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Knee Arthroscopy Meniscectomy Synovectomy Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right knee lateral meniscus tear.

POSTOPERATIVE DIAGNOSES:
1.  Right knee complex lateral meniscus tear.
2.  Medial synovial plica/synovitis.

PROCEDURES PERFORMED:
1.  Right knee arthroscopy.
2.  Right knee partial lateral meniscectomy.
3.  Limited synovectomy/medial plica excision.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:
General.

ESTIMATED BLOOD LOSS:
Minimal.

COMPLICATIONS:
None.

CONDITION:
The patient was transferred to the recovery room in stable condition.

INDICATIONS FOR OPERATION:
This patient is a (XX)-year-old gentleman with a history of persistent right knee pain. MRI findings as well as clinical exam was significant for lateral meniscus tear. The patient failed nonoperative management. Following explanation of risks, benefits and alternatives to treatment, he opted to proceed with right knee arthroscopy.

DESCRIPTION OF OPERATION:
Following informed consent, the patient was taken to the operating room and placed upon the operating table. Following adequate induction of general anesthesia, tourniquet was applied to the right lower extremity. It was not used during this case. The right lower extremity was placed into the leg holder. The left lower extremity was well padded, and all bony prominences were well padded. The right lower extremity was then prepped and draped in the usual sterile fashion.

A standard inferomedial portal site was then made. Trocar was then inserted. Diagnostic arthroscopy was begun. Suprapatellar pouch showed no abnormalities. Examination of patellofemoral joint showed it tracked appropriately. No chondral lesions on the undersurface of the patella or the trochlea. Medial and lateral gutters were free of debris. Examination of his medial compartment showed he had a large thickened synovial plica band, and the joint shows no evidence of any chondral abnormalities. No meniscus tear. Examination of his intercondylar notch again showed a bunch of hypertrophic synovium.

Examination of his lateral compartment once entered showed there was obvious complex tear of his lateral meniscus extending from the posterior horn to mid body. This is a trizonal-type tear with several loose unstable flaps.

At this time, a spinal needle was inserted. Medial portal was made, and the partial lateral meniscectomy was performed with use of combination of shavers, meniscal binders and radiofrequency probe. This was done back to a nice stable margin. There was no evidence of any chondral lesions on the lateral side. At this time, a shaver was then used to do a limited synovectomy as well as excision of this medial plica.

The wound was then irrigated out through the arthroscope. It was then removed. Portal sites were closed with use of simple interrupted nylon sutures. The knee was then injected with 25 mL of 0.5% Marcaine. A sterile well-padded compressive dressing was applied as well as ice pack. The patient tolerated the procedure well without any apparent complications noted.