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Orthopedic Operative Procedures
(ver batim from medical legal reports)
May 21 & 22, 1998.
Orthopedic Surgeon's report.
Procedures and Findings
The patient was given a general and epidural anesethetic. He was positioned supine on the operating table. Tourniquet was placed about both the right and left upper thighs. The right knee and left thigh, knee and leg were then shaved and scrubbed and then prepped and draped in the usual fashion.
Attention was first drawn to the right leg. The limb was elevated, tourniquet was inflated. A wound debridement was then undertaken of the anterior knee wound. This involved excision of skin margins, subcutaneous tissue and deeper fascia. This wound was extended surgically proximally and distally. The skin flaps were raised.
Examination showed ther was a fracture of the inferior pole of the patella. In essence, it was a patellar tendion avulsion with comminuted fracture fragments attached to the proximal end of the patellar tendion. This was associated with a wide retinacular rent across the anterior aspect of the knee joint. The femoral condyles were widely exposed. The remainder of the wound was then further surgically debrided and then thourghly irrigated with copious normal saline solution.
This included the knee joint of course.
We then turned our attention to the repair of the extensor mechanism. Drill holes were made in the patella obliquely. We then passed No. 5 Ethibond suture through these drill holes and then over the fragments of bone in the end of the patellar tendon and back up the drill holes. Multiple sutures were placed. These were then tightened and tied restoring the apposition of the tendon to the inferior pole of the patella. The inferior patellar fracture was extra-articular. We further repaired the retinaculum on the medial and lateral sides in a figure-of- eight No. 1 Vicryl. the anterior patellar fascia was then repaired with the patellar tendon as well with interrupted figure- of-eight 0 Vicryl.
The subcutaneous tissue and skin edges of the surgically opened portion of that wound were then repaired with interrupted inverted 2-0 Vicryl subcutaneous tissue and Prolene to the skin. The traumatic portion of the wound was left open. The wound was then dressed with vaseline gauze over the surgical portions and saline soaked gauze on the open wound with dry gauze and then Kling. A Zimmer splint was then applied to the knee joint to hold this into extension.
The touriquet time for the right extremity was approximately 80 minutes.
Attention was then drawn to the left lower extremity The limb was elevated and tourniqet was inflated. The limb was prepped and debridement was undertaken of the wounds. There was a 5 cm wound over the anteromedial aspect of the knee extending down to the knee joint. There was a second wound over the anterior compartment of the proximal leg.
The wounds were surgically debrided throughly. The wounds in the knee joint were then thoroughly irrigated with copous amounts of normal saline irragation solution. We next made a surgical incision from the lateral aspect of the distal thight toward the tibial tubercle down to the anterior aspect of the leg. Skin flaps were raised.
The fascia over the anterior compartment was incised at the bone sharply in the surical portions of the incision and divided subcutaneously later on as a subcutaneous fasciotomy.
We made a lateral parapatellar arthrotomy. This allowed a wide exposure to the knee joint and to the tibial fracture into the femoral condyles. Reirrigation with copious saline was then carried out. In the process of our debridement, we identified a number of devitalized cortical fragments of bone in the metaphysis of the tibia and in the metaphysis of the distal femur. These were removed and discarded. In addition, there were some bone fragments containing small fragments of articular cartilage which fell into the wound again devoid of soft tissue and were dicarded.
The fractures and wounds were thoroughly debrided and then reirrigated with copios irrigation.
Examination of the tibial fracture showed this to be exceedingly comminuted in the metaphysis extending up into the knee joint. The split was predominately in two fragments seperating the medial and lateral condyles with communtion of the intercondylar notch area. The anterior cruciate ligament origin was dirupted as was the posterior cruciate ligament insertion apperaed.
There was a rent in the anterior portion of the knee capsule on the medial side where the anterior horn of the medial meniscus attached. The intermeniscal ligament was absent.
We then turned our attention to reducing tibial plateau and tibial metapyseal fracture. We worked on reducing the condyles back into position. This is somewhat difficult in view of the comminution in the intercondylar notch. Ultimately we accomplished this satisfactorily. This was temperoarily held with forceps and K wires. We then then passed three full threaded large fragment cancellous screws from lateral to medial in the tibial condyles with satisfactory fixation obtained with the joint surface in satisfactory position.
