Preoperative Patient Care A Intermediate Evaluation and Management 1 Obtains focused history and physical history symptoms physical exam recognizes factors that could predict complications or poor outcome 2 Orders and interprets required diagnostic studies radiographs 3 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 4 Postop: 3-4 Week Postoperative Visit wound check start full range of motion at 4 with progressive quadriceps strengthening, edema control, pain control and gait training continue to use the brace in community setting until adequate quadriceps strength has returned at about 6 weeks diagnose and management of early complications B Advanced Evaluation and Management 1 Modifies post-operative plan based on response to treatment patient fails to improve post-operatively C Preoperative H & P 1 Obtains history and performs basic physical exam check range of motion 2 Screen medical studies to identify and contraindications for surgery 3 Orders appropriate initial imaging and laboratory studies 4 Perform operative consent describe complications of surgery including arthrofibrosis continued pain injury to the cutaneous nerves recurrent instability Operative Techniques E Preoperative Plan 1 Examine the knee under anesthesia this should include a lachman test , anterior posterior drawer test, medial and lateral patellar instability test with the knee in 45 degrees of knee flexion translation of the patella over 50% of the width of the patella laterally indicates incompetency of the medal patellofemoral ligament and the medal retinaculum 2 Execute a surgical walkthrough describe steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation 2 Room setup and equipment standard OR table 3 Patient positioning flex the foot of the table to 30 or 45 degrees place a lateral post for valgus moment G Skin Incision 1 Perform arthroscopic lateral release 2 Make the skin incision make a 4 to 5 cm limited medial approach centered on the widest portion of the patella 3 Create subcutaneous skin flaps elevate subcutaneous flaps to allow great mobility of the prepatellar skin to limit the size of the incision 4 Dissect through the subcutaneous tissue H Medial Parapatellar Incision 1 Make a medial parapatellar incision leave about 2 mm of tendon with the VMO I Tendon and Retinaculum Incision 1 Incise the tendon and the retinaculum this incision in the tendon and the retinaculum should be 3 to 4 cm above the superior pole of the patella distally to 3-4 cm distal to the inferior pole of the patella leave enough retinaculum with the tendon to suture later incise the entire depth of the tendon and retinaculum J Patellar realignment 1 Position the knee place and hold the knee in 45 degrees of flexion 2 Realign the patella position the patella in the center of the trochlea 3 Places sutures place three no. 1 or no. 2 sutures in a horizontal mattress fashion these are placed 25 to 40 % across the width of the patella from medial to lateral while imbricating the edge of the tendon of the VMO and the retinaculum distally and laterally 4 Test realignment hold the sutures tight while testing a thorough range of motion from full extension to 90 degrees of flexion this is done to check if enough imbrication has been performed K Suture Tying 1 Tie the sutures for realignment tie the sutures and use 0 absorbable suture above and below the imbrication for reinforcement L Wound Closure 1 Deep closure close the subcutaneous tissue with 3-0 vicryl 2 Superficial wound closure close the skin with running monocryl suture 3 Dressings and immobilization place in a locked hinged knee brace in full extension Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated IV fluids pain control physical therapy start active and passive range of motion in a few days to prevent any arthrofibrosis use protected weightbearing with crutches until the patient is comfortable enough to walk in a locked knee brace in full extension restrict range of motion to 0 to 90 degrees for the first 3 to 4 weeks 2 Discharges patient appropriately pain control schedule follow up in 3-4 weeks wound care R Complex Patient Care 1 Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings
A Intermediate Evaluation and Management 1 Obtains focused history and physical history symptoms physical exam recognizes factors that could predict complications or poor outcome 2 Orders and interprets required diagnostic studies radiographs 3 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 4 Postop: 3-4 Week Postoperative Visit wound check start full range of motion at 4 with progressive quadriceps strengthening, edema control, pain control and gait training continue to use the brace in community setting until adequate quadriceps strength has returned at about 6 weeks diagnose and management of early complications B Advanced Evaluation and Management 1 Modifies post-operative plan based on response to treatment patient fails to improve post-operatively C Preoperative H & P 1 Obtains history and performs basic physical exam check range of motion 2 Screen medical studies to identify and contraindications for surgery 3 Orders appropriate initial imaging and laboratory studies 4 Perform operative consent describe complications of surgery including arthrofibrosis continued pain injury to the cutaneous nerves recurrent instability
E Preoperative Plan 1 Examine the knee under anesthesia this should include a lachman test , anterior posterior drawer test, medial and lateral patellar instability test with the knee in 45 degrees of knee flexion translation of the patella over 50% of the width of the patella laterally indicates incompetency of the medal patellofemoral ligament and the medal retinaculum 2 Execute a surgical walkthrough describe steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation 2 Room setup and equipment standard OR table 3 Patient positioning flex the foot of the table to 30 or 45 degrees place a lateral post for valgus moment G Skin Incision 1 Perform arthroscopic lateral release 2 Make the skin incision make a 4 to 5 cm limited medial approach centered on the widest portion of the patella 3 Create subcutaneous skin flaps elevate subcutaneous flaps to allow great mobility of the prepatellar skin to limit the size of the incision 4 Dissect through the subcutaneous tissue H Medial Parapatellar Incision 1 Make a medial parapatellar incision leave about 2 mm of tendon with the VMO I Tendon and Retinaculum Incision 1 Incise the tendon and the retinaculum this incision in the tendon and the retinaculum should be 3 to 4 cm above the superior pole of the patella distally to 3-4 cm distal to the inferior pole of the patella leave enough retinaculum with the tendon to suture later incise the entire depth of the tendon and retinaculum J Patellar realignment 1 Position the knee place and hold the knee in 45 degrees of flexion 2 Realign the patella position the patella in the center of the trochlea 3 Places sutures place three no. 1 or no. 2 sutures in a horizontal mattress fashion these are placed 25 to 40 % across the width of the patella from medial to lateral while imbricating the edge of the tendon of the VMO and the retinaculum distally and laterally 4 Test realignment hold the sutures tight while testing a thorough range of motion from full extension to 90 degrees of flexion this is done to check if enough imbrication has been performed K Suture Tying 1 Tie the sutures for realignment tie the sutures and use 0 absorbable suture above and below the imbrication for reinforcement L Wound Closure 1 Deep closure close the subcutaneous tissue with 3-0 vicryl 2 Superficial wound closure close the skin with running monocryl suture 3 Dressings and immobilization place in a locked hinged knee brace in full extension
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated IV fluids pain control physical therapy start active and passive range of motion in a few days to prevent any arthrofibrosis use protected weightbearing with crutches until the patient is comfortable enough to walk in a locked knee brace in full extension restrict range of motion to 0 to 90 degrees for the first 3 to 4 weeks 2 Discharges patient appropriately pain control schedule follow up in 3-4 weeks wound care R Complex Patient Care 1 Able to develop a comprehensive preoperative plan that includes options based on intraoperative findings