Operative Report Sample:

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OPERATIVE REPORT

DATE OF OPERATION:  01/06/12
PREOPERATIVE DIAGNOSIS: Right knee medial meniscal tear. 
POSTOPERATIVE DIAGNOSIS:
Right knee medial meniscal tear osteochondral defect medial femoral condyle. 
OPERATIVE PROCEDURE:
Right knee arthroscopic partial medial meniscectomy, chondroplasty medial femoral condyle 
SURGEON: Harry Richard, M.D.
ASSISTANT: Pamela Walker, C.R.N.A.
ANESTHESIOLOGIST: Caroline Moss, M.D.  
ANESTHESIA: General.
TOURNIQUET: Tourniquet x 45 minutes.
ESTIMATED BLOOD LOSS: 25 cc.
COMPLICATIONS: None.

SURGICAL TECHNIQUE:  Patient was in the supine position under general anesthesia.  Patient received prophylactics antibiotics prior to the surgical procedure.  A tourniquet was placed around the right thigh area.  The right lower extremity was placed in a leg holder.  The right lower extremity was draped and prepped in the usual standard fashion.  At the beginning of the procedure, the tourniquet was inflated up to 300 mm Hg.  Using a scalpel, a stab wound incision was done at the superomedial aspect of the right knee for insertion of the in-flow cannula.  The knee joint was distended.  Using a scalpel, a stab wound incision was done in the inferolateral aspect of the right knee for insertion of the camera.  The first compartment was the patellofemoral.  There was high-grade chondromalacia in the patellofemoral compartment with fraying of the cartilage with some areas of degeneration

Then the medial gutter was inspected with no evidence of loose bodies.  The medial compartment was inspected.  There was osteochondral defect in the medial femoral condyle of approximately 2 x 2 cm.  In addition, there was a complex degenerative tear of the medial meniscus posterior horn throughout the body.  There was also loss of cartilage at the tibial plateau.  Under direct visualization, the inferomedial portal was done.  The probe was inserted for inspection of the area.  Several photographs were taken as evidence of our intraoperative findings and procedures.  A partial meniscectomy was done using meniscal biters and the meniscal cutter.  Then the chondral defect was debrided using the meniscal cutter for exposure of the subchondral bone.  The subchondral bone then was debrided and also several holes were done using the fracture pick until the cruciate ligament was present and patentThe lateral compartment was intact with no evidence of meniscal tears or cartilage damage.  Patellar gutter was inspected with no evidence of loose bodies.  The tourniquet was released and the osteochondral defect was evaluated.  There was active bleeding through the holes made with the fracture pick.  Several photographs were taken as evidence of out intraoperative findings.  The knee joint was drained and the instruments were removed. 

Portal wounds were approximated with 3-0 nylon.  The knee was injected with 25 cc of plain Marcaine 0.50%.  Sterile dressing was applied over the surgical wound.  The tourniquet was released during the procedure.  Patient was taken to the Recovery Room after extubation in stable condition with no complications during or after the procedure.