Further examination of the left knee articular surfaces showed that there was an extensive articular injury to the undersurface of the patella. The articular cartilage was sheared off the lower two-thirds of the patella in an area the size of a 50 cent piece.
The comminution in the intercondylar notch area was accepted. This predominatly was nonarticular. We then reduced the shaft to the joint construct. There was extensive comminution of the metaphyseal with a bone defect measuring about 3x2x3 cm. where the cortical bone fragments had been debrided. After getting good realignmentof the leg, we than contoured a lateral buttress plate to the medial aspect of the upper tibia and affixed it tothe bone with cortical screws distally and concellous screws proximally.
Stable fixation in good alignment was achieved. AP and lateral radiographs were obtained showing the fracture to be in satisfactory position as was the hardware.
We then thoroughly irrigated the wound again. A temporary dressing was then applied and held in place with Kling bandage. Tourniquet time for the lower left extremity was 120 minutes. The tourniquet was deflated at this point and the tibilal plateau reduction continued without tourniquet with moderat bleeding noted.
I then repositioned the patient on the operating table in the semilateral position with the left side up on a bean bag. The left leg dressings were then removed and then the limb was reprepped and draped, the limb freed.
The incision on the lateral aspect of the distal thigh was carried proximally. We elevated the vastus lateralis in the intermusclar septum and from the lateralaspect of the femur and retracted this anteriorly.
Examination showed that exceedingly comminuted fracture of the supracondylar area of the femur with what was an apparent fairly large bone defect. The medial condyle was split into three fragments with coronal fractures through the bone with relatively minimal displacement of these fractures. There was major displacement in the intercondylar area present.
The condyles were then reduced one to another and the temporarily held with reduction forceps and K wires. We then placed two compression screws from the large fragment set from lateral to medial. A further screw was placed anterior to posterior in the medial femoral condyle to stablize the cornonal splits with a small fragment screwfully threaded buried in the articular cartilage in the anterior portion of the medial femoral condyle.
We then placed a guide pin for the DCS screw parallelto the articular surface and then measured and renamed it to 65 mm.We then inserted after tapping a 65 mm. DCS screw with a good purchase being obtained to the bone.
We then selected a 10 hole DCS plate and placed this on the base of the screw against the lateralfemoral condyle. The plate wasaffixed to the distal fragment with fully threaded cancellous screws. We then realigned the condyles to the shaft.
This was somewhat difficult in view of the bone loss in the metaphyseal area. Ultimately, however, was obtained a satisfactory alignment of the limb and the affixed the DSC plate to the femoral shaft with multiple cortical screws with appropriate drilling and tapping carried out throughout. Stable fixation and satisfactory alignment was achieved.
Intraoperative radiographs of the distal femur AP and lateral showed the reduction to be satisfactory with satisfactory position of the hardware.
The wound was then again irrigated thoroughly. We then closed in layers with figure-of-eight 0 Vicryl to the fascia and to the knee capsule. The subcutaneous tissue was closed with interrupted inverted 2-0 Vicryl and the skin with surgical staples.
The traumatic wounds were left open,dressed with saline gauze. The surical incisions were dressed with vaseline gauze and large abd. pads and Kling. The was then immobilized with a Zimmer splint.
The total blood loss for the procedure was approximately 2,000 cc. There were no operitive or anestetic complications. The patient was taken to the recovery room in satisfactory condition.
January 6, 1998:
Preoperative diagonosis:
Operation performed:
Procedures and Findings
The patient was given a general anaesthetic and positioned in supine on the operating table on a bean bag.
Attention was first drawn to the right knee. A tourniquet was placed around the right upper thigh. The right knee was then shaved, and prepped and draped in the usual fashon, with the limb free.
A curilinear skin incision was made over the anterior aspect of the knee in line with the previous scar and skin flaps were raised subcutaneously. We identified an attenuation of the previous repair of the pattellar tendon from the distal patella. This area of attenuated scar tissue was elevated and then excised. We incised the rentinaculum proximally on the lateral side, and distally on the medial side, fof further exposure. The bone of the distal patella and the fragment of boneon the patellar tendon were freshened with curettes and rongeurs.
We then ware able to approximate the inferior pole of the patella to the patellar tendon satisfactorily. Multiple #5 Ethibond sutures were placed through the drill holes in the patella, and then tightened and tied. This approximated the patella to the patellar tendon satisfactorily. The anterior flap of soft tissue was brought over the patella and the sutured with figure-of-eight #1 Vicryl. The retinaculum was repaired with figure-of-eight #1 Vicryl additionally.
Examination showed that the repair was intact, with flexion beyond 90 degress. The wound was then thoroughly irrigated. We then deflated the tourniquet. Haemostasis was satisfactory. We then placed a 1/8 inch Davol drain through a stab incision supralaterally. We then closed in layers, using interrupted 2-0 Vicryl to subcutaneous tissue and surgical staples to the skin.
The incision was dressed with Vaseline gauze, toppers, ABD pads, and a tensor. The knee was immobilized in a knee brace, locked in extension. A lateral radiograph at the completion of the procedure showed restoration of the extensor mechanism bonefragments satisfactorily.
We then turned our attention to the left distal femur. The left lower extremity and both iliac crests were prepped and draped in the usual fashion. The patient was then tipped on his right side, supported on the bean bag.
A longitudinal skin incision at the lateral aspect of the distal half of the femur was utilized in line with the previous scar. Dissection was carried down through the subcutaneous tissue, through the iliotibial band. The quadriceps muscle was dissected from the lateral aspect of the femur and retracte anteriorly.
We identified the plate and femur and entered the knee joint distally. Knee range of motion was 15-30 degrees flexion, with extensive artrofibrosis. It appeared that the intercondylar portion of the fracture had healed. There was a large defect in the metaphysis of the femur. This was not united laterally. There was bridging bone onthe medial side, over about 2 cm in width. A large bone defect, measuring about 4x5x4 cm was present. Scar tissue from this area was removed with sharp dissection, curettes, and rongeurs. One screw was loose proximally and was removed.
We then turned our attention to the left iliac crest. A skin incision was made along the anterior aspect of the crest. Dessection was carried down to the bone, through subcutaneous tissue. The fascia was incised laterally, a trap door was devloped and swung medially with osteomes. We the harvested cancellous and corticocancellous bone from the lateral aspect and inner aspect of the ileum with osteotomes and rongeurs and curettes. A good volume of bone graft was harvested. This was supplemented by 10 ml of Osteoset beads. The bone graft and beads were mixed and packed into the defect in the distal femur, with a good volume of bone graft being placed. This filled the defect nicely.
The wounds were then irrigated thoroughly and closed in layer over Dovol drains, with figure-of-eight #0 Vicryl to the muscular facia at the bone graft site. The trap door was therefore closed. The subcutaneous tissue was closed with interrupted inverted 2-0 Vicryl and the skin with surgical staples. The wound was dressed with Vaseline gauze, toppers, ABD pads and tape.
The left thigh was then closed in layers with figure-of-eight #0 Vicryl to the fascia lata and to the knee capsule distally. The subcutaneous tissue was closed with interrupted inverted 2-0 Vicryl and the sin with surical staples. The incision was dressed with Vaseline gauze, toppers, and Kling.
During the procedure, the knee was gently manipulated. We gained flexion to 45 degrees. We did not feel that in view of the bone defect in the femur and the condition of the knee, that an extensive knee release was advisable at this time.
Blood loss for the latter half of the procedure was approximately 300 cc. There were no operative anaesthetic complications. The patient was taken to the recovery room in satisfactory condition, after x-rays were obtained in the bed.
These are only two of many procedures performed over a two and a half year period. Additional Operative Procedures will be posted at a later date.
- 1) repair of chronic patellar tendon disruption, right knee.
- 2) Bone graft from left iliac crest to left distal femur, with Osteoset bead supplement.
- Disruption of extensor mechanism, right knee, chronic.
- Fracture, left distal femur, with bone defect
