Outpatient Surgery Patient Case Number: OPSX32-Sandall, Oscar Patient Name: Oscar Sandall Date of Se

Outpatient Surgery Patient Case Number: OPSX32-Sandall, Oscar Patient Name: Oscar Sandall Date of Service: 05-05-XX DOB: 02-19-72 Sex: M Surgeon: Sandra Cullman, MD Pre-Operative Diagnosis Right knee complex medial meniscus tear Post-Operative Diagnosis Right knee complex medial meniscus tear and medial plica Procedure Performed: Knee arthroscopy w/ partial medial meniscectomy, chondroplasty of medial femoral condyle, excision of medial plica Anesthesia: General Complications: None Indication for Procedure: The patient is a 46y/o male who was referred to me with complaints of right knee pain. He has had pain for several months and failed nonoperative treatment. I recommended a right knee arthroscopy with partial medial meniscectomy. The risks, benefits and possible complications from the surgery were discussed in detail and the patient wishes to proceed. The potential risks include: Infection, bleeding, neurovascular damage, residual pain and dysfunction, recurrence as well as the surgery possibly not improving the patient’s symptoms. If a meniscectomy is performed the patient understands that there is an increased chance of developing or accelerating any existing arthritis in that knee. The patient also understands the risks of anesthesia which include stroke, heart attack, aspiration, blood clot, pulmonary embolus and death. Description of Procedure: After consent was obtained the patient was taken to the operating room and was administered a general anesthetic and intubated. A well-padded tourniquet was applied to the right upper thigh. The extremity was then prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the right lower extremity and the tourniquet inflated to 325 mmHg. a superomedial portal was made for the introduction of the inflow. An anterolateral portal was made for the introduction of the arthroscope. An anteromedial portal was made for the introduction of arthroscopic instruments. The findings are as follows: 1. Suprapatellar pouch: Normal 2. Medial plica: Frayed 3. Medial gutter: Normal 4. Lateral gutter: Normal 5. Patella: Normal 6. Trochlea: Grade I Chondromalacia – Softening Articular Cartilage https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Outpatient_OP_Note/OPSX32SandallOscar… 1/2 6/6/2021 OPSX32SandallOscar 7. Medial Femoral Condyle: Grade IIA Chondromalacia – Fissures/Fragmentation Articular Cartilage <50% and Grade 118 Chondromalacia -Fissures/Fragmentation Articular Cartilage >50% 8. Medial meniscus: Tear, Complex- Root, Posterior Horn, Body 9. Medial Tibial Plateau: Normal 10. ACL: Normal 11. PCL: Normal 12. Lateral Femoral Condyle: Normal 13. Lateral Meniscus: Normal 14. Lateral Tibial Plateau: Normal 15. Popliteus: Normal 16. Popliteal Hiatus: Normal A partial medial meniscectomy was performed. Using a combination of an upbiting basket, straight basket and a 4.2 mm Cuda shaver I removed 50 % of the root, 75 % of the posterior horn, 25 % of the body and 0 % of the anterior horn of the medial meniscus. The rim was smoothed with a 4.2 mm Tiger shaver. A 4.2 mm Cuda shaver was used to remove the medial plica. A chondroplasty was performed of the medial femoral condyle. A 4.2 mm tiger shaver was used to debride the unstable, fibrillated articular cartilage. The portals were closed with 3-0 Prolene suture. The knee was injected with 10 cc of 0.25% Marcaine and 5 mg of Duramorph. A sterile dressing was applied with a Polar Care pad incorporated into the dressing. The tourniquet was deflated at 18 minutes. The patient was awakened and extubated by anesthesia and taken to the recovery room in stable condition. The patient tolerated the procedure well with no immediate complications. Post-op Condition of Patient: Stable Electronically Signed By: Sandra Cullman, M

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