DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left distal radioulnar joint instability.
2. Left wrist triangular fibrocartilage complex tear.
POSTOPERATIVE DIAGNOSES:
1. Left distal radioulnar joint instability.
2. Left wrist triangular fibrocartilage complex tear.
OPERATION PERFORMED:
1. Open left distal radioulnar joint reconstruction using palmaris longus autograft.
2. Open repair of left triangular fibrocartilage complex tear.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General with axillary block.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and positioned supine on the operating table for open left distal radioulnar joint reconstruction using palmaris longus autograft and open repair of left triangular fibrocartilage complex tear. A timeout was taken to confirm the patient’s identity, procedure, laterality and surgical plan, reviewed and confirmed. IV cefazolin 1 g was administered and general anesthesia was induced. An axillary block was placed by the anesthesiologist. A left arm tourniquet was placed and the left upper extremity was then prepped and draped in a standard sterile surgical fashion.
The planned volar and dorsal incisions were marked out. After exsanguination, the tourniquet was inflated. The dorsal longitudinal incision was first made overlying the 5th dorsal compartment. This was entered and an L-shaped capsular flap was made. Immediately apparent was a very unstable DRUJ with some evidence of degeneration of the ulnar head without significant degeneration within the sigmoid notch.
Also noted was attachment of the TFCC to the fovea, as well as portion of the radius; although, the ulnocarpal components appeared to be rather attenuated. Despite the small amount of degeneration, the patient did not appear to be symptomatic from this, and therefore, the decision was made to proceed with a reconstruction. The palmaris longus tendon was harvested through a small volar incision using a tendon stripper.
After creating a start point that was well proximal and radial to the lunate facet and sigmoid notch respectively, the guidepin for the 3.2 mm cannulated drill was inserted from posterior to anterior. Volarly, a longitudinal incision was made and carefully carried down through the subcutaneous tissue, identifying and protecting the ulnar neurovascular bundle.
The finger flexors were retracted radially, and after elevation of the pronator quadratus and protection of the volar radiocarpal ligaments, the guidepin was localized and the drill hole using the 3.2 mm drill was made. A second drill hole starting from the ulnar fovea, exiting the ulnar neck laterally was also made in a similar fashion.
The palmaris longus was then passed from anterior to posterior using a 20 gauge wire. The volar limb was then passed through the volar capsule deep to the TFCC. Both limbs were then passed into the fovea and exiting the ulnar neck laterally.
One limb was then passed around the ulnar neck, and with the forearm in neutral pronation and a small amount of compression placed on the DRUJ, the two ends were tied to one another and secured into place using interrupted 3-0 Ethibond suture.
There was satisfactory reproduction of ulnar head stability with this. The capsular flap was then reapproximated using interrupted 3-0 Monocryl suture. The dorsal and distal TFCC attenuation was repaired with 3-0 Monocryl suture, restoring coverage of the ulnar head. The dermis was then reapproximated using interrupted 3-0 Monocryl suture, followed by a running 4-0 Monocryl subcuticular stitch.
The volar wrist incision was then repaired using interrupted 4-0 Monocryl in the dermis. Then, 0.5% Marcaine with epinephrine was injected into the skin about the incisions. Hand was then washed and dried, and a dry sterile dressing followed by a well-padded sugar tong splint was placed with the arm in neutral position. The tourniquet was let down with immediate reperfusion to the entire hand.
The patient tolerated open left distal radioulnar joint reconstruction using palmaris longus autograft and open repair of left triangular fibrocartilage complex tear well. Estimated blood loss was minimal. Sponge, needle and instrument count correct x2.
