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Orthopedic Medical Transcription Operative Sample Report


PREOPERATIVE DIAGNOSIS: Right adhesive capsulitis of the shoulder, status post fracture dislocation.

POSTOPERATIVE DIAGNOSIS: Right adhesive capsulitis of the shoulder, status post fracture dislocation.

1. Right shoulder arthroscopy with limited glenohumeral debridement. 
2. Right shoulder manipulation under anesthesia.



ANESTHESIA: Scalene block plus LMA.






DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the table in the supine position. Adequate level of LMA and scalene block anesthesia were obtained. C-arm was used prior to manipulation, and the shoulder appeared to be well healed and moved as a unit. Passive forward flexion to about 95, abduction to about 50, external rotation with her arm abducted position to 5 degrees, and internal rotation to about neutral. After manipulation, forward flexion was about 175-80, abduction to 125, external rotation to about 50 degrees, and internal rotation to 30. X-rays were then used again to verify no fracture or dislocation.

The right upper extremity was then prepped and draped in the normal sterile fashion. She was placed in the beach-chair position. Posterior incision was then made, and arthroscopy of the shoulder was performed. The blood was d├ębrided from the joint. There was no evidence of any superior or anterior labral tears. The biceps tendon appeared to be intact. No evidence for any rotator cuff tears. Subscapularis appeared to be intact. No loose body was noted. Because of visualization difficulties and loose pieces of cartilages as well as some fraying of the superior and anterior labrum, a limited glenohumeral debridement was performed through an anterior portal.

All the instruments were then removed. Sutures were placed on the skin. A sterile dressing followed by sling was then applied. The patient was extubated and transferred to the recovery room in good stable condition. There were no complications.


PREOPERATIVE DIAGNOSIS:  Right knee medial meniscus tear.

1.  Medial femoral condyle flap tear.
2.  Trochlear groove chondromalacia grade 3.
3.  Lateral femoral condyle flap tear.

1.  Right knee arthroscopy.
2.  Debridement of flap tears, medial and lateral femoral condyles, with chondroplasty medial and lateral femoral condyles.
3.  Injection of 20 mL of 0.25% Marcaine with epinephrine and 40 mg of Kenalog.

SURGEON:  John Doe, MD

DESCRIPTION OF PROCEDURE:  The patient was placed supine on the operating table after adequate general anesthesia was obtained with LMA. Then, 1 g Ancef IV was given to the patient. The patient's leg was placed in a tourniquet on the right side and well-padded leg holder. Left leg was placed in a well-leg holder. Foot of the bed was bent down. The right leg was prepped and draped in the usual sterile fashion. An infrapatellar medial portal and infrapatellar lateral portal were established. Infrapatellar lateral portal was established for introduction of the arthroscope. Examination of patellofemoral joint revealed grade 3 changes in the trochlear groove extending onto grade 4 changes over the medial femoral condyle over an area about the size of a quarter. The patient had medial and lateral gutters examined and these were free and clear of loose bodies. Examination of the medial compartment revealed a large complex flap tear involving about 50-60% depth of the cartilage surface on the medial femoral condyle. This extended onto the weightbearing surface of the medial femoral condyle. We carefully debrided back with a 4.0 shaver. The patient also was seen to have a longitudinal fissure in the medial tibial plateau that was approximately 3.5 cm x 2.5 cm down to bone. There was exposed bone in this area, and the flaps were carefully debrided with a full radius 4.0 shaver. The medial meniscus was carefully examined from front to back and was probed and was found not to have a through-and-through meniscal tear. The anterior cruciate ligament was examined and probed and found to be intact. Examination of the lateral compartment revealed a flap tear of the lateral femoral condylar cartilage involving 75-80% thickness of the cartilage in an area of weightbearing bone where the area of flap was approximately the size of a dime. This was debrided back to stable edges. We then irrigated out the knee copiously, returned to the suprapatellar pouch, instilled 20 mL of 0.25% Marcaine with epinephrine and 40 mg of Kenalog into the knee joint, closed the portals with 4-0 nylon simple suture, dry sterile dressing, and Ace wrap and EBIce. The patient was extubated in the operating room and returned to recovery room in good condition.

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