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Notes

SUBJECTIVE:

Resting comfortable.  Pain relatively well managed.  Gradually improving.  

 

OBJECTIVE:

General Appearance: well-nourished, well developed in no acute distress

Orientation: oriented to person, place and time.    Mood / Affect: calm

Dressing clean, dry and intact 

Strength LE: 5/5 EHL, tibialis anterior, plantar flexion

Sensation: Subjective normal distal sensation bilaterally

Vasculature: <2 second capillary bilaterally    

Soft tissues: Normal .

 

 

ASSESSMENT:

 s/p Total Joint Replacement

 

PLAN:

Doing well and improving.  

PT, gait training.

Plan d/c home with outpatient PT.

Follow up in 2 weeks.  

 

    

Implants:  Stryker Gamma nail

 

Indications

We discussed the natural history and both operative and non-operative treatment options.  We discussed the risks, benefits and expected rehabilitative course of all alternate, viable medical modes of treatment, including further diagnosis, both operative and non-operative treatments as well as no further treatment.  All questions were answered.  We had a frank discussion in layman’s terms about surgical treatment including the potential risks, benefits, and alternative treatments.  We discussed the risks of surgery including, but not limited to: nonunion, malunion, CRPS, incomplete relief of pain, incomplete return of function, the risks of bleeding, infection, scarring, loss of motion, loss of strength, screw cut out and loss of fixation, possible need for future additional surgery and conversion to hip arthroplasty. We also discussed the potential injury to nerves, arteries, muscles, ligaments, tendons, or other vital structures in the region.  Additionally risks of anesthesia and surgery were discussed including blood clots, pulmonary embolism, heart attack, stroke, paralysis, or even death in rare circumstances.   

 

 

Procedure

The patient was taken to the operative room and placed supine on the fracture table.  They were given pre-operative antibiotics and the operative site was signed prior to surgery.   Anesthesia was established.  All bony prominences were well padded.   The perineal post was well-padded.  The affected leg and it was placed in the traction boot.

 

The fracture was reduced under c-arm guidance. Gentle longitudinal traction with the leg externally rotated followed by internal rotation was applied.  

 

The affected extremity was prepped and draped in the standard sterile fashion.  A guide-wire was used to draw a line along the anterior hip and thigh in the desired position for the screw and to mark the greater trochanter.

 

A 2cm lateral longitudinal incision was made 2-4cm above tip of greater trochanter. Blunt dissection was taken down to the greater trochanter.  A guide pin was placed just medial to the tip of the greater trochanter on the A/P view and centered on the lateral view.  The nail entrance was then reamed over the guide pin.  A medially directed pressure was used to ensure the lateral cortex was not removed. A guide was then placed and the femur was reamed. 

 

The selected nail was then attached to its insertion guide and placed into the intrameduallary canal over the guide wire. The guide wire is then removed. The nail was seated with simple hand pressure.

 

The guide for the sliding hip screw was then utilized to place a guide pin in the center / center position.   The tract was then reamed and the hip screw placed in standard fashion.   Traction was released prior to placing the compression screw. 

 

The distal locking screw was then placed via a stab incision using the guide.

 

Fluoroscopic images in multiple planes were taken demonstrating near anatomic reduction of the fracture and appropriate hardware placement.

 

The area was then copiously irrigated.  The fascia lata was then closed with O-vicryl sutures.  The subcutaneous tissue was closed with monocryl inverted interrupted sutures.  The skin was closed with staples. 

 

A dressing of xeroform, 4x4’s and a tegaderm was then applied.  The patient was then awakened and taken to the post-anesthesia care unit in stable condition.  All sponge, instrument and needle counts were correct. 

 

 

 

 

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