DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right ankle fracture with severe dislocation.
POSTOPERATIVE DIAGNOSIS:
Right ankle fracture with severe dislocation.
OPERATION PERFORMED:
1. Attempted closed reduction with pinning at the right lower extremity.
2. Application of external fixator, right lower extremity.
SURGEON: John Doe, DPM
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 5 mL.
MATERIALS: Smith and Nephew Jet-X external fixator.
INJECTABLES: None.
PATHOLOGY: None.
INDICATIONS FOR OPERATION: This is a (XX)-year-old female patient who presented about 1 week ago. At that point, she had a trimalleolar type ankle fracture to the right lower extremity. She was evaluated by Dr. Jane Doe and then referred to her office for followup care. X-rays taken by Dr. Doe revealed a complete posterior dislocation of the ankle joint. There were also increased skin problems on the anterior aspect of the ankle. The patient was then sent to me for evaluation and surgical consultation. This was deemed as an emergent case due to vascular compromise of the anterior aspect of the ankle and the gross deformity. The patient was therefore admitted. Cardiac clearance was required. Therefore, after cardiac clearance, the patient presented today to the operating room for surgical reconstruction.
DESCRIPTION OF OPERATION: The patient was consented for the procedure and brought to the operating room where the name and allergy bands were rechecked. The patient was then brought into the operating room and placed on the table in the supine position. After induction of general anesthesia, the patient was prepped and draped in the usual sterile fashion.
At this time, attention was directed to the right lower extremity where under intraoperative image intensification, attempted closed reduction was performed. We were unable to relocate the talus into the ankle mortise at that time. It was deemed necessary to apply the monolateral external fixator device. The Jet-X fixator was applied in standard technique. Cannulated half-pins were inserted into the talar neck and calcaneus. This was used as a pinpoint and the 2 proximal tibial screws were placed in standard technique. These were cannulated. All half-pins were visualized under intraoperative fluoroscopy. Next, the traction device was placed onto the external fixator and attempted traction reduction was then performed. Repeated attempts at reduction were unable to be performed at this time.
Though complete closed reduction was not able to be completed, tension was able to be removed from the anterior aspect of the ankle in hopes to prevent further skin necrosis. The external fixator was locked in place. Wound was lightly dressed with Xeroform gauze. At this point, it was determined that the patient has a vascular risk and risk of limb loss for open technique.
At this point, it was deemed necessary to allow the soft tissues to calm in the next 24 to 48 hours and will be monitored at bedside to ensure further necrosis does not occur. It is likely an open technique will be necessary. Further vascular status evaluation will be performed as well. The patient tolerated the procedure and surgery well and left the operating room to the recovery with vital signs stable and vascular status intact. No complications were noted at this time. The patient will be readmitted and will more than likely return to the OR in the next 24 to 48 hours.
