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Knee Arthroscopy Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Degenerative joint disease with possible torn medial meniscus, right knee.

POSTOPERATIVE DIAGNOSIS:
Degenerative joint disease of the right knee with grade 3 chondromalacia of the patella, femoral groove, and lateral femoral condyle, and loose bodies.

OPERATION PERFORMED:
Right knee arthroscopy with chondroplasty and removal of loose bodies.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

IV FLUIDS:  1000 mL.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

SPECIMENS:  None.

DESCRIPTION OF OPERATION:  The patient was seen in the preoperative hall and correct operative site was identified. He was transported to the operating suite and placed supine on the operating table and given a general anesthetic without difficulty. A tourniquet was placed on the right thigh but not utilized during the case. Right lower extremity was placed through an arthroscopy leg holder. The right lower extremity was then prepped with DuraPrep solution and draped in the usual sterile manner for this case.

Anteromedial and anterolateral portals were established initially. The arthroscope was placed into the suprapatellar pouch. There were some loose articular fragments noted in this region. These were removed with an arthroscopic shaver. There were also loose articular fragments in the medial gutter, and these were also removed with the arthroscopic shaver. The lateral gutter was clear.

The lateral compartment was entered. The lateral tibial plateau had grade 1 to 2 chondromalacia, but this was very mild. The lateral meniscus was probed in its entirety and was found to be intact. The lateral femoral condyle, however, had an area of grade 3 chondromalacia on the weightbearing surface. This was probed and found to have a delaminating flap. An arthroscopic shaver was used to debride the edges of this flap and in the end it was approximately a 2 cm diameter defect with grade 3 cartilage loss on the weightbearing surface of the lateral femoral condyle. An arthroscopic thermal probe was used for thermal chondroplasty to stabilize the edges of this lesion.

The anterior cruciate ligament was visualized and was found to be intact. The medial compartment was then entered. The articular surfaces of the medial femoral condyle and medial tibial plateau were intact. The medial meniscus was probed in its entirety and found to be without evidence of tear. The patellofemoral articulation was then visualized. There was significant grade 3 chondromalacia of the apex of the patella, extended to both lateral and medial facets. In addition, there was grade 3 chondromalacia involving the majority of the trochlea. An arthroscopic shaver was used to debride both areas taking articular edges to stable configuration. A thermal chondroplasty was performed in these regions as well.

After all intraarticular issues were addressed, excess fluid was drained from the knee. Marcaine 30 mL, 0.25%, with epinephrine was instilled into the knee and instruments were removed. Portal sites were closed with nylon sutures. A sterile dressing was then applied. An EBIce pad was placed over the dressing. The patient was returned to the supine position and general anesthetic was reversed without difficulty. He was transferred supine on the operative gurney and transported to the postanesthesia care unit in stable condition.