op note posted
Here's the op note:
PREOPERATIVE DIAGNOSES
1. Left distal tibial pelon fracture, closed, intra-articular,
displaced.
2. Status post external fixation, left lower extremity.
3. Late complications of trauma, left lower extremity.
POSTOPERATIVE DIAGNOSES
1. Left distal tibial pelon fracture, closed, intra-articular,
displaced.
2. Status post external fixation, left lower extremity.
3. Late complications of trauma, left lower extremity.
PROCEDURE
1. Open treatment, left distal tibial pelon fracture with internal
fixation, (27827).
2. Removal of deep hardware, left tibia, (20680).
3. Removal of deep hardware, left calcaneus, (20680).
4. Removal of deep hardware, left first metatarsal, (20680).
5. Removal of deep hardware, left fifth metatarsal, (20680).
6. Curettage, left tibia, (27635).
7. Curettage, left calcaneus, (28180).
8. Curettage, left worse first metatarsal, (28104).
9. Curettage, left fifth metatarsal, (28104).
10. Vitagel soft tissue autograft insertion, left ankle wound (20926).
Stable to the Post Anesthesia Care Unit.
INDICATIONS
The patient is a 35-year-old male who was seen previously with a
work-related injury. He was pinned against the machine and a wall. He
had an open grade 1 distal fibula fracture and a distal tibial patella
fracture. These were displaced. Due to the open nature of the injury,
he was taken emergently for surgery of the ankle. The lateral ankle
wound had an irrigation and debridement with a formal ORIF of the
distal fibula. The wound was very clean. The wound looked very good in
the office recently. There were no signs of infection. He has been
healing well. We did place on external fixator of the left lower
extremity, reducing the distal tibia. A CT scan was taken. There was
intra-articular extension with 3 main fragments of the distal tibia.
This was satisfactorily reduced with external fixation. It has been
over a week and the patient's pain and swelling has decreased
significantly. We did schedule him for a formal removal of hardware, as
well as ORIF the left distal tibial pelon. The risks and benefits,
complications were reviewed, and appropriate consent was obtained. The
patient want to proceed with surgery.
DESCRIPTION OF PROCEDURE
The patient was seen in the preoperative holding by the department of
orthopedics and anesthesia, at which time we identified the left lower
extremity as the appropriate extremity for the procedure. I placed my
initials on the extremity for identification. He was given IV
antibiotics preoperatively for prophylaxis. He refused a preoperative
block by anesthesia. He was taken back to the OR suite, and placed
supine on a well-padded table. He was placed under general anesthesia
without complication. A well-padded tourniquet was placed on the left
upper thigh. The external fixator was removed first from the tibia
using the wrenches and undoing the clamps from the Stryker-Hoffman
frame. Next, the pin through the calcaneus was removed deeply from bone
using a T-handled chuck after cutting the pin on 1 side of the
calcaneus. Next, a T handle was used to remove the hardware from the
first metatarsal with the T-handled chuck. The deep hardware from the
5th metatarsal was then removed again with a T-handled chuck. Once the
hardware was removed, the extremity was sterilely prepped and draped in
the normal fashion. I did place separate drapes over the leg and
curetted out deeply, the tibia first and then the calcaneus, and then
the 5th and 1st metatarsals. These were curetted out and then irrigated
out extensively. I then placed Ioban over these holes to not
contaminate the distal tibial level open reduction and internal
fixation. Once these were cleaned and covered, the drapes were removed
and the new drapes were placed over the leg. The leg was elevated, and
the tourniquet was inflated to 350 mmHg. A skin incision was made over
the medial malleolus. Blunt dissection was taken up to the medial
aspect of the distal tibia. A short distal tibial locking plate by
Synthes was placed up the medial malleolus and the tibial shaft. A pin
was placed distally through the plate as well as proximally. The plate
was used to reduce the fracture. This was viewed under fluoroscopy and
felt to be adequate. There was a fracture also between the anterior and
posterior tibial articular surfaces. A clamp was placed on these
articular fragments holding them together. One screw was placed through
the plate distally with a 3.5 fully-threaded cortical screw, compressing
the medial and lateral fracture fragments. This was done in the lag
manner over drilling the proximal cortex. Another cortical screw was
placed proximally pulling plate to the shaft. I did make a small
incision of the skin and a 3.5 fully-threaded cancellous screw to obtain
a good bite was placed through the anterior and posterior fragments
articular surface in a compressive manner. Blunt dissection was taken
down to bone and then the 2.5-mm drill was used and the appropriate
length screw was placed in. The proximal cortex was over reamed for
compression. This held this piece nicely. Again, fluoroscopy was used
and the reduction was satisfactory with good position of the hardware.
I then filled the remaining screws with locking screws using the guides
and then drilling, and measuring the appropriate size length. Once this
was completed, the pins were removed. Final x-rays were taken. There
was satisfactory alignment of the distal tibia with good position of
hardware. The wound was copiously irrigated out with normal saline.
The deep tissue was closed with 0 Vicryl. The superficial tissue was
closed with 2-0 Vicryl and staples were placed on the skin. Local
anesthetic was injected. The Vitagel soft tissue autograft processed
with the patient's blood for postoperative hemostasis and potential
healing was injected deeply. Sterile dressing was applied as well as a
posterior splint with a sugar-tong. The tourniquet was released, and
the patient awakened from anesthesia without complication and
transferred to the Post Anesthesia Care Unit in stable condition.
