2. Operative Report (Do not code Fluoroscopy)
PREOPERATIVE DIAGNOSES: Unstable oblique ankle fracture, right fibula
POSTOPERATIVE DIAGNOSES: Unstable oblique ankle fracture, right fibula
PROCEDURES: Open reduction internal fixation right ankle
ANESTHESIA: General endotracheal

INDICATIONS: This young man fell at home on the ice and sustained the above fracture. He was brought to the emergency room and was admitted for surgery.

OPERATIVE TECHNIQUE: The patient was brought to the operating room, placed in the supine position. Appropriate IV access and monitors were placed. Clindamycin 900 mg IV was given for prophylaxis as the patient has a penicillin allergy. SCD was on the left leg. General endotracheal anesthesia was performed and the patient was positioned with bumps under his buttocks and his right arm over his belly pads. He was in a semi-lateral position. His left leg was padded well and again had the SCD boot. A tourniquet was placed on his upper right thigh. The lateral aspect of his right ankle was shaved, and his right leg and foot were provisionally prepped with Betadine followed by a formal prep and drape with Chlora Prep. The leg was exsanguinated and the tourniquet inflated to 300 mmHG. Tourniquet time for the case was 54 minutes.
Incision was made and the periosteum was allowed to remain intact, but the soft tissue was dissected off his fibula. My assistant held traction and I used a lobster claw clamp to complete the reduction and clamp it in place. I then placed a 3.5 mm lag screw from anterior to posterior with good purchase. My finger was in the posterior aspect of the fibula to ensure that was not too posterior and that it would not irritate the peroneal tendons.
I removed the clamp and then placed the Synthes stainless steel periarticular locking plate on the distal fibula. It fit well. I placed 2 screws in the fibula shaft. Checked alignment and placement and then placed all the distal screws in a unicortical locking screw fashion. All screws were checked in multiple fluoroscopic vies, showing good placement. The remainder of the shaft screws proximally were 3.5 mm bicortical screws. Because the patient had excellent bone quality all screws bit well.
I then placed a towel clip on the distal fibula, and under live fluoroscopy stressed the syndesmosis. Then placed dorsiflexion and eversion and tried to stress the syndesmosis. The syndesmosis was stable in all views and the mortise had been restored. The medial clear space was not well aligned.
Permanent pictures were taken in multiple views. This showed good placement of the hardware, good reduction of the fracture. The wounds were then irrigated and closed in layers with #1 Vicryl suture, followed by 2-0 Vicryl suture. The wound was injected with 20cc bupivacaine 0-5% without epinephrine. Steri-strips, Xeroform, sterile gauze, sterile Webril were then placed. A significant amount of padding, particularly on the ankle and heel, was then placed. I placed a posterior mold, followed by a sugar-tong splint. He was awakened, extubated, brought to the recovery room in stable condition. His leg was elevated properly, and again the SCD boot remained on his leg.
Blood loss was 10mL. No specimens were sent, no drains used. No complications were noted. The patient tolerated the procedure well.

Dissecting an Operative Report Worksheet: Case Study 4-2
Intent of Procedure:
Root Operation: (Index Main Term)
Where: Major—(Body System):
Minor—(Body Part): (Index Sub-Term)
Approach: (See Approach Decision Tree)
Device: Yes—See Table, No—Z
Qualifier: Yes—See Table, No—Z
Code the Procedure (Hint: Some cases may have more than one code):

Rationale (How you arrived at the root operation, body part and the code or codes if applicable):

Guidelines pertinent to the coding of this case: