MUSCULOSKELETAL TEST FILES

ORTHO_T1

PREOPERATIVE DIAGNOSIS:  Failed total hip, right.

POSTOPERATIVE DIAGNOSIS:  Failed total hip, right.

OPERATION PERFORMED:  Revision total hip, right.

GROSS FINDINGS:  The patient has had a failed total hip, manifested by migration of the cement as well as the prosthesiss distally and accompanied by considerable amounts of pain.

PROCEDURE:  Preceded by Betadine soak and a Betadine scrub, Monocid, and isolated with U drapes, a straight lateral incision was made and carried down to the femur.  A small fragment of the greater trochanter was identified to have been reattached by a fibrous union.

The gluteus medius and minimus were detached anteriorly, and the gluteus maximus was reflected posteriorly.  The fascia lata was divided to accomplish this move.

The capsule was then excised sufficiently to identify the head, which was readily dislocated.

The subjacent area of the femoral neck was debrided, and then using an impactor, the head was tapped, and the prosthesis, a Zimaloy prosthesis, was removed with no accompanying cement.  Then the shaft, which was covered with a fibrous material outside the cement (that is, there was the prosthesis, the fibrous material, the cement, and then more fibrous material), was identified, and essentially the total amount of the cement was removed.

Then it was necessary to ream the distal fragment. This was accomplished by inserting a drill down the center of the Synthes wire guide utilizing it as a centering device, and the distal plug was reamed.  Then a guide wire for the flexible reamers was inserted, then using serial reamers up to 14, the shaft was minimally enlarged at the isthmus, and the cement at the plug was all removed.  Copious amounts of antibiotic irrigation were utilized during the course of the procedure.

When this had been accomplished, the trials were used to ream the proximal end.  A 14 could not be inserted far enough distally, and a 12 was ultimately decided upon.

Two packages of freeze-dried bone were ground up together with some chips, and were inserted into the shaft prior to and at the time of the insertion of the permanent stem.

Initially a minus 5 stem was used and it was felt to be too short.  It was removed, and a neutral neck was utilized.

With the neutral neck and debridement of the acetabular base, the reduction was accomplished with the skid with some difficulty but provided a very substantial fit.

A drill was then made in the greater trochanter, and the loose fragment of bone together with the gluteus minimus and medius was reattached.

Tevedek #1 was used for this purpose.  Then #1 Vicryl was used to reapproximate the heavier fascial and muscular structures.  A Jackson-Pratt was inserted.

The balance of the closure was accomplished with 2-0.  Ultimately skin clips were used on the skin. Blood loss was estimated to be 800 CC.

The patient received 1 unit of blood during the procedure.

The patient received an additional gram of Ancef during the course of the procedure.

ORTHO_T2

Orthopedics

OPERATIVE REPORT

PREOPERATIVE DIAGNOSES

1.  Loose body, right shoulder.

2.  Recurrent anterior dislocation.

POSTOPERATIVE DIAGNOSES

1.  Loose body.

2.  Recurrent anterior-inferior dislocations.

PROCEDURES

1.  Arthroscopic debridement.

2.  Bankart shoulder repair.

INDICATIONS:  An 18-year-old recently seen and examined under an anesthetic, with some presumed posterior instability.  Because of the uncertainty at the time of surgery, she was rescheduled for x-ray studies before an open procedure.  She is now brought to the operating room for a diagnostic arthroscopy and debridement followed by an arthrotomy.

OPERATIVE FINDINGS:  Under arthroscopic examination, the patient was found to have a rather large loose body that appeared to be attached at the inferior lip of the glenoid.  This was an obvious source of the impingement.  The biceps tendon was inspected and was normal.  The patient had some degenerative changes of her labrum which were debrided at the time of arthroscopy.  She had a Bankart lesion that was noted at approximately 5 o’clock.  At the time of her open procedure, the patient was found to have similar findings, with the loose body being removed and the Bankart lesion reattached utilizing a single stitch.

PROCEDURE:  After obtaining informed consent, the patient was taken to the operating room where she was given an inhalant anesthetic.  She was placed in the lateral decubitus position with the right arm draped free, utilizing approximately 15 pounds of skin traction.  A posterior portal was used for the introduction of the scope, with an anterior portal being used for triangulation, as well as the shaver.  The 25-degree scope was introduced into the shoulder for diagnostic arthroscopy.  The patient’s rotator cuff was seen and was normal.  The patient was noted to have a large, approximately 2 X 2 cm defect about the posterolateral aspect of her humerus.  This was beyond the bare area and involved a portion of the articular surface of the humerus.  The patient’s glenoid was inspected carefully and was normal.  The scope was then removed, with a reprep and drape in the beach chair position.  The right arm was draped free.

A midaxillary line incision was utilized as the operative approach.  The skin folds were used to ensure cosmetic appearance.  The dissection was carried down deep to the skin and subcutaneous tissues between the deltopectoral interval.  The cephalic vein was retracted laterally, which allowed visualization of the clavipectoral fascia.  This was divided, followed by a detachment of the subscapularis approximately 1.5 cm lateral to its attachment.  Tag stitches were inserted prior to its medial displacement.  A humeral head retractor was then inserted which allowed visualization of the underlying articular surface.  This had to be removed to remove the large loose body which was attached to the inferior lip.  The wound was irrigated with saline, followed by identification of the Bankart lesion.  The lesion was approximately a centimeter and located at about 5 o’clock on the glenoid rim.  A drill hole was made along the articular surface, followed by a reattachment of the glenoid labrum after roughening the outer surface.  It was apparent that the loose body had attached to this portion of the glenoid.  The wound was then irrigated followed by a meticulous repair of the subacapularis muscle utilizing the same suture, i.e., #2 Tevdek.  The wound was irrigated further, followed by an approximation of the deltopectoral interval as well as a layered closure usint 1-0 and 1-0 Vicryl and an intracuticular stitch for the skin.  Steri-Strips and a small Hemovac drain were both applied, with the patient being placed in a sling and transferred to the recovery room stable condition.  She tolerated the procedure well, and there were no intra-operative complications.