cclarson
Guru
Hello Everyone,
I just wanted to confirm whether or not this pt op note includes a capsulotomy in the body portion of the report? Sometimes the doctor will word it in a way that I'm not familiar with, and I wanted to know if this was one of those occasions. If it's not mentioned, I'll have the doctor create an addendum. Thank you!
POSTOPERATIVE DIAGNOSES:
1. Painful hammer toe deformity second digit, right foot.
2. Elongated second metatarsal, right foot.
3. Partial dislocation second metatarsophalangeal joint, right foot.
OPERATION PERFORMED:
Hammer toe repair with arthrodesis of the proximal interphalangeal joint, capsulotomy of the metacarpophalangeal joint, and Weil osteotomy of the second metatarsal.
DESCRIPTION OF PROCEDURE:
The patient was brought into the OR and placed supine on the table. General anesthesia was initiated. The right lower extremity was prepped to the knee and draped in the usual sterile fashion. The thigh tourniquet was inflated.
Attention was directed to the second toe. Two converging semi-elliptical were created overlying the PIPJ. A midline incision adjoined this extending proximal to the MPJ. The incision was deepened to deep fascia. The extensor tendon was divided in Z-plasty lengthening fashion. The articular cartilage was resected at the PIPJ on both sides. A Weil osteotomy was created in the second metatarsal to allow the capital fragment to retract proximally. It was fixated with a 13 mm 2.0 twist off screw. The PIP arthrodesis was fixated with a 0.045 smooth K-wire, which was driven from the middle and distal phalanges and retrograded back to the base of the proximal phalanx under fluoroscopic guidance. The long flexor tendon was then harvested from the plantar aspect of the second toe, divided into medial and lateral slips and rerouted dorsally and sutured in the extensor hood mechanism.
Intraoperative x-rays validated satisfactory position of the toe and the internal fixation. The extensor tendon was then repaired in a lengthened fashion with 3-0 Vicryl and the skin was repaired with 4-0 nylon.
The above noted amounts of local anesthetic were then utilized to block the surgical site. The foot was bandaged with Xeroform gauze, dry sterile dressing, Kling, and Coban. The patient left the OR in stable and satisfactory condition. He will be discharged with appropriate instructions and follow up in Dr. Hamilton office next Monday.
I just wanted to confirm whether or not this pt op note includes a capsulotomy in the body portion of the report? Sometimes the doctor will word it in a way that I'm not familiar with, and I wanted to know if this was one of those occasions. If it's not mentioned, I'll have the doctor create an addendum. Thank you!
POSTOPERATIVE DIAGNOSES:
1. Painful hammer toe deformity second digit, right foot.
2. Elongated second metatarsal, right foot.
3. Partial dislocation second metatarsophalangeal joint, right foot.
OPERATION PERFORMED:
Hammer toe repair with arthrodesis of the proximal interphalangeal joint, capsulotomy of the metacarpophalangeal joint, and Weil osteotomy of the second metatarsal.
DESCRIPTION OF PROCEDURE:
The patient was brought into the OR and placed supine on the table. General anesthesia was initiated. The right lower extremity was prepped to the knee and draped in the usual sterile fashion. The thigh tourniquet was inflated.
Attention was directed to the second toe. Two converging semi-elliptical were created overlying the PIPJ. A midline incision adjoined this extending proximal to the MPJ. The incision was deepened to deep fascia. The extensor tendon was divided in Z-plasty lengthening fashion. The articular cartilage was resected at the PIPJ on both sides. A Weil osteotomy was created in the second metatarsal to allow the capital fragment to retract proximally. It was fixated with a 13 mm 2.0 twist off screw. The PIP arthrodesis was fixated with a 0.045 smooth K-wire, which was driven from the middle and distal phalanges and retrograded back to the base of the proximal phalanx under fluoroscopic guidance. The long flexor tendon was then harvested from the plantar aspect of the second toe, divided into medial and lateral slips and rerouted dorsally and sutured in the extensor hood mechanism.
Intraoperative x-rays validated satisfactory position of the toe and the internal fixation. The extensor tendon was then repaired in a lengthened fashion with 3-0 Vicryl and the skin was repaired with 4-0 nylon.
The above noted amounts of local anesthetic were then utilized to block the surgical site. The foot was bandaged with Xeroform gauze, dry sterile dressing, Kling, and Coban. The patient left the OR in stable and satisfactory condition. He will be discharged with appropriate instructions and follow up in Dr. Hamilton office next Monday.
