Module 3 Case Study
1. Operative Report. Code the following case study.
Preoperative Diagnosis: Torn medial meniscus, left knee
Postoperative Diagnosis: Combination horizontal cleavage tear/flap tear,
posterior horn, medial meniscus, left knee.
Operation: Arthroscopic subtotal medial meniscectomy, left knee
Anesthetic: General endotracheal
Description of Procedure: The patient was placed on the operating table
in the supine position and general endotracheal anesthesia was
administered. After an adequate level of anesthesia was achieved, the
patient's left lower extremity was prepped with Betadine scrubbing solution,
then draped in a sterile manner. Several sites were then infiltrated with 1%
Xylocaine solution with Epinephrine to help control bleeding from stab
wounds to be made at these sites. These stab wounds were made
anterolaterally at the level of the superior pole of the patella for insertion of
an irrigation catheter into the suprapatellar pouch area, anterolaterally at the
level of the joint line for insertion of the scope and anteromedially at the
level of the joint line for insertion of the various arthroscopic cutting and
grasping instruments. The knee was explored, no abnormalities were noted
in the suprapatellar pouch area. A very small, un-inflamed, non-thickened
medial plica was noted. This did not appear to be of any significant problem
to the patient, however. It was elected to leave the area alone. The
undersurface of the patella showed some very minimal signs of
chondromalacia in the central portions as well as on the medial
meniscus. With further probing it was noted that he had both a flap tear of
the posterior most portions of the posterior horn of the medial meniscus,
along with a horizontal cleavage involving a fair amount of the remainder of
the posterior horn of the medial meniscus. The flap tear portion of the
medial meniscus tear was removed with the 3.5 mm. basket forceps in
combination with the Dyonics intra-articular shaver. The horizontal cleavage
tear was probed and it was felt the upper leaf of the horizontal cleavage was
the thinner of the two remaining components of the horizontal cleavage
tear. The upper leaf of the horizontal cleavage tear was then resected in a
piecemeal fashion utilizing combination of the 3 mm. basket forceps and the
Dyonics intra-articular shaver. The rim of the meniscus was then smoothed
down and balanced and the remaining portions of the meniscus were probed
and found to be stable and intact. The intracondylar notch area was
1. Operative Report. Code the following case study.
Preoperative Diagnosis: Torn medial meniscus, left knee
Postoperative Diagnosis: Combination horizontal cleavage tear/flap tear,
posterior horn, medial meniscus, left knee.
Operation: Arthroscopic subtotal medial meniscectomy, left knee
Anesthetic: General endotracheal
Description of Procedure: The patient was placed on the operating table
in the supine position and general endotracheal anesthesia was
administered. After an adequate level of anesthesia was achieved, the
patient's left lower extremity was prepped with Betadine scrubbing solution,
then draped in a sterile manner. Several sites were then infiltrated with 1%
Xylocaine solution with Epinephrine to help control bleeding from stab
wounds to be made at these sites. These stab wounds were made
anterolaterally at the level of the superior pole of the patella for insertion of
an irrigation catheter into the suprapatellar pouch area, anterolaterally at the
level of the joint line for insertion of the scope and anteromedially at the
level of the joint line for insertion of the various arthroscopic cutting and
grasping instruments. The knee was explored, no abnormalities were noted
in the suprapatellar pouch area. A very small, un-inflamed, non-thickened
medial plica was noted. This did not appear to be of any significant problem
to the patient, however. It was elected to leave the area alone. The
undersurface of the patella showed some very minimal signs of
chondromalacia in the central portions as well as on the medial
meniscus. With further probing it was noted that he had both a flap tear of
the posterior most portions of the posterior horn of the medial meniscus,
along with a horizontal cleavage involving a fair amount of the remainder of
the posterior horn of the medial meniscus. The flap tear portion of the
medial meniscus tear was removed with the 3.5 mm. basket forceps in
combination with the Dyonics intra-articular shaver. The horizontal cleavage
tear was probed and it was felt the upper leaf of the horizontal cleavage was
the thinner of the two remaining components of the horizontal cleavage
tear. The upper leaf of the horizontal cleavage tear was then resected in a
piecemeal fashion utilizing combination of the 3 mm. basket forceps and the
Dyonics intra-articular shaver. The rim of the meniscus was then smoothed
down and balanced and the remaining portions of the meniscus were probed
and found to be stable and intact. The intracondylar notch area was
