CAN YOU ONLY CAPTURE THIS ONCE FOR THE 20680??
Retained hardware, right ankle with malunion of bimalleolar ankle fracture, rule out infected nonunion.
POSTOPERATIVE DIAGNOSIS: Retained hardware, right ankle with malunion of bimalleolar ankle fracture, rule out infected nonunion.
PROCEDURE: Removal of hardware, right ankle, from medial malleolus and distal tibia with multiple bone cultures to rule out osteomyelitis.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: 40 minutes.
SPECIMENS: Multiple cultures from the right ankle.
CLINICAL NOTE: This is a 65-year-old woman who had a bimalleolar right ankle fracture dislocation treated by a doctor in Florida. She had two operations, one for the initial ORIF, and another for revision ORIF secondary to hardware failure and loss of fixation. The patient developed postoperative infection and was treated with antibiotics through a PICC line and then with oral antibiotics, and her soft-tissue wounds eventually healed, but she has pain now from prominent hardware. The medial malleolar screw was backing out, and there are multiple loose screws in the distal fibula as well. After a lengthy discussion regarding treatment options, it is elected to remove the hardware and perform multiple bone cultures to rule out infected nonunion. Depending on the results of the bone cultures devise more definitive care at a later date. Informed consent was obtained prior to coming to the operating room.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating room table where general anesthetic was administered by the Anesthesia Department. One gram of Kefzol was administered intravenously. The tourniquet was placed on the right calf. The foot was prepped and draped in the usual sterile fashion, exsanguinated with an Esmarch, and the tourniquet inflated to 250 mmHg. A 2 cm incision was made on the medial aspect of the ankle where the palpable screw in the medial malleolus was encountered very superficially in the ankle. Dissection was carried out down to the medial malleolar cortex. The screw was removed, and curettes were used to culture the bone tissue. This material was sent for culture sensitivity as well as histopathology to rule out osteomyelitis. This wound was copiously irrigated and closed with 4-0 nylon suture. An incision was then made on the lateral aspect of the ankle using the previous surgical incision from the tip of the fibula proximally about 6 cm and carried down sharply through skin and subcutaneous tissues and fascia and then directly down to the lateral fibular cortex where there was encountered two small fragment plates from a manufacturer not readily recognized, one anteriorly and one laterally. The multiple screws were loosened and backing out into the soft tissue. All screws were easily removed, and the plates were removed with an elevator. Inspection then indicated that there was a fibrous nonunion of the distal fibular fracture as well with gross motion noted upon varus/valgus stress of the ankle. Soft-tissue debridement was performed, and the wound was copiously irrigated and then closed with 0 Vicryl in the fascia, 2-0 Vicryl in subcutaneous tissues, and surgical skin staples in the skin. Then, 0.5% plain Marcaine was infiltrated in the incisions for postoperative analgesia, and then the wounds were dressed with Adaptic, dry sterile dressings, and a well-padded, nonweightbearing, short-leg fiberglass cast. The tourniquet was deflated, and the patient was awakened and transferred to the recovery room in stable condition having tolerated the procedure well
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