Thursday, November 24, 2011

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Removal of deep implant (OP Report Sample)


PREOPERATIVE DIAGNOSIS: Symptomatic retained hardware, status post open ankle fracture dislocation right ankle.

POSTOPERATIVE DIAGNOSIS: Symptomatic retained hardware, status post open ankle fracture dislocation right ankle.

OPERATIONS PERFORMED: Removal of deep implant. Incisions right ankle.

OPERATION: Patient was taken to the operating room, and after induction of general anesthesia with laryngeal mask intubation, the right lower extremity was prepped and draped in the usual fashion.  A tourniquet was applied prior to prepping and draping for total tourniquet time at 300 mmHg; please refer to the nurse's notes.  A safety time-out was performed, and the patient was properly identified.  After exsanguination, tourniquet was elevated. The previous lateral approach was used.  Skin and subcutaneous tissues were divided.  We elevated peroneal musculature posteriorly off of the fibula exposing the fibular plate.  We removed the screws without difficulty and the plate without difficulty, curetted and rongeured the holes and irrigated.  This was closed in the usual layered fashion.  On the medial side because of the irregular horizontally oriented traumatic laceration, a separate longitudinal laceration centered between the 2 screws was performed instead.  Skin and subcutaneous tissues were divided.  There was extensive scar tissue in this area, some of which was debrided.  The screw heads were identified, were removed, and the wound was irrigated and closed in the usual layered fashion.  Care was taken to protect the saphenous nerve and vein throughout the case.  The wounds were closed.  Xeroform, sterile dressings were applied followed by an Ace bandage.  Tourniquet was deflated.  Patient was aroused, extubated, and taken to recovery room in stable condition.  Final sponge and needle counts were correct.

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