESTHESIA: MAC with local.
HEMOSTASIS: A pneumatic right ankle tourniquet set at 250 mmHg.
MATERIALS: 3-0 Vicryl, 4-0 Vicryl, 4-0 nylon
ESTIMATED BLOOD LOSS: Less than 10 cc 

JUSTIFICATION FOR PROCEDURE:  This is a 52-year-old male who presented to the Leon Medical Clinic and was treated by Dr. Azucena Lapan for painful bony proliferation and limited joint range of motion of the patient’s right first MPJ.  Upon clinical evaluation Dr. Caban took x-rays and reviewed the osteoarthritic changes and the osteophyte that was seen on the first metatarsal dorsally.  It was reviewed with the patient the likelihood for conservative treatment to be unable to completely resolve his problem.  The patient was to explore less conservative measures.  Surgery was reviewed.  The patient was explained that there would be a small bone cut, taking away the sharp bony proliferation and there would be an incision on the dorsal aspects of his foot.  There would be minimal chance of decrease range of motion for anywhere from 2-4 months status post procedure.  The patient understood all risks and benefits of the procedure and wished to continue with the procedure.  Preoperative medical clearance was obtained from the patient PCP.

PROCEDURE IN DETAIL:  Under mild sedation the patient was brought in the Operating Room, placed on the operating table in the supine position.  Following induction of monitored anesthesia care, local anesthesia was obtained.  The patient’s right first utilizing 16 cc of 1:1 mixture of 1.0% Xylocaine plain and 0.5% Marcaine plain.  The patient’s foot was than scrubbed prepped and draped in usually aseptic fashion.  Esmarch bandage was used to exsanguinate the patient’s right foot and the pneumatic ankle tourniquet was set 250 mm Hg.  A skin scriber was used to outline an incision over the first MPJ that was approximately 6 cm in length.  It was over the central aspect just medial to extensor hallucis longus.  A #15 blade was used to make an incision down the epidermis and dermis being careful not to violate the extensor hallucis longus.  All bleeding structures that are encounter were ligated as deemed necessary.  Sharp and blunt dissection was carried out to level of the capsular tissue.  Immediately, there was noted to be a very firm presentation of the capsular tissue consistent with chronic synovitis.  A #15 blade was used to make capsular and periosteal incision over the dorsal aspect of the first MPJ in which the medial collateral ligament was now explored.  There was noted to be a large prominent osteophytic lipping of the dorsal aspect of the first MPJ.  There was noted be an intraosseous joint mice/loose bodies attached to the dorsal aspect of the proximal phalanxes.  There was noted to be degenerative changes to the dorsal one-third of the first MPJ articular surface.  At this time, a #38 blade was used to resect the exostosis of the dorsal aspect of the first metatarsal.  All rough edges that were seen in the medial dorsal and lateral aspect of the MPJ with a smooth utilizing power rasp.  A rongeur was also used at this time, to debride any sharp osteophytic lipping of the base of the proximal phalanx.  The wound was then flushed with copious balanced salt saline and the McClamary elevator was used to free up any plantar capsular adhesions.  The first MPJ was brought through a range of motion.  There was noted to be a drastic increase in range of motion.  A 4/5 K-wire was used at this time to place approximately 8 holes, utilizing a 4/5 K-wire a.k.a. subchondral drilling into the dorsal one-third of the first metatarsophalangeal joint. 

Next, the wound was then also flushed with copious amounts of normal saline.  It was explored to make sure there were not any loose bony artifacts in the first MPJ.  The capsule and periosteum was closed utilizing 3-0 Vicryl.  Deep dermis was closed utilizing 4-0 Vicryl and the skin was closed utilizing 4-0 nylon.  The patient’s foot was then scrubbed with a wet and dry Ray-Tec.  Betadine soaked with Baciguent was the placed over the incision site.  Then 4 x 4 Ace, Coban and Kling were placed around the patient’s right foot.  The pneumatic ankle tourniquet was dropped at the time and there was noted to be a prompt hyperemic response to all digits of the right foot with adequate capsule time of digits 1-5.  The patient was then transferred from Operating Room to PACU with all vitals sable and vascular status intact and all areas of the right foot.  The patient received the following postoperative instructions.  To remain partial weight bearing while wearing only postoperative shoe on the right heal.  The patient will be given crutches if deem necessary.  The patient is given a prescription with p.o. antibiotics and p.o. pain medication.  The patient will follow-up with Dr. Gregorio Caban in the postoperative Leon Medical Clinic.  The patient is instructed to keep the bandage clean, dry, and intact.