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Proximal Interphalangeal Arthroplasty Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Posttraumatic arthrosis of the left third proximal interphalangeal joint, status post arthroplasty of the left third proximal phalanx.

POSTOPERATIVE DIAGNOSIS:  Posttraumatic arthrosis of the left third proximal interphalangeal joint, status post arthroplasty of the left third proximal phalanx.

OPERATIONS PERFORMED:
1.  Left third finger proximal interphalangeal arthroplasty with prosthetic replacement.
2.  Removal of deep hardware.
3.  Tenolysis of flexor and extensor tendons.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

TOURNIQUET TIME:  130 minutes.

FLUIDS GIVEN:  Lactated Ringer's.

BLOOD LOSS:  25 mL.

SPECIMEN:  None.

CONDITION:  The patient tolerated the procedure well and was taken to the recovery room in stable condition.

INDICATIONS FOR OPERATION:  This is a (XX)-year-old male who sustained a table saw injury to the left third finger approximately eight months ago.  He had a primary repair.  There was a segment of bone loss through the articular surface of both the proximal phalanx head as well as the base of the middle phalanx.  An osteoplasty was performed with iliac crest bone grafting to fill the defect of both the proximal phalanx and the middle phalanx.  Once the iliac crest bone graft had fully consolidated over the course of eight months, the patient then developed posttraumatic arthrosis.  The patient now presents for operative treatment for arthroplasty secondary to severe pain.  The risks and benefits of the surgery, including infection, bleeding, recurrent contracture, possible subluxation, possible dislocation, and possible persistent pain of the finger, were explained to the patient.  The patient understands the risks and benefits of the surgery and wishes to proceed.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed on the operating table in the supine position.  General anesthesia was induced.  The left upper extremity was prepped and draped in the usual sterile fashion.  The limb was exsanguinated, and tourniquet was inflated to 250 mmHg. The previous old curvilinear incision was reincised from distal to proximal and also extended 1 cm obliquely in both locations.  The incision was on the radial aspect of the finger, and the skin flap was then raised as an ulnar based skin flap and retracted.  Copious amounts of scar tissue were found on top of the extensor tendon and this was removed. At this point, the extensor tendon was then incised in a chevron type of distally based flap with the flap left attached to the central strip on the middle phalanx.  Proximally, it was brought together in a chevron type of incision, and the extensor tendon was then elevated off the proximal phalanx and folded on top of itself from the middle phalanx exposing the PIP joint.

At this point, an extensive tenolysis was performed using tenolysis knife of the extensor mechanism as well as the flexor tendon mechanism circumferentially around the proximal phalanx.  The volar plate was also elevated both proximally and distally from the undersurface of the PIP joint. At this point, the PIP joint was inspected.  The radial condyle was completely obliterated and arthritic along with the corresponding section on the proximal phalanx as well as the corresponding section on the middle phalanx.  At this point, it was determined that a PIP implant arthroplasty was necessary.  The Ascension PIP implant was selected.  The starting guide off for the proximal phalanx was then used to enter the metacarpal head.  Proper placement of awl was verified in the AP, lateral planes using FluoroScan. At this point, the intramedullary canal was entered.  The distal cutting guide was then placed at the proper location at the end of the proximal phalanx head, and the end of the proximal phalanx head was then excised with the sagittal saw.  At this point, the intramedullary canal of the proximal phalanx was broached appropriately to the size 30 Ascension PIP proximal phalangeal implant.

Afterwards, the oblique cutting guide was then inserted into the proximal phalanx.  Throughout this entire process, the guides were verified in the appropriate position using FluoroScan imaging.  The oblique cutting guide was then used to cut the volar cortex appropriately.  At this point, the preparation of the proximal phalanx was complete and attention was then diverted to the middle phalanx. The PIP surface of the middle phalanx was then removed with a cutting bur, and it was flattened to an even surface perpendicular to the middle phalanx.  At this point, the intramedullary canal was entered at the appropriate location with a cutting bur, and the proximal phalanx was then incrementally broached to a size 30.  Proper placement of the broach was verified in the AP and lateral planes using FluoroScan.

Once this was done, the broaches were removed and the trial implant components were placed at the proper position and rotation.  At this point, the finger was taken through a full range of motion.  There was laxity of the radial collateral ligament with intact and strong ulnar collateral ligament.  At this point, all the trial components were removed, once proper fitting was achieved.  The range of motion was tested with the components, which was from 20 to 90 easily.  Despite elevation of the volar plate and removal of excessive bone, the patient still was able to achieve no extension beyond 20 degrees.  At this point, the trial components were removed.

The wound was copiously irrigated with bacitracin-impregnated saline.  A 2-0 Vicryl figure-of-eight mattress suture was then placed through the radial collateral ligament, which was to be tied after seating of the implant.  At this point, the middle phalanx was further prepared and the final implants were then seated appropriately with the Ascension PIP PyroCarbon implant, size 30, on the proximal phalanx and size 30 on the middle phalanx.  Once these were seated, the joint was reduced and found to be stable throughout range of motion.  At this point, the suture to the radial collateral ligament was tightened.  This restored the integrity of the radial collateral ligament.  Final range of motion was 20-95 degrees in the operating room.

At this point, the wound was copiously irrigated with normal saline.  The extensor chevron slip was then reattached to the remainder of the extensor mechanism with 4-0 Ethibond single interrupted sutures and 3-0 Vicryl single interrupted sutures.  Once this was done, the tourniquet was deflated.  Meticulous hemostasis was achieved.  The skin flap was closed with 5-0 nylon single interrupted sutures.  Bulky sterile dressing and a splint were applied.

The patient tolerated the procedure well and was taken to the recovery room in stable condition.