DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Septic right knee.
POSTOPERATIVE DIAGNOSIS: Septic right knee.
OPERATION PERFORMED: Open excisional debridement of right knee with synovectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General anesthesia.
ESTIMATED BLOOD LOSS: 50 mL.
COMPLICATIONS: None noted.
SPECIMEN: Synovium for tissue culture and biopsy.
DRAINS: Hemovac, medium x1.
DISPOSITION: Stable to PACU for recovery.
INDICATIONS FOR OPERATION: The patient is an (XX)-year-old Hispanic male with end-stage renal disease, who has had a history of right knee pain. He underwent an arthroscopic irrigation and debridement. He did seem to improve after that time; however, in the last two days, it was noted that he was having increased effusion of his right knee as well as increasing pain. Aspiration of his right knee was performed, which was concerning for a septic joint. It was recommended that he undergo repeat irrigation and debridement of that right knee, and this time that will be an open excisional debridement with synovectomy. Risks and benefits were discussed, and informed consent was obtained.
DESCRIPTION OF OPERATION: The patient was properly identified in the preoperative holding area. He was brought back to the operating room and placed in the supine position on the operating room table. After satisfactory induction of general anesthesia, a well-padded tourniquet was applied to the right upper thigh. A bump was placed underneath the right hip. The right leg was then prepped and draped in the usual sterile fashion. A timeout was performed to confirm the patient, site of surgery, and type of surgery to be performed. He received his scheduled antibiotics prior to incision.
The right extremity was elevated, and the tourniquet was inflated. A midline 10 cm incision was made overlying the right knee extending from 2 cm proximal to the superior pole of the patella to about the level of the tibial tubercle. A #10 blade was utilized and incised through the skin till the subcutaneous tissue until the extensor mechanism was identified. Hemostasis was obtained with electrocautery. Full-thickness flaps were then elevated both medially and laterally.
A standard medial parapatellar arthrotomy was then performed, and it was noted upon performing that arthrotomy, that significant amounts of purulence was expressed from the joint. After performing the arthrotomy and looking inside the joint, there was significant amount of boggy purulent synovitis and purulence that was present. Swab cultures were taken at this point.
We then proceeded to perform a synovectomy of the knee. A plane was obtained just deep to the extensor mechanism of the synovium, and this was bluntly taken off starting along the proximal and medial aspect of the knee and extending distally. This was then sharply excised once this was bluntly dissected from deep to the extensor mechanism. We then performed a synovectomy along the lateral side using a similar fashion developing a plane bluntly between the synovium and the extensor mechanism in the patella and then excising the boggy synovitis that was present. Tissue cultures were sent of the synovium as well as biopsy. A rongeur was then utilized to remove any remaining synovitis that was present and any purulence. Exposure was assisted also with flexing the knee. Special care was taken in identifying the medial collateral ligament and the two menisci while performing the debridement. It was noted that the chondral surfaces of the distal femur were intact and did not appear to be much changed from his prior irrigation and debridement.
After completely performing this excisional debridement synovectomy, the knee was irrigated with 9 liters of sterile saline via Pulsavac irrigation system, including 3 liters containing bacitracin in the middle bags. We then closed the incision in a layered fashion consisting of figure-of eight 0 Vicryl sutures to close the extensor mechanism. A medium Hemovac drain was placed deep inside the joint and exiting superolateral. The subcutaneous tissue was closed using inverted 2-0 PDS suture, and the skin was closed using 2-0 nylon horizontal mattress sutures. The incision was dressed with a sterile dressing consisting of bacitracin, Adaptic, dry gauze, Webril, and Ace wrap. The tourniquet was let down, and it was noted that the patient had good perfusion of his toes. There were no complications noted prior to the patient leaving the operating room.
