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Left Hip Open Reduction and Internal Fixation Medical Transcription Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left hip intertrochanteric three-part fracture.

POSTOPERATIVE DIAGNOSIS:  Left hip intertrochanteric three-part fracture.

OPERATION:  Left hip open reduction and internal fixation.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Regional lumbar plexus block and local.

SPECIMENS:  None.

ESTIMATED BLOOD LOSS:  200 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was taken to the operative room and he received preoperative antibiotics intravenously prior to skin incision.  A lumbar plexus block was administrated by the anesthesia team prior to entrance into the operating room.  The patient was then placed on the fracture table.  The right lower extremity was well padded and abducted.  The left lower extremity was placed in traction.  The left hip three-part intertrochanteric hip fracture was reduced, verifying with fluoroscopy in the AP, lateral, and oblique planes.  

The left hip was prepped and draped in the normal sterile fashion.  A 1 inch incision was made just proximal to the greater trochanter.  Dissection was carried down to the fascia, which was incised in line with the skin incision.  The guide pin was then placed in the appropriate starting point on the greater trochanter and was passed into the proximal femur.  This was followed by the 17 mm cannulated proximal drill to make the entrance for the TFN nail.  The nail preselected was then inserted with ease into the proximal femur.  The lateral jig was then placed for the lag screw.  A small skin incision was made.  The trocar was inserted down to the lateral femur.  The guide pin was then inserted into the center of the femoral head and measured for length.  The appropriate sized lag screw was then inserted, after drilling through the lateral cortex.  Good placement was verified in the AP, lateral, and oblique planes.  At this point, the guide for distal locking screw was placed.  A small skin incision was made.  The trocar was inserted down to the lateral femur and the drill was used to drill for the distal locking screw.  The screw was measured and placed.

Again, fluoroscopic views were obtained of the construct, which showed reduction of the fracture and proper placement of the hardware in multiple views using fluoroscopy.  The wounds were then irrigated with copious irrigation solution.  The fascia proximally was closed with 2-0 Vicryl, subcutaneous tissue with 2-0 Vicryl and 3-0 Monocryl, and the skin with Dermabond.  Sterile dressing was applied.  The patient tolerated the procedure well.  Sponge and instrument counts were correct at the end of the case.

